Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2022 May 31.
Published in final edited form as: Psychol Trauma. 2020 Oct;12(7):716–724. doi: 10.1037/tra0000604

Military Sexual Trauma Types and Alcohol Misuse among Military Veterans: The Roles of Negative and Positive Emotion Dysregulation

Shannon R Forkus 1, Anthony J Rosellini 2, Lindsey L Monteith 3,4, Ateka A Contractor 5, Nicole H Weiss 1
PMCID: PMC9152990  NIHMSID: NIHMS1738403  PMID: 33001678

Abstract

Introduction:

Alcohol misuse is a significant clinical concern among military and veteran populations, particularly among individuals who have experienced military sexual trauma (MST). Emotion dysregulation may be an important factor influencing alcohol misuse among individuals with MST.

Objective:

The current study, thus, examined the role of negative and positive emotion dysregulation in the association between MST type and alcohol misuse among military veterans.

Method:

Data were collected from a community sample of 515 veterans (M age= 37.48, 71.3% male, 70.5% White).

Results:

Mediation analyses indicated that negative and positive emotion dysregulation (separately) explained the relation between military sexual assault and alcohol misuse, but not military sexual harassment.

Conclusions:

Findings emphasize the clinical relevance of addressing negative and positive emotion dysregulation in relation to alcohol misuse among veterans with a history of sexual assault MST.

Keywords: Military veterans, military sexual trauma, alcohol misuse, negative emotion dysregulation, positive emotion dysregulation

Alcohol misuse is a serious and widespread problem in the United States (U.S.) military (Fuehrlein et al., 2016). U.S. military personnel and veterans endorse high rates of heavy alcohol use (20%) and binge drinking (47%; Bray, Brown, & Williams, 2013). Further, compared to civilian populations, they are more likely to receive past-year (14.8%) and lifetime (42.2%) alcohol use disorder diagnoses (Fuehrlein et al., 2016; Grant et al., 2015). Alcohol misuse among U.S. military personnel and veterans is associated with significant costs to individuals (e.g., health comorbidities; functional impairment; Fuehrlein et al., 2016; Ghose et al., 2013), institutions (e.g., productivity loss; Fisher, Hoffman, Austin-Lane, & Kao, 2000), and also globally (e.g., economic burden; Dall et al., 2007). Considering the high prevalence and deleterious effects, continued efforts are needed to identify factors that increase risk for alcohol misuse in this population.

Military sexual trauma (MST) may be an important risk factor to consider in this context. The Department of Veteran Affairs defines MST as unwelcome and inappropriate verbal or physical contact of a sexual nature, including sexual harassment (MSH; unwanted attention, remarks, advances) and sexual assault (MSA; sexual activity that occurs without consent or by force, intimidation, or coercion; Title 38 U.S. Code 1720D). Rates of MST are high among military populations, with a recent systematic review estimating rates ranging from 13.9–31.2% (Wilson, 2018). Individuals who experience MST may consume alcohol as a strategy to cope with MST-related distress (Khantzian, 1997), such as undesirable emotions (Weiss, Tull, & Sullivan, 2015). Indeed, treatment-seeking individuals who have a history of MST are up to three times more likely to be diagnosed with an alcohol use disorder, compared to those without a history of MST (Kimerling, 2010; Kimerling, Gima, Smith, Street, & Frayne, 2007).

Identifying mechanisms that may underlie this relation is an important next step to inform targeted interventions for alcohol misuse among individuals with a history of MST. An important consideration in this regard is emotion dysregulation, a transdiagnostic phenomenon that involves maladaptive ways of responding to emotions, including a lack of awareness, understanding, and acceptance of emotions; an inability to control impulsive behaviors in the context of intense emotions; and a lack of access/ability to appropriate strategies to modulate the duration/intensity of emotions in order to meet individual goals and situational demands (Gratz & Roemer, 2004). Emotion dysregulation has been implicated in the onset, course, and treatment of alcohol misuse (Weiss, Sullivan, & Tull, 2015). For instance, research has consistently found higher levels of emotion dysregulation to be associated with greater alcohol consumption (Dvorak et al., 2014; Messman-Moore & Ward, 2014) and alcohol-related consequences (Dvorak et al., 2014; Garofalo & Velotti, 2015; Tripp et al., 2015). Additionally, treatment studies suggest that improvement in emotion regulation skills are associated with reduced alcohol use frequency (Axelrod, Perepletchikova, Holtzman, & Sinha, 2011). These findings provide evidence for the role of emotion dysregulation in alcohol misuse.

However, the vast majority of research in this area has examined dysregulation of negative emotions. There is growing evidence that individuals experience difficulties regulating positive emotions in ways that parallel that of negative emotion (Weiss, Darosh, Contractor, Schick, & Dixon-Gordon, 2019). Positive emotion dysregulation involves being non-accepting of positive emotions, experiencing difficulties controlling impulsive behaviors and engaging in goal-directed behaviors in the context of positive emotions. Trauma-exposed individuals have been shown to be at particular risk for dysregulation of positive emotions (Weiss, Dixon-Gordon, Peasant, & Sullivan, 2018; Weiss, Nelson, Contractor, & Sullivan, 2019). Stimulus generalization of fear responses may lead trauma-exposed individuals to negatively evaluate positive emotions. For instance, physiological arousal associated with positive emotions may be perceived as frightening due to pairings with trauma-related symptoms and distress (Litz, Orsillo, Kaloupek, & Weathers, 2000). Alternatively, trauma-exposed individuals may exhibit negative emotional reactions to stimuli that generally elicit positive emotions (i.e., negative affect interference; Frewen, Dean, & Lanius, 2012) or maladaptive cognitions (e.g., “I don’t deserve to be happy”) in the context of positive emotions (Norman, Wilkins, Myers, & Allard, 2014).

