Improving Psychosocial Functioning in Older Veterans With PTSD
Phase: NA
Conditions: Posttraumatic Stress Disorder
Sponsor: VA Office of Research and Development

  
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Research Protocol Narrative 
Improving Psychosocial Functioning in Older Veterans with PTSD 
 
NCT02803125 
ID: D1832-W 
 
Date: 6/18/2021 (Version 5) 
 
 
 
 

  
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Research Protocol Narrative 
Improving Psychosocial Functioning in Older Veterans with PTSD 
Anica Pless Kaiser, PhD (PI), Avron Spiro III, PhD, Denise Sloan, PhD, Jennifer Moye, PhD, Joan Cook, 
PhD, and Dawne Vogt, PhD  
 
(1)  Rationale  
 
(a)  Statement of the Problem.  Evidence suggests that stressors associated with aging (e.g., 
retirement, increased medical problems, bereavement) can exacerbate PTSD symptoms. Older 
Veterans with partial and full PTSD are likely to have comorbid physical and medical problems, take 
multiple medications, and be more socially isolated than younger Veterans. All of these factors 
likely contribute to greater functional impairment and decreased quality of life. Given the prevalence 
of PTSD and comorbid mental and physical problems among older Veterans, it is important to 
develop interventions that assist older Veterans in regaining fuller, more satisfying functioning and 
quality of life. 
 
(b)  Hypotheses or Key Question.  This study involves the development of an intervention for older male 
Veterans with PTSD. This study will be conducted in several phases. 1) Intervention development, 
2) Conducting focus groups to help us better understand impairments in older Veterans with PTSD 
and to help us modify the proposed intervention modules, 3) Conduct pilot groups with the 
developed intervention, and 4) Conduct intervention groups and support group controls to evaluate 
the utility of the developed intervention. Primary outcomes are psychosocial functioning and quality 
of life, with PTSD and depressive symptoms as secondary outcomes. A complementary objective is 
to improve attitudes toward mental health treatment and to increase readiness for change and 
engagement in evidence-based psychotherapies, as appropriate. Results from this study will 
provide feasibility data for future development and testing of the intervention protocol. 
 
Focus group research questions:  
• 
To what extent do Veterans indicate that the proposed intervention modules address 
important areas of impairment?  
• 
Within each intervention module, what areas do Veterans view as most and least important?  
• 
In what ways do Veterans think the material from each module should be presented?  
• 
Are there any additional areas that are important to address in the intervention protocol?   
Pilot Phase research questions:  
• 
Is the intervention feasible as conducted with older Veterans with PTSD?  
• 
Are Veterans satisfied with the intervention? 
• 
Do Veterans comply with assignments (e.g., monitoring forms)? 
Comparison Phase research questions:  
• 
Compared to support group participants, do intervention group participants experience 
greater increases in psychosocial functioning and quality of life and reductions in PTSD and 
depressive symptoms?  
• 
Are pre-post changes maintained at 1 and 6 month follow-up?  
 
(c)  Specific Objectives.   
 
Aim 1: Develop a group-based intervention for older Veterans with PTSD that targets areas of 
psychosocial functional impairment. 
 
Aim 2: Conduct focus groups with older Veterans with PTSD and revise the intervention.  
Aim 3: Implement pilot groups and revise protocol as indicated. Examine feasibility, acceptability, 
retention, and satisfaction. 
Aim 4: Implement and evaluate the intervention protocol. Compare intervention against support 
group control. Consult expert panel and finalize intervention protocol. 