In these circumstances, individuals may use alcohol to avoid or distract from positive emotions perceived as aversive (Baker, Piper, McCarthy, Majeskie, & Fiore, 2004). Further, positive emotions may lead trauma-exposed individuals to engage in decision making that prioritizes short-term (vs. long-term) goals, such as using alcohol for its immediate benefits (i.e., altering the intensity/duration of positive emotions) and disregarding long-term consequences (e.g., reinforcement of maladaptive coping strategy; Slovic, Finucane, Peters, & MacGregor, 2004). Finally, trauma-exposed individuals may experience difficulties inhibiting impulsive behaviors in the context of positive emotions, potentially due to a shift in motivational and attentional resources away from undesirable experiences (i.e., emotions) toward immediately gratifying behaviors (Inzlicht & Schmeichel, 2012), such as alcohol use. Thus, trauma-exposed individuals may experience difficulties regulating both negative and positive emotions.

Initial empirical evidence indicates that positive emotion dysregulation may also increase risk for alcohol misuse. For instance, in community samples, higher levels of positive emotion dysregulation have been found to be associated with greater severity of alcohol misuse (Weiss, Forkus, Contractor, & Schick, 2018) and differentiate individuals with and without an AUD (Weiss, Darosh, et al., 2019). Further, greater alcohol misuse has been observed among community women who experience domestic violence that are characterized by a more severe pattern of positive emotion dysregulation (Weiss, Darosh, et al., 2018). Importantly, the relation between positive emotion dysregulation and alcohol misuse is not dependent on the experience of negative emotion dysregulation (Weiss, Forkus, Contractor, & Dixon-Gordon, 2020; Weiss, Nelson, et al., 2019), emphasizing the utility of examining this type of emotion dysregulation independently. These findings have yet to be examined in the context of MST.

Notably, examining the role of emotion dysregulation may be particularly relevant in the context of MST. Individuals who experience betrayal trauma (i.e., trauma perpetrated by a source that an individual would otherwise rely on for support and/or survival; Freyd, 1996) have increased difficulties regulating emotions (Ehring & Quack, 2010; Goldsmith, Chesney, Heath, & Barlow, 2013). This is particularly salient in the context of MST, as service members depend on the military (and fellow service members/leadership) for safety, survival, and employment (Monteith, Bahraini, Matarazzo, Soberay, & Smith, 2016). One potential explanation for heightened rates of emotion dysregulation is the perpetrator or institution may implicitly or explicitly invalidate and/or question the appropriateness of certain emotional displays (e.g., military emphasis on traditional masculinity; Lorber & Garcia, 2010), influencing both emotional processing and responses. Importantly, MST can involve betrayal at both the individual (perpetration by a trusted authority or fellow service member) and institutional (lack of institutional prevention, responsiveness, accountability) levels (Monteith et al., 2016; Monteith et al., 2019; Smith & Freyd, 2014), potentially amplifying emotional difficulties, as well as deterring help-seeking (Holliday & Monteith, 2019). Additional significant barriers faced by individuals with MST histories (e.g., stigmatization and safety concerns; Holland, Rabelo, & Cortina, 2016; Klap et al., 2019) also may motivate MST survivors to seek alternative ways to cope with their distress, such as through alcohol use.

The current study sought to fill important gaps in the literature by examining if negative and positive emotion dysregulation separately explained the relation between MST and alcohol misuse. We will also examine this model across MST types, including those who experienced military sexual harassment (MSH) and assault (MSA), separately, as recent research has emphasized the importance of distinguishing between types of MST (Blais et al., 2019). Consistent with past research (Blais et al., 2019; Monteith et al., 2016), we expect that these associations will be strongest among those with a history of MSA. Specifically, the association between MST (MSA and MSH) and alcohol misuse would be accounted for by emotion dysregulation, such that a history of MST would be associated with higher levels of emotion dysregulation, which, in turn, would be associated with greater levels of alcohol misuse.

Method

Procedure/Participants

Data were collected on military veterans recruited via Amazon’s Mechanical Turk (MTurk). MTurk is a crowdsourcing website that allows researchers to post human intelligence tasks (HITS) to obtain high-quality data that is both time and cost-efficient (Shapiro, Chandler, & Mueller, 2013) and that closely resembles the general population in terms of mental health problems (Shapiro et al., 2013). The current study was advertised as a study about how military experiences affect mental and behavioral health. Eligibility criteria included: 1) at least 18 years old, 2) living in North America, 3) working knowledge of the English language, and 4) self-identified as a U.S. military veteran. Individuals who met all eligibility criteria then provided informed consent and completed the survey on a data collection platform. Participants were compensated $2.50 for their participation. All procedures were approved by the Institutional Review Board at the University of Rhode Island.

To improve the quality of data, several validity checks were embedded throughout the survey to verify military status and assess attentive responding/comprehension (Meade & Craig, 2012). Specifically, individuals were required to correctly respond to two military-specific questions.1 In addition, individuals had to correctly respond to questions that were developed to identify careless or inattentive responding. There were 2,644 individuals who initially accessed the study. Of those, 997 (62.3%) were excluded for not meeting inclusionary criteria. Of the remaining 1,647 eligible individuals, 899 (54.6%) were excluded for failing to pass the embedded attention/comprehension validity questions, 134 (8.1%) for failing to pass the military validity questions, and 79 (4.8%) for answering the questionnaire more than once. The final sample contained 535 participants. Lastly, an additional 20 (1.2%) participants were excluded for missing more than 30% of item-level data on primary measures (see measures) to ensure there was sufficient data to estimate missing data. The final analytic sample comprised 515 individuals and was mostly white (70.5%) and male (71.3%), with a mean age of 37.48 years (see Table 1).

Table 1.

Sample Demographic Information

Full Sample (n = 515)
Variables Mean (SD)
Age 37.48 (11.17)
n (%)
Gender
 Female 145 (28.3%)
 Male 366 (71.3%)
 Other 2 (0.4%)
Racea
 White 363 (70.5%)
 African American/Black 112 (21.7%)
 Asian 26 (5.0%)
 American Indian/Alaska Native 22 (4.3%)
 Native Hawaiian/Other Pacific Islander 6 (1.2%)
 Not Listed 5 (1.0%)
Ethnicity
 Hispanic or Latino/a 117 (23.3%)
 Not Hispanic or Latino/a 386 (76.7%)
Branch of Servicea
 Army 328 (63.7%)
 Navy 50 (9.75)
 Air Force 100 (19.4%)
 Marines 33 (6.4%)
 Coast Guard 6 (1.2)
Component
 Active Duty 413 (79.9%)
 Guard/Reserve 104 (20.1%)
Pay Grade
 Enlisted 429 (87.6%)
 Officer 56 (11.4%)
 Warrant Officer 5 (1.0%)
Number of deployments
 None 114 (22.9%)
 One 137 (27.6%)
 Two 114 (22.9%)
 Three or more 132 (26.5%)
Involved in Combat Operations
 Yes 244 (67.8%)
 No 116 (32.2%)
Military Sexual Trauma
 Assault 65 (12.6%)
 Harassment 49 (9.5%)
 Neither 377 (77.9%)
Open in a new tab
a

Could endorse more than one category.

Measures

Military Sexual Trauma.

MST was assessed with two items derived from the VA MST screen to capture experiences of military sexual harassment (“While you were in the military…Did you ever receive uninvited or unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks?”) and sexual assault (“While you were in the military…Did someone ever use force or the threat of force to have sex against your will?”). Participants indicated whether they had experienced either form of MST. Two separate variables were created. An MSH only variable was developed to capture those who experienced MSH only (i.e., did not also report MSA). A second variable was developed to capture those who reported MSA, regardless of whether they also experienced MSH. This approach is consistent with past research (e.g., Blais et al., 2019) The two question MST screen used in the current study has been used extensively in past research and is psychometrically sound (Mengeling et al., 2019).

Difficulties in Emotion Regulation Scale – 16 (DERS-16; Gratz & Roemer, 2004).

The DERS-16 is a 16-item self-report measure used to assess emotion dysregulation across five domains: nonacceptance of negative emotions, difficulty engaging in goal-directed behavior when distressed, difficulty controlling impulsive behaviors when distressed, limited access to effective emotion regulation strategies for negative emotions, and lack of emotional clarity. Participants rate each item using a 5-point Likert-type scale (1 = almost never, 5 = almost always). A total score was computed by summing all items, with higher scores indicating greater negative emotion dysregulation. The DERS-16 has excellent psychometric properties, including good test-retest reliability, convergent validity, and discriminant validity (Bjureberg et al., 2016). Reliability was excellent in the current study (α = .97).

Difficulties in Emotion Regulation Scale – Positive (DERS-P; Weiss, Gratz, et al., 2015).

The DERS-P is a 13-item self-report measure used to assesses positive emotion dysregulation across three domains: nonacceptance of positive emotions, difficulty engaging in goal-directed behaviors when experiencing positive emotions, and difficulty controlling impulsive behaviors when experiencing positive emotions. Participants rate each item using a 5-point Likert-type scale (1 = almost never, 5 = almost always). A total score was computed by summing all items, with higher scores indicating greater positive emotion dysregulation. The DERS-P has good psychometric properties (Weiss, Gratz, et al., 2015), including in the current study (α = .98).

Alcohol Use Disorders Identification Test (AUDIT; Babor et al., 2001).

The AUDIT is a 10-item self-report scale that assesses unhealthy alcohol use, defined by hazardous rates of alcohol consumption and alcohol-related consequences over the past 12 months. Responses are provided on a scale between 0–4. A total score was calculated by summing all items, with higher scores indicating greater alcohol misuse. The AUDIT has demonstrated good internal consistency (Searle et al., 2015), and had excellent reliability in the current study (α = .92).

Data Analyses

As a first step, preliminary analyses and descriptive statistics were obtained using SPSS 25. For the primary analyses, two parallel mediation models were examined using R version 3.4.1 (R core team, 2017), using full-information maximum likelihood (FIML) to handle missing data. The two models were developed to test the indirect effects of negative and positive emotion dysregulation on the association between MSA and MSH and alcohol misuse, separately.

Results

Descriptive information is presented in Table 1.

The first model (see Figure 1) examined the indirect effect of negative and positive emotion dysregulation on the association between MSH and alcohol misuse. Findings revealed that the a paths linking MSH and negative and positive emotion dysregulation were nonsignificant. The b paths linking negative and positive emotion dysregulation to alcohol misuse were both significant. Further, the direct path linking MSH and alcohol misuse was not significant before (c path) or after controlling for the indirect effects in the model (c’ path). The total and specific indirect effects through both negative and positive emotion dysregulation together, and, individually, were nonsignificant. See Table 2 for a summary of findings.

Figure 1.

Figure 1.

Open in a new tab

Path models examining the indirect role of negative and positive emotion dysregulation in the association between military sexual trauma and alcohol misuse

Note. Standardized coefficients reported. Solid lines indicate significant paths and dashed lines indicate nonsignificant paths.

Gender was included as a covariate (see Table 2 for summary of findings).

Table 2.