  
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(2)  Background and Significance  
 
(a) Background.   
The demographic profile of Veterans in the United States is changing, with increasing numbers of 
Veterans advancing into older age. As of 2010, there were nine million U.S. Veterans who were at 
least 65 years of age.1 This population represents Veterans of World War II, the Korean Conflict, 
and Vietnam. Additionally, current military and newer Veterans are older than those of earlier 
conflicts, given the increasing numbers of Reservists and National Guard troops being activated 
and deployed. An important mental health issue for aging Veterans is posttraumatic stress disorder 
(PTSD). As defined by the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition 
(DSM-5)2, PTSD is a disorder that can develop after a person experiences an extremely stressful or 
traumatic event. Symptoms include intrusions (e.g., distressing memories, dreams, flashbacks), 
avoidance of reminders of the trauma (e.g., avoiding thoughts, people, situations), negative 
alterations in cognition or mood (e.g., negative beliefs or emotional state, feeling detached, inability 
to experience positive emotions), and hyperarousal (e.g., irritable behavior, hypervigilance, 
exaggerated startle). Symptoms must onset or increase following the trauma and last for at least 
one month, and also cause clinically significant distress or impairment in functioning. Older 
Veterans are seeking treatment for PTSD from the VA in increasing numbers3, and for some, it is 
for the first time. Given the aging of the approximately 7.6 million Veterans who served during the 
Vietnam era, and the many more Veterans who will be reaching their older years in coming 
decades, it is important to develop and provide treatments that will meet the needs of older 
Veterans with PTSD.  
Estimates of the prevalence of current PTSD in adults age 60 and older range from 0.6 to 
4.5%.4 Among older Veterans seeking mental health treatment, estimates of current PTSD are 
higher, 37-80%.5 Some older Veterans may experience symptoms of PTSD but not meet the full 
diagnostic criteria. The percentage of older adults with sub-syndromal levels of PTSD symptoms 
range from 7-15%6-8, and those with partial or sub-syndromal PTSD also experience related 
difficulties. Although many definitions of partial PTSD exist, for the purposes of the current project, it 
will be defined to include endorsement of a criterion A event, at least one intrusion symptom (cluster 
B), one avoidance symptom (cluster C), one symptom related to negative alterations in cognition or 
mood (cluster D), one symptom related to alterations in arousal or reactivity (cluster E), and the 
experience of distress or impairment in functioning (criterion G).2 All further references to PTSD will 
include both partial and full PTSD. 
There is some evidence to suggest that stressors associated with aging (e.g., retirement, 
increased medical problems, bereavement) can exacerbate PTSD symptoms.9-10 Additionally, older 
Veterans with PTSD tend to report more somatic problems and are at greater risk for cognitive 
impairment.11-12 Older Veterans with PTSD are also likely to have comorbid physical and medical 
problems, take multiple medications, and be more socially isolated than younger Veterans.13 All of 
these factors likely contribute to greater functional impairment problems and decreased quality of 
life in this population. Given the prevalence of PTSD symptoms and common comorbid problems 
(such as difficulties in psychosocial functioning) among older Veterans, it is important for VA to 
develop and disseminate interventions that assist these Veterans in regaining fuller, more satisfying 
psychosocial functioning and enhancing their quality of life.  
There are several evidence-based trauma-focused psychotherapies (EBPs) for PTSD that 
target a reduction in PTSD symptoms, such as Prolonged Exposure (PE)14 and Cognitive 
Processing Therapy (CPT).15 Evidence also suggests that more generalized cognitive-behavioral 
therapy (CBT) is effective; a meta-analysis conducted by Bradley and colleagues showed that 56% 
of those enrolled in PTSD treatment and 67% of those who completed it no longer met criteria for 
PTSD.16 However, few of these treatments have been tested in RCTs with older Veterans. There is 
accruing evidence that PE can be delivered effectively with older Veterans.17 However, not all 