Summary of Direct Paths

Model 1
Direct Paths β SE z p
MSH → Negative Emotion Dysregulation (a1) −.06 2.62 −1.28 .20
MSH → Positive Emotion Dysregulation (a2) −.06 2.31 −1.23 .22
Negative Emotion Dysregulation → Alcohol Misuse (b1) .21 .03 3.76 <.001
Positive Emotion Dysregulation → Alcohol Misuse (b2) .33 .04 5.99 <.001
Gender → Alcohol Misuse (c2) −.05 .83 −1.14 .25
Gender → Negative Emotion Dysregulation (b3) .05 1.63 1.19 .24
Gender → Positive Emotion Dysregulation (b4) −.03 1.45 −.73 .47
MSH → Alcohol Misuse (c1) −.002 1.32 −.06 .95
MSH → Alcohol Misuse (c’) −.03 1.51 −.72 .47
Indirect Paths β SE z p
Total Indirect Effects −.03 .75 −1.34 .18
Specific Indirect Effects Through Negative Emotion Dysregulation −.01 .33 −1.21 .23
Specific Indirect Effects Through Positive Emotion Dysregulation −.02 .50 −1.22 .23
Model 2
Direct Paths β SE z p
MSA → Negative Emotion Dysregulation (a1) .25 2.17 5.61 <.001
MSA → Positive Emotion Dysregulation (a2) .30 1.89 6.77 <.001
Negative Emotion Dysregulation → Alcohol Misuse (b1) .18 .03 3.53 <.001
Positive Emotion Dysregulation → Alcohol Misuse (b2) .25 .03 4.76 <.001
Gender → Alcohol Misuse (c2) −.11 .77 −2.91 .004
Gender → Negative Emotion Dysregulation (b3) .005 1.60 .11 .91
Gender → Positive Emotion Dysregulation (b4) −.09 1.40 −2.03 .04
MSA → Alcohol Misuse (c1) .36 1.08 9.33 <.001
MSA → Alcohol Misuse (c1’) .47 1.14 11.80 <.001
Indirect Paths β SE z p
Total Indirect Effects .12 .58 5.75 <.001
Specific Indirect Effects Through Positive Emotion Dysregulation .05 .42 3.01 .003
Specific Indirect Effects Through Positive Emotion Dysregulation .07 .52 3.91 <.001
Open in a new tab

Note. MSH = military sexual harassment; MSA = military sexual assault. Boldface text represents significant paths. Gender was included in this model as a covariate. Findings remained the same when adjusting for age, total number of lifetime traumas, combat involvement, number of deployments, and branch of service.

The second model (see Figure 1) examined the indirect effect of negative and positive emotion dysregulation on the association between MSA and alcohol misuse. Findings revealed that the a paths linking MSA and negative and positive emotion dysregulation were significant. Further, the b paths linking negative and positive emotion dysregulation to alcohol misuse were both significant. The direct path linking MSA and alcohol misuse was significant before (c path) and after controlling for the indirect effects in the model (c’ path). The total and specific indirect effects through both negative and positive emotion dysregulation together, and, individually, were significant. See Table 2 for a summary of findings.

Discussion

Individuals with a history of MST are at increased risk for alcohol misuse (Hankin et al., 1999; Kimerling et al., 2007). To extend knowledge of potential factors that underlie this association, the current study examined whether negative and positive emotion dysregulation explained the relation between MST types and alcohol misuse in a community sample of U.S. military veterans. Partially consistent with expectations, both negative and positive emotion dysregulation accounted for the association between MSA and alcohol misuse, but not MSH, such that a history of MSA was associated with higher levels of emotion dysregulation, which, in turn, was associated with greater alcohol misuse. The significant finding for assault, but not harassment, adds to the growing body of literature underscoring the importance of distinguishing between different types of MST (e.g., Monteith et al., 2016). Specifically, certain consequences have been found to differentially relate to assault vs. harassment only MST (e.g., Monteith et al., 2016), and failure to distinguish between MST types can interfere with the ability to correctly identify those at heightened risk for distress and dysfunction (Blais et al., 2019). These findings highlight the potential clinical utility of targeting negative and positive emotion dysregulation as a means of reducing alcohol misuse among veterans who have experienced MSA.

These findings also advance theory on how alcohol misuse develops and is maintained post-trauma. In particular, our findings are consistent with theoretical explanations of alcohol being used to cope with aversive emotional states (Baker et al., 2004; Cooper et al., 1995; Khantzian, 1997), while also extending this among MSA survivors. Further, our findings advance theory by extending the scope of emotion dysregulation to include positive emotional experiences. This is important, as the vast majority of research has focused on negative emotions, precluding our understanding of how positive emotions are evaluated and responded to among MST survivors. Individuals with a history of MSA may perceive positive emotions as aversive as a result of stimulus generalization in which the fear associated with negative emotions stemming from MSA become generalized to positive emotions (Litz et al., 2000). Alternatively, certain self-directed attributions common among MSA survivors, such as believing they are responsible for the causes and consequences of MSA (Carroll et al., 2018) may drive guilt-based cognitions (e.g., “I don’t deserve to be happy”) in the context of positive emotions (Norman et al., 2014). This may be particularly salient among MSA survivors: the experience of victimization may undermine expectations instituted by the military (e.g., self-sufficiency; Castro, Kintzle, Schuyler, Lucas, & Warner, 2015), leading to more pronounced attributions of personal responsibility and perceived personal failings (Carroll et al., 2018); this may translate to beliefs that they are undeserving of positive emotions. Similar to negative emotion dysregulation, individuals who experience positive emotion dysregulation may use alcohol as a maladaptive emotion regulation strategy to cope with unwanted or undesirable positive emotional states (Weiss et al., 2020). Findings underscore the relevance of positive emotion dysregulation in understanding alcohol misuse risk among those with a history of MSA.

While the findings emphasize the role of negative and positive emotion dysregulation on the association between MSA and alcohol misuse, the indirect association was not significant for MSH. This is consistent with previous work that has found that MSA and MSH differentially relates to negative outcomes (Monteith et al., 2016). The significant findings for MSA may be attributable to the violation of physical integrity inherent to experiences of sexual assault. This finding underscores the importance of distinguishing between types of MST as well as highlights the need for additional research to further clarify mechanisms that uniquely underlie the association between different types of MST and alcohol misuse, while accounting for important factors, such as the frequency, nature of victimization, and assailant characteristics.