  
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Veterans agree to engage in these types of interventions, and even if they do, some drop out or do 
not experience a significant decrease in their symptomatology.18  
There are many possible explanations why some Veterans decline to participate in or drop 
out of PE or CPT or why VA providers do not offer such treatments to the Veterans on their 
caseloads.19 For example, Veterans with complicated psychiatric comorbidities or active suicidal 
ideation might have more difficulty participating in such treatment. Avoidance or motivational issues 
could play a role. It is also possible that literacy issues or difficulties in complying with extensive 
between-session assignments influence these decisions. Additionally, some Veterans may not have 
the emotional or cognitive resources or coping skills they feel they need to engage in cognitive-
affective processing of trauma.20 Furthermore, Veterans may refuse trauma-focused treatments 
because they believe they are not “ready” to engage in this type of treatment. Providers have stated 
that they do not have enough clinical time to administer these treatments. In such instances, 
Veterans are often referred to skills-based treatment programs as a precursor, as an adjunct to 
CPT or PE, or instead of these other interventions.21  
A recent study examined presenting problems that Veterans with PTSD identified as most 
important for them to improve when they engaged in treatment within a VA setting. The most 
prevalent concern reported was anger, followed by sleep problems, nightmares, and feeling 
isolated. About 20% of the sample identified a goal of improving relationships (trust, 
communication) and improving coping or functioning.22 In summary, we need to expand the array of 
evidence-based treatments for individuals with PTSD that address some of the limitations of current 
treatments. In particular, we need to develop treatments that are suitable for older adults, target 
quality of life more broadly (versus symptom reduction in particular), and are amenable to those for 
whom more intense trauma-focused treatments are not suitable. In addition, it may be that 
participation in a pre-treatment intervention that provides an introduction to mental health treatment 
more generally, teaches symptom management skills, and provides information about available 
interventions, would increase some Veterans’ willingness to engage in further treatment for PTSD. 
Recovery-Oriented Conceptual Framework for Development of Psychosocial 
Intervention 
The theoretical model used to frame the proposed study is recovery-oriented23 and is based 
on the hypothesis that psychoeducation and skill building can significantly reduce functional 
impairment associated with PTSD. Although the recovery model is often applied to addictions or 
severe mental illness, it is also a useful framework for viewing change within other mental health 
disorders such as PTSD. Recovery is “a process of change through which individuals improve their 
health and wellness, live a self-directed life, and strive to reach their full potential (SAMHSA).”24 
Further, recovery is typically viewed as a process rather than an outcome or a cure. This model 
acknowledges that many people experience mental health conditions chronically and report 
symptoms that wax and wane over time. Recovery is based on continual growth and improved 
functioning.  
At SAMHSA’s 2005 summit on recovery, it was determined that recovery-oriented systems 
of care are as complex and dynamic as the process of recovery itself. These systems are designed 
to support individuals seeking to overcome disorders across their lifespan. Some of the important 
elements of a recovery-oriented intervention include being person-centered, research-based, and 
inclusive of family members or support people. As such, the recovery-oriented model supports 
interventions that focus on decreasing impairment and distress and improving functioning in a 
meaningful way.  
This model presents a broad picture of the variety of domains of functioning that are affected 
by mental health problems. Areas of functional impairment associated with PTSD include social, 
interpersonal, occupational, educational, and physical health. Specifically, DSM-5 documents that 
PTSD is often associated with problems in social and familial functioning, problems at work, and 
lower educational and occupational achievement.2 Common comorbid psychological problems 
include depressive disorders, anxiety, sleep problems, and substance abuse and dependence. 
Thus, there are a number of psychosocial functioning domain deficits associated with PTSD to 

  
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serve as potential targets for intervention. Improving psychosocial functioning in individuals with 
chronic disease has been linked to decreased depression25, less loneliness26, more support, and 
less use of health care resources.27 Domains of psychosocial functioning (e.g., interpersonal 
relationships, social activity, communication skills, regulation of anger, behavioral activation, stress 
management) are the focus of the intervention to be developed in the current study. The importance 
of community and peer support delineated in the recovery model will also be incorporated into the 
group-based intervention for older Veterans with PTSD   
In summary, by using a recovery-oriented conceptual model, the intervention developed in 
this project will fill the gap regarding improvement of psychosocial functioning for older Veterans 
with PTSD symptoms. This model will guide the focus of the intervention toward restoring 
psychosocial functioning and helping to improve quality of life across several domains.  
Applying a Recovery-Oriented Framework to PTSD 
The nature and course of PTSD can be variable, and several trajectories are commonly 
discussed in the literature. In the aftermath of a traumatic experience, individuals can experience an 
initial increase in symptoms, followed by gradual recovery from those symptoms. Others experience 
relatively mild symptoms and maintain a healthy (or resilient) trajectory. Still others can have no 
symptoms, or their symptoms remain at low levels until months or years following the traumatic 
event when symptoms increase, often in response to a specific trigger or change in functioning. A 
chronic trajectory, in which a person develops symptoms that are maintained over a long period of 
time, can also occur (See Figure 1).28 Approximately a third of those who develop PTSD continue to 
experience symptoms at a chronic level.29 These individuals are likely to have increased difficulties 
with work, social functioning, and physical health problems, as well as lower quality of life. Among a 
sample of older adults and Veterans, Chopra and colleagues (2014) documented both chronic and 
fluctuating courses of PTSD over the course of one year and found that those who met criteria for 
PTSD had worse mental health-related quality of life.30 VA Cooperative Study 420 compared two 
group treatments for Vietnam Veterans: trauma-focused group therapy and present centered group 
therapy. 
 
In the three cohorts examined, the effect of trauma-focused therapy was stronger in one, the effect 
of present centered therapy was stronger in another, and there were no significant differences by 
treatment type in the third. However, 40% of the sample showed a clinically significant decline in 
PTSD severity on the Clinician-Administered PTSD Scale (CAPS) at 7 and 12 month follow-ups.31 
These results suggest that chronic symptoms can improve with treatment but may not completely 
disappear. These findings indicate that a recovery perspective, with a focus on symptom 
management and rehabilitation of quality of life and functioning, is an appropriate treatment goal.32 
Given that PTSD develops into a chronic disorder for numerous Veterans and is often maintained 
over many years, a recovery-oriented framework provides a solid foundation on which to 
conceptualize and investigate effective interventions.  
PTSD and Difficulties in Psychosocial Functioning 
Social isolation has been associated with a range of negative health factors such as 
cardiovascular disease, suicide risk, and all-cause mortality.33 Research consistently links social 
support to better health outcomes, despite the vast array of definitions and measures used to 
Time since event
PTSD Symptoms
Chronic
Delayed
Recovery
Resilience
Figure 1.  Trajectories of PTSD Symptomatology over time