Our findings provide important empirical support for the relationships between MST, emotion dysregulation, and alcohol misuse. In particular, the indirect effects of emotion dysregulation were only significant for those with a history of MSA, which, unlike MSH, falls within the definition of a trauma outlined by the DSM-5 (APA, 2012). Considering this, our findings are consistent with previous literature that has found links between trauma and both emotion dysregulation (Ehring & Quack, 2010) and alcohol misuse (Debell et al., 2014). Although our findings highlight the potential role of negative and positive emotion dysregulation, additional risk and resilience for both emotion dysregulation and alcohol misuse should be explored to further elucidate this model (e.g., sociodemographic and psychopathology; Debell et al., 2014; Kalaydjian et al., 2019; McLean & Foa, 2017), as well as the link between trauma and alcohol misuse more broadly. Recent research has also emphasized the relevance of reciprocal relations between alcohol and trauma/PTSD (Berke et al., 2019), suggesting support for a mutual maintenance model whereby trauma symptoms and alcohol use are mutually reinforcing. Thus, examining this model using a longitudinal framework is necessary to clarify temporal associations and fully understand the nature of these relationships.

Our findings highlight the potential clinical utility of targeting negative and positive emotion dysregulation in efforts aimed at preventing or reducing alcohol misuse among veterans with a history of MSA. For instance, emotion-focused psychoeducation could be used proactively to educate individuals about how emotion dysregulation can increase risk for and/or reinforce alcohol misuse. Clinical interventions could incorporate mindfulness skills into treatment to help MSA survivors respond to emotions in a nonjudgmental and accepting manner (Bowen, Chawla, & Marlatt, 2011); by altering their relationships with their emotions, they may be less inclined to engage in impulsive behavior to escape undesirable emotional states. Further, Acceptance and Commitment Therapy could be used to encourage value-based action in the context of undesirable emotions (Hayes, Strosahl, & Wilson, 2009). These approaches could be advantageous by increasing one’s emotion regulation capabilities and reducing the tendency to engage in impulsive or values-inconsistent behavior in the context of undesirable emotion.

Importantly, although current interventions may already integrate emotion regulation strategies, there may be less attention to the dysregulation of positive emotions. For instance, clinicians may focus primarily on negative emotions, and potentially ignore or attempt to increase positive emotions. For individuals with difficulties regulating positive emotions, this may maintain or exaggerate current use of alcohol. As such, the dysregulation of both negative and positive emotions should be assessed. A focus on emotion regulation may be particular important among military populations, in particular. The military values a controlled response to emotions, which may interfere with the expression, disclosure, and experience of emotions, particularly among military men who adhere to more traditionally masculine assumptions about emotions (McAllister, Callaghan, & Fellin, 2019). In sum, our findings underscore the importance of both negative and positive emotion dysregulation as a potential target for reducing alcohol misuse among those with a history of MSA. This suggests that these skills could be incorporated into existing treatments and complement existing strategies that focus on reducing trauma-related distress and alcohol-related behaviors.

Some study limitations warrant consideration. First, given the cross-sectional and correlational nature of the data, we are unable to draw conclusions regarding the directionality of MSA, emotion dysregulation, alcohol misuse. Future work should examine these associations using prospective and longitudinal designs to better clarify the nature and direction of these relations. Second, the exclusive reliance on self-report measures is contingent upon willingness and ability to accurately report on the variables of interest and can thus introduce bias, which is an important consideration given the potentially sensitive nature of MST and alcohol misuse. Future studies should incorporate objective measures of emotional responding (e.g., behavioral, physiological), as well as examine other ways to assess alcohol misuse (e.g., structured clinical interviews). Third, this study focused on how the experience of MSA relates to alcohol misuse through emotion dysregulation; future work should examine the role of PTSD in these associations. Fourth, online data collection can be prone to self-selection bias, sample bias, and lack of control over the research environment, which may limit generalizability. Fourth, although our use of MTurk allowed access to a diverse subject pool that represents the U.S population in demographics and mental health outcomes (Shapiro et al., 2013), the representativeness of MTurk for military samples has yet to be examined. Despite this, the demographics of our sample are representative of the U.S armed forces, with a larger proportion of female veterans than is typically found in military samples (e.g., Gilmore et al., 2016). Given the demographic profile, future work should replicate and extend these findings across minority military samples (e.g., racial and ethnic minority samples). Lastly, due to the nature of working with MTurk samples, we had to exclude those who did not pass validity checks (Hauser et al., 2018). Although necessary, this resulted in a large portion of our sample (>60%) being removed; this process may have unintentionally excluded valid responses.

Despite these limitations, our findings advance research on the associations between MSA, emotion dysregulation, and alcohol misuse, as well as provide further support for the importance of distinguishing between MST types. Moreover, this study is unique in doing so in a community sample, rather than focusing on U.S. veterans currently receiving Veterans Health Administration healthcare. Our findings suggest that both negative and positive emotion dysregulation are potential underlying mechanisms in the association between MSA and alcohol misuse. These results underscore the importance of additional research on the clinical utility of addressing both negative and positive emotion dysregulation in efforts to prevent and reduce alcohol misuse among military veterans with a history of MSA.

Clinical Impact Statement.

Findings from the current study suggest that negative and positive emotion dysregulation are important considerations in the relation between military sexual assault and alcohol misuse. Experiencing military sexual assault, but not harassment, was associated with greater levels of both negative and positive emotion dysregulation, which, in turn, was associated with greater levels of alcohol misuse. Clinicians can use this information to inform alcohol misuse treatments among individuals with a history of military sexual assault.

Acknowledgments

This material is based upon work supported in part by the Department of Veterans Affairs (VA) and the Rocky Mountain MIRECC for Suicide Prevention. The views expressed are those of the authors and do not necessarily represent the views or policy of the VA or the United States Government. Work on this paper by the last author (NHW) was supported, in part, by National Institute on Drug Abuse grant K23DA039327.