  
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assess both constructs. In fact, public health experts suggest that evidence linking social ties to 
health is as strong as the epidemiological evidence linking smoking and negative health outcomes. 
Social isolation is associated with higher levels of psychological distress and loneliness as well as 
with poor overall health and well-being.34 From a recovery standpoint, social support has been 
shown to mediate the relationship between recovery initiation and long-term maintenance; research 
also demonstrates that poor social support detrimentally impacts recovery and places individuals at 
risk for relapse.35A specific difficulty linked to decreased quality of life among those with PTSD 
symptoms, and perhaps particularly relevant for older Veterans, is having problems with 
psychosocial functioning.36 PTSD symptoms are associated with decreased quantity and quality of 
social relationships. A negative consequence of this association is that Veterans who have 
problematic social relationships have worse treatment outcomes.37 In addition, PTSD negatively 
affects family cohesion and marital relationships.37-38 Specifically, emotional numbing, withdrawal, 
and the expression of anger by Veterans can push family members away. This withdrawal of 
support can serve to increase symptoms and create a vicious cycle that serves to maintain 
relationship dysfunction and symptoms. Unfortunately, chronic PTSD symptoms often lead 
Veterans to erode their support networks over time.  
In addition to decreased social support and problems in social functioning in general, 
another psychosocial problem associated with PTSD is difficulty regulating anger. Cognitive, 
arousal, and behavioral deficits are several aspects of anger associated with combat-related 
PTSD.39 Anger has been identified as a risk factor for the development and maintenance of PTSD 
and related problems.40 Further, anger has been correlated with a variety of negative 
consequences, such as impulsive aggression41 and poorer treatment outcomes.42 Of note, the 
association between PTSD and anger is significant across trauma types, but Orth and Wieland43 
found it to be strongest among combat Veterans. Kulkarni and others44 examined the relationship 
between PTSD and anger among 214 male Veterans who presented for treatment at a VA PTSD 
clinic. After accounting for demographic covariates, anger predicted PTSD symptom severity. 
These authors suggested that anger is an active avoidance strategy that provides a false sense of 
control and is associated with over-controlling behaviors such as hypervigilence and acting out. 
Despite these findings, it has been noted that anger and irritability are symptoms of PTSD, so it is 
important to question whether or not associations between PTSD and anger are inflated due to this 
overlap. This question was addressed in a sample of Vietnam combat Veterans by removing anger-
related items from the PTSD measure and examining whether correlations were substantially 
reduced relative to the relationship between anger and the full PTSD measure. Findings indicated 
that the association between PTSD and anger was virtually unchanged.45  
Another problem commonly reported by older adults and Veterans with PTSD that likely has 
an incremental impact on each of the psychosocial domains discussed above, is stress. Stress 
management strategies often include discussion of sleep, relaxation, exercise, and diet. 
Psychoeducation around the nature of sleep and common sleep problems, as well as introduction 
to and implementation of sleep hygiene strategies can be quite beneficial.46 Finally, getting anyone 
(including older adults and Veterans) to make and maintain behavioral changes that promote 
healthier living and decrease stress is difficult. Depression is often comorbid with PTSD and 
especially relevant for older Veterans who tend to isolate from others. Older adults and Veterans 
face multiple challenges (e.g., retirement, physical ailments) that require important life changes. As 
such, it is particularly important, psychosocially and medically, for older adults and Veterans to 
make certain lifestyle changes to reduce stress and depression (often targeted using behavioral 
activation.)47 
In summary, psychosocial domains such as poor social functioning (e.g., isolation, lack of 
social support), interpersonal dysfunction (e.g., poor communication strategies), anger, problems 
associated with stress and depression, are associated with PTSD symptom severity and contribute 
to impairment and decreased quality of life among Veterans. Thus, it is important to develop 
strategies to help Veterans improve in these areas. This is especially important for older Veterans 

  
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who are more likely to be socially isolated, have difficulty making behavioral changes on their own, 
and may have long histories of dysfunctional interpersonal relationships. 
Interventions that Improve Quality of Life for Persons with PTSD   
Perlman and colleagues48 developed a 15-week group intervention to improve quality of life 
through physical and behavioral activation exercises emphasizing self-care, social interactions, 
physical activity, and relaxation exercises. The intervention was implemented with 83 Veterans who 
attended a mental health intake (regardless of psychiatric diagnosis). Veterans improved on 6 out of 
8 subscales of the SF-36; the largest effect sizes were found for domains of social and emotional 
functioning (Cohen’s d = .34 -.38). Subjective ratings of overall wellness also improved.    
Other interventions have been developed to target some PTSD symptoms that do not 
always improve with exposure therapy, such as social skills difficulties, relationship problems, and 
anger management issues.49 For example, Beidel and colleagues50 presented the results of a 
randomized controlled trial that examined the efficacy of a multi-component cognitive-behavioral 
intervention, called Trauma Management Therapy (TMT), to reduce symptoms of PTSD and 
improve quality of life among male combat Veterans. There were two groups in this study, one 
received exposure therapy (14 sessions of exposure and 14 sessions of psychoeducation and 
supportive therapy), and the other received exposure therapy plus social and emotional 
rehabilitation training (TMT; 14 sessions of exposure and 14 sessions of social and emotional skills 
training). Both groups demonstrated improvement in PTSD symptoms and social functioning at 
post-treatment, but only the TMT group had significant increases in frequency and duration of social 
activities, and only after the social and emotional rehabilitation sessions. Neither group showed 
improvement on global ratings of anger or quality of life.  
Interventions that Improve Psychosocial Functioning  
Anger management interventions have successfully reduced anger and aggression in 
several populations51, including combat Veterans with PTSD.39,52 Many of these interventions 
include cognitive-behavioral techniques such as challenging unhelpful thinking, relaxation 
strategies, effective communication skills, and coping skills.53 Some argue that the link between 
anger and PTSD can be partially explained by information processing deficits.54 Specifically, men 
who experience anger and engage in aggression report more irrational beliefs and cognitive 
distortions than men who are nonviolent.55 Thus, it would follow that teaching people with anger 
management difficulties to identify cognitive biases and use cognitive challenging skills would be 
beneficial. Further, when working to decrease anger, healthcare providers suggest conducting 
group interventions so that individuals understand that they are not alone in their difficulties and to 
create a forum for discussion of successful strategies as well as a place to share difficult feelings 
and situations. Additionally, a group is an ideal environment in which to model appropriate 
interpersonal behaviors and provide feedback on adaptive ways of handling difficult issues.53  
In summary, with regards to psychosocial functioning, there is some support to be gained 
from the scientific literature to inform interventions. Given the reciprocal relationship between PTSD 
symptoms (such as emotional numbing, anger, and withdrawal) and lower social support, 
researchers have recommended that mental health practitioners include interpersonal skills training 
in treatment for Veterans. Additional recommendations include working with Veterans to maintain 
existing social supports as well as forming new ones.38  
Interventions that Improve Psychosocial Functioning and Quality of Life for Older 
Adults and Veterans 
Catten and colleagues26 conducted a systematic literature review to determine the 
effectiveness of interventions targeting social isolation in older adults. They reviewed 30 
intervention studies, about a half of which were randomized control trials and 17 were group 
interventions. Overall, effective interventions were group-based and targeted specific groups of 
people. Strategies used in the group interventions included education, discussion, self-help, 
exercise, and skills training. Five out of nine group interventions that utilized education 
demonstrated a significant decrease in social isolation. Several groups that focused on increasing 
social support were successful in decreasing social isolation among group members. Components 

  
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of these interventions included encouraging participants to organize social activities, increasing 
intra-personal resources, and improving communication skills.   
Silverstein and Parker56 conducted interviews with a nationally representative sample of 
older adults [from Sweden (N = 324) in 1981 and 1992] to determine factors that influenced change 
in their quality of life. Participants were questioned about 15 domains of activities. Results indicated 
that those participants who increased their involvement in activities across domains over time 
perceived improvement in their quality of life. This effect was strong for those who had lost spouses, 
had low contact with family, and for those who had developed functional impairment. Thus, for 
those older adults who had some impairments or interpersonal difficulties, engagement in enjoyable 
activities appeared to buffer some of the potential negative consequences of these problems.  
 
     (b)   Significance.   
This project will provide valuable information about an intervention designed to enhance 
psychosocial functioning and quality of life, and reduce distress, among older male Veterans with 
PTSD. Specifically, the completion of this project will result in: 1) the development of a brief group 
intervention to improve psychosocial functioning among Veterans, 2) a greater understanding of 
psychosocial impairment within this population (through focus groups with Veterans), 3) the 
provision of aid to several groups of Veterans with PTSD and the collection of feasibility data, and 
4) testing the effectiveness of the group intervention protocol against support group controls. 
 