Footnotes

1

Military-specific validity checks: “What is the acronym for the generic term that the military uses for various job fields?” and “What is the acronym for the locations where final physicals are taken prior to shipping off for basic training?”.

We have no known conflict of interest to disclose.

References

  1. American Psychiatric Association [APA]. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. [Google Scholar]
  2. Axelrod SR, Perepletchikova F, Holtzman K, & Sinha R (2011). Emotion regulation and substance use frequency in women with substance dependence and borderline personality disorder receiving dialectical behavior therapy. The American Journal of Drug and Alcohol Abuse, 37(1), 37–42. 10.3109/00952990.2010.535582 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Baker TB, Piper ME, McCarthy DE, Majeskie MR, & Fiore MC (2004). Addiction motivation reformulated: an affective processing model of negative reinforcement. Psychol Review, 111(1), 33. 10.1037/0033-295X.111.1.33 [DOI] [PubMed] [Google Scholar]
  4. Babor TF, Higgins-Biddle JC, Saunders JB, & Monteiro MG (2001). The Alcohol Use Disorders Identification Test: Guidelines for use in primary care (2nd ed.). Geneva, Switzerland: World Health Organization. [Google Scholar]
  5. Berke DS, Yeterian J, Presseau C, Rusowicz-Orazem L, Kline NK, Nash WP, & Litz BT (2019). Dynamic changes in marines’ reports of PTSD symptoms and problem alcohol use across the deployment cycle. Psychology of Addictive Behaviors, 33(2), 162–170. 10.1037/adb0000430 [DOI] [PubMed] [Google Scholar]
  6. Bjureberg J, Ljótsson B, Tull MT, Hedman E, Sahlin H, Lundh L-G, … Gumpert CH. (2016). Development and validation of a brief version of the difficulties in emotion regulation scale: the DERS-16. Journal of Psychopathology and Behavioral Assessment, 38(2), 284–296. 10.1007/s10862-015-9514-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Blais RK, Brignone E, Fargo JD, Livingston WS, & Andresen FJ (2019). The importance of distinguishing between harassment-only and assault military sexual trauma during screening. Military Psychology, 31(3), 227–232. 10.1080/08995605.2019.1598218 [DOI] [Google Scholar]
  8. Bowen S, Chawla N, & Marlatt GA (2011). Mindfulness-based relapse prevention for addictive behaviors: A clinician’s guide: Guilford Press. [Google Scholar]
  9. Bray RM, Brown JM, & Williams J (2013). Trends in binge and heavy drinking, alcohol-related problems, and combat exposure in the US military. Substance Use & Misuse, 48(10), 799–810. 10.3109/10826084.2013.796990 [DOI] [PubMed] [Google Scholar]
  10. Carroll KK, Lofgreen AM, Weaver DC, Held P, Klassen BJ, Smith DL, … Zalta AK. (2018). Negative posttraumatic cognitions among military sexual trauma survivors. Journal of Affective Disorders, 238, 88–93. 10.1016/j.jad.2018.05.024 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Castro CA, Kintzle S, Schuyler AC, Lucas CL, & Warner CH (2015). Sexual assault in the military. Current Psychiatry Reports, 17(7), 54. 10.1007/s11920-015-0596-7 [DOI] [PubMed] [Google Scholar]
  12. Dall TM, Zhang Y, Chen YJ, Wagner RCA, Hogan PF, Fagan NK, … & Tornberg DN. (2007). Cost Associated with Being Overweight and with Obesity, High Alcohol Consumption, and Tobacco Use within the Military Health System’s TRICARE Prime—Enrolled Population. American Journal of Health Promotion, 22(2), 120–139. 10.4278/0890-1171-22.2.120 [DOI] [PubMed] [Google Scholar]
  13. Debell F, Fear NT, Head M, Batt-Rawden S, Greenberg N, Wessely S, & Goodwin L (2014). A systematic review of the comorbidity between PTSD and alcohol misuse. Social psychiatry and psychiatric epidemiology, 49(9), 1401–1425. 10.1007/s00127-014-0855-7 [DOI] [PubMed] [Google Scholar]
  14. Dvorak RD, Sargent EM, Kilwein TM, Stevenson BL, Kuvaas NJ, & Williams TJ (2014). Alcohol use and alcohol-related consequences: Associations with emotion regulation difficulties. The American Journal of Drug and Alcohol Abuse, 40(2), 125–130. 10.3109/00952990.2013.877920 [DOI] [PubMed] [Google Scholar]
  15. Ehring T, & Quack D (2010). Emotion regulation difficulties in trauma survivors: The role of trauma type and PTSD symptom severity. Behavior Therapy, 41(4), 587–598. 10.1016/j.beth.2010.04.004 [DOI] [PubMed] [Google Scholar]
  16. Fisher CA, Hoffman KJ, Austin-Lane J, & Kao T-C (2000). The relationship between heavy alcohol use and work productivity loss in active duty military personnel: A secondary analysis of the 1995 Department of Defense Worldwide Survey. Military Medicine, 165(5), 355–361. 10.1093/milmed/165.5.355 [DOI] [PubMed] [Google Scholar]
  17. Frewen PA, Dean JA, & Lanius RA (2012). Assessment of anhedonia in psychological trauma: Development of the Hedonic Deficit and Interference Scale. European Journal of Psychotraumatology, 3(1), 8585. 10.3402/ejpt.v3i0.8585. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Freyd JJ (1996). Betrayal trauma: The logic of forgetting childhood abuse: Harvard University Press. [Google Scholar]
  19. Fuehrlein BS, Mota N, Arias AJ, Trevisan LA, Kachadourian LK, Krystal JH, … Pietrzak RH. (2016). The burden of alcohol use disorders in US military veterans: results from the National Health and Resilience in Veterans Study. Addiction, 111(10), 1786–1794. 10.1111/add.13423 [DOI] [PubMed] [Google Scholar]
  20. Garofalo C, & Velotti P (2015). Alcohol misuse in psychiatric patients and nonclinical individuals: The role of emotion dysregulation and impulsivity. Addiction Research & Theory, 23(4), 294–300. 10.3109/16066359.2014.987758 [DOI] [Google Scholar]
  21. Gilmore AK, Brignone E, Painter JM, Lehavot K, Fargo J, Suo Y, … & Gundlapalli AV. (2016). Military sexual trauma and co-occurring posttraumatic stress disorder, depressive disorders, and substance use disorders among returning Afghanistan and Iraq veterans. Women’s Health Issues, 26(5), 546–554 10.1016/j.whi.2016.07.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Goldsmith RE, Chesney SA, Heath NM, & Barlow MR (2013). Emotion regulation difficulties mediate associations between betrayal trauma and symptoms of posttraumatic stress, depression, and anxiety. Journal of Traumatic Stress, 26(3), 376–384. 10.1002/jts.21819 [DOI] [PubMed] [Google Scholar]
  23. Grant BF, Goldstein RB, Saha TD, Chou SP, Jung J, Zhang H, … Huang B (2015). Epidemiology of DSM-5 alcohol use disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry, 72(8), 757–766. doi: 10.1001/jamapsychiatry.2015.0584 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Gratz KL, & Roemer L (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54. [Google Scholar]
  25. Hankin CS, Skinner KM, Sullivan LM, Miller DR, Frayne S, & Tripp TJ (1999). Prevalence of depressive and alcohol abuse symptoms among women VA outpatients who report experiencing sexual assault while in the military. Journal of Traumatic Stress, 12(4), 601–612. 10.1023/A:1024760900213 [DOI] [PubMed] [Google Scholar]
  26. Hauser D, Paolacci G, & Chandler JJ (2018). Common concerns with MTurk as a participant pool: Evidence and solutions. 10.31234/osf.io/uq45c [DOI] [Google Scholar]
  27. Hayes SC, Strosahl KD, & Wilson KG (2009). Acceptance and commitment therapy: American Psychological Association; Washington, DC. [Google Scholar]
  28. Holland KJ, Rabelo VC, & Cortina LM (2016). Collateral damage: Military sexual trauma and help-seeking barriers. Psychology of Violence, 6(2), 253–261. 10.1037/a0039467 [DOI] [Google Scholar]
  29. Holliday R, & Monteith LL (2019). Seeking help for the health sequelae of military sexual trauma: A theory-driven model of the role of institutional betrayal. Journal of Trauma & Dissociation, 20(3), 340–356. 10.1080/15299732.2019.1571888. [DOI] [PubMed] [Google Scholar]
  30. Inzlicht M, & Schmeichel BJ (2012). What is ego depletion? Toward a mechanistic revision of the resource model of self-control. Perspectives on Psychological Science, 7(5), 450–463. 10.1177/1745691612454134 [DOI] [PubMed] [Google Scholar]
  31. Kalaydjian A, Swendsen J, Chiu WT, Dierker L, Degenhardt L, Glantz M, … & Kessler R. (2009). Sociodemographic predictors of transitions across stages of alcohol use, disorders, and remission in the National Comorbidity Survey Replication. Comprehensive psychiatry, 50(4), 299–306. 10.1016/j.comppsych.2008.09.012 [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Khantzian EJ (1997). The self-medication hypothesis of substance use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4(5), 231–244. [DOI] [PubMed] [Google Scholar]
  33. Kimerling R (2010). Military-related sexual trauma among Veterans Health Administration patients returning from Afghanistan and Iraq. American Journal of Public Health, 100(8), 1409–1412. 10.2105/AJPH.2009.171793 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Kimerling R, Gima K, Smith MW, Street A, & Frayne S (2007). The Veterans Health Administration and military sexual trauma. American Journal of Public Health, 97(12), 2160–2166. 10.2105/AJPH.2006.092999 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Klap R, Darling JE, Hamilton AB, Rose DE, Dyer K, Canelo I, … Yano EM. (2019). Prevalence of stranger harassment of women veterans at Veterans Affairs medical centers and impacts on delayed and missed care. Women’s Health Issues, 29(2), 107–115. 10.1016/j.whi.2018.12.002 [DOI] [PubMed] [Google Scholar]
  36. Litz BT, Orsillo SM, Kaloupek D, & Weathers F (2000). Emotional processing in posttraumatic stress disorder. Journal of Abnormal Psychology, 109(1), 26. [DOI] [PubMed] [Google Scholar]
  37. Lorber W, & Garcia HA (2010). Not supposed to feel this: Traditional masculinity in psychotherapy with male veterans returning from Afghanistan and Iraq. Psychotherapy: Theory, Research, Practice, Training, 47(3), 296–305. 10.1037/a0021161 [DOI] [PubMed] [Google Scholar]
  38. Lynn BM-D, & Morgan JK (2016). Using Amazon’s Mechanical Turk (MTurk) to recruit military veterans: Issues and suggestions. The Military Psychologist, 31(3), 8–14. [Google Scholar]
  39. McAllister L, Callaghan JE, & Fellin LC (2019). Masculinities and emotional expression in UK servicemen:’Big boys don’t cry’?. Journal of Gender Studies, 28(3), 257–270. 10.1080/09589236.2018.1429898 [DOI] [Google Scholar]
  40. McLean CP, & Foa EB (2017). Emotions and emotion regulation in posttraumatic stress disorder. Current opinion in psychology, 14, 72–77. 10.1016/j.copsyc.2016.10.006 [DOI] [PubMed] [Google Scholar]
  41. Meade AW, & Craig SB (2012). Identifying careless responses in survey data. Psychological methods, 17(3), 437. 10.1037/a0028085 [DOI] [PubMed] [Google Scholar]
  42. Mengeling MA, Burkitt KH, True G, Zickmund SL, Ono SS, Bayliss NK, … Sadler AG. (2019). Sexual trauma screening for men and women: examining the construct validity of a two-item screen. Violence and Victims, 34(1), 175–193. 10.1891/0886-6708.VV-D-17-00003 [DOI] [PubMed] [Google Scholar]
  43. Messman-Moore TL, & Ward RM (2014). Emotion dysregulation and coping drinking motives in college women. American Journal of Health Behavior, 38(4), 553–559. 10.5993/AJHB.38.4.8 [DOI] [PubMed] [Google Scholar]
  44. Monteith LL, Bahraini NH, Matarazzo BB, Soberay KA, & Smith CP (2016). Perceptions of Institutional Betrayal Predict Suicidal Self-Directed Violence Among Veterans Exposed to Military Sexual Trauma. Journal Clinical Psychology, 72(7), 743–755. 10.1002/jclp.22292 [DOI] [PubMed] [Google Scholar]
  45. Monteith LL, Menefee DS, Forster JE, & Bahraini NH (2016). A closer examination of sexual trauma during deployment: Not all sexual traumas are associated with suicidal ideation. Suicide and Life-Threatening Behavior, 46(1), 46–54. 10.1111/sltb.12171 [DOI] [PubMed] [Google Scholar]
  46. Norman SB, Wilkins KC, Myers US, & Allard CB (2014). Trauma informed guilt reduction therapy with combat veterans. Cognitive and Behavioral Practice, 21(1), 78–88. 10.1016/j.cbpra.2013.08.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Searle AK, Van Hooff M, McFarlane AC, Davies CE, Fairweather-Schmidt AK, Hodson SE, … Steele N. (2015). The validity of military screening for mental health problems: diagnostic accuracy of the PCL, K10 and AUDIT scales in an entire military population. International Journal of Methods in Psychiatric Research, 24(1), 32–45. 10.1002/mpr.1460 [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Shapiro DN, Chandler J, & Mueller PA (2013). Using Mechanical Turk to study clinical populations. Clinical Psychological Science, 1(2), 213–220. 10.1177/2167702612469015 [DOI] [Google Scholar]
  49. Slovic P, Finucane ML, Peters E, & MacGregor DG (2004). Risk as analysis and risk as feelings: Some thoughts about affect, reason, risk, and rationality. Risk Analysis: An International Journal, 24(2), 311–322. 10.1111/j.0272-4332.2004.00433.x [DOI] [PubMed] [Google Scholar]
  50. Smith CP, & Freyd JJ (2014). Institutional betrayal. American Psychologist, 69(6), 575–587. 10.1037/a0037564 [DOI] [PubMed] [Google Scholar]
  51. Stout RW, Parkinson MD, & Wolfe WH (1993). Alcohol-related mortality in the US Air Force, 1990. American Journal of Preventive Medicine, 9(4), 220–223. 10.1016/S0749-3797(18)30718-9 [DOI] [PubMed] [Google Scholar]
  52. Tripp JC, McDevitt-Murphy ME, Avery ML, & Bracken KL (2015). PTSD symptoms, emotion dysregulation, and alcohol-related consequences among college students with a trauma history. Journal of Dual Diagnosis, 11(2), 107–117. 10.1080/15504263.2015.1025013 [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Weiss NH, Darosh AG, Contractor AA, Schick MM, & Dixon-Gordon KL (2019). Confirmatory validation of the factor structure and psychometric properties of the Difficulties in Emotion Regulation Scale-Positive. Journal of Clinical Psychology, 75(7), 1267–1287. 10.1002/jclp.22768 [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Weiss NH, Dixon-Gordon KL, Peasant C, & Sullivan TP (2018). An examination of the role of difficulties regulating positive emotions in posttraumatic stress disorder. Journal of Traumatic Stress, 31(5), 775–780. 10.1002/jts.22330 [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Weiss NH, Forkus SR, Contractor AA, & Dixon-Gordon KL (2020). The interplay of negative and positive emotion dysregulation on mental health outcomes among trauma-exposed community individuals. Psychological Trauma: Theory, Research, Practice, and Policy, 12(3), 219–226. 10.1037/tra0000503. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Weiss NH, Forkus SR, Contractor AA, & Schick MR (2018). Difficulties regulating positive emotions and alcohol and drug misuse: A path analysis. Addictive Behaviors, 84, 45–52. 10.1016/j.addbeh.2018.03.027 [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Weiss NH, Forkus SR, Raudales AM, Schick MR, & Contractor AA (2020). Alcohol misuse to down-regulate positive emotions: A cross-sectional multiple mediator analysis among US military veterans. Addictive Behaviors, 105, 106322. 10.1016/j.addbeh.2020.106322 [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Weiss NH, Gratz KL, & Lavender JM (2015). Factor structure and initial validation of a multidimensional measure of difficulties in the regulation of positive emotions: The DERS-Positive. Behavior Modification, 39(3), 431–453. 10.1177/0145445514566504 [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Weiss NH, Nelson RJ, Contractor AA, & Sullivan TP (2019). Emotion dysregulation and posttraumatic stress disorder: A test of the incremental role of difficulties regulating positive emotions. Anxiety, Stress, & Coping, 32(4), 443–456. 10.1080/10615806.2019.1618842 [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Weiss NH, Sullivan TP, & Tull MT (2015). Explicating the role of emotion dysregulation in risky behaviors: A review and synthesis of the literature with directions for future research and clinical practice. Current Opinion in Psychology, 3, 22–29. 10.1016/j.copsyc.2015.01.013 [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. Wilson LC (2018). The prevalence of military sexual trauma: A meta-analysis. Trauma, Violence, & Abuse, 19(5), 584–597. 10.1177/1524838016683459 [DOI] [PubMed] [Google Scholar]

RESOURCES