 
(c)   Relevance to Veterans Health.  
Older Veterans are seeking treatment for PTSD from the VA in increasing numbers3, and for some, 
it is for the first time. Given the aging of the approximately 7.6 million Veterans who served during 
the Vietnam era, and the many more Veterans who will be reaching their older years in coming 
decades, it is important to develop and provide treatments that will meet the needs of older 
Veterans with PTSD. Given the prevalence of PTSD symptoms and common comorbid problems 
(such as difficulties in psychosocial functioning) among older Veterans, it is important for VA to 
develop and disseminate interventions that assist these Veterans in regaining fuller, more satisfying 
psychosocial functioning and enhancing their quality of life. This intervention will contribute to the 
work being done to fill this gap, as it involves the development of an intervention geared toward 
improving functioning and quality of life among older Veterans with PTSD.  
 
 
(3)  Work Accomplished  
 
(a) The PI was previously involved with an examination of late-onset stress among older combat 
Veterans (at VA Boston). Late-onset stress symptomatology is a phenomenon that occurs among 
older combat Veterans without histories of stress-related disorders who start to reminisce, with or 
without associated distress, about their past experiences as they age. As part of studying this 
process, focus groups with older combat Veterans were conducted to gain an understanding of their 
perceptions and experiences of aging and the effects of military service in their lives. The PI was 
involved in the recruitment, planning, and facilitation of these focus groups. The PI also has 
experience with empirical research on aging and trauma and has worked with large longitudinal 
datasets comprised of older Veterans to answer questions related to understanding the effects of 
trauma over the lifespan. The PI is currently involved in a large scale validation study that involved 
recruitment, telephone screening, and collection of mail surveys to examine correlates of late-onset 
stress among older combat Veterans (now in the data analysis phase). The PI has also developed 
several brief group interventions for Veterans, mainly within a substance abuse clinic setting. In 
addition, the PI of this study is also currently PI on another study that focuses on development and 
validation of a psychoeducational discussion group for older Veterans with late-onset stress. Along 
with a Co-Investigator, Dr. Jennifer Moye, and several colleagues, the PI developed the group 
protocol for this study, and we recently completed data collection from the first group of older 
combat Veterans.Veterans reported benefiting from this group, and we had an 100% retention rate 

  
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for the 8 Veterans across the 10-week group and initial post-group assessment. Group sessions for 
the second cohort are currently underway.  
Experience/competence of key collaborators 
Trauma, PTSD and Health among Older Veterans, Lifespan Developmental Perspective, 
Research Design and Analysis – Dr. Avron Spiro  
  
Dr. Avron Spiro has conducted research in the areas of aging, trauma, PTSD, personality, 
mental health and well-being, and the longitudinal effects of health and disease on cognitive aging 
for over 35 years. He brings expertise in research design and methodology to his work, and has 
written prolifically about the importance of incorporating a lifespan developmental perspective into 
longitudinal trauma and health research. Dr. Spiro and colleagues wrote one of the often-cited 
papers on PTSD in older men in which they address the long-term effects of combat and refer to 
military service as a “hidden variable” in the study of aging men.57 In this study, among the 1,210 
Veterans of World War II and the Korean War who participated, PTSD prevalence ranged from 0% 
to 12.4%. World War II Veterans who experienced moderate to heavy combat were 13.3 times more 
likely to have PTSD symptoms 45 years after the war than noncombat Veterans. Dr. Spiro is the co-
director of the Stress, Health, and Aging Research Program (SHARP), a multidisciplinary group of 
researchers who investigate the effects of combat and other stressful or traumatic events on physical 
and mental health over the lifespan. In this role, Dr. Spiro has been involved in recent projects that 
make use of large longitudinal datasets to examine the effects of military service, stress, and trauma 
on long-term health.  
  
Dr. Spiro has also examined the relationship between PTSD and health status among a 
large sample of male Veteran VA ambulatory care patients. Of those exposed to traumatic events, 
24% screened positive for PTSD. Those with PTSD reported having more medical problems than 
those without. Veterans with PTSD had lower health status on all domains assessing quality of life 
than participants with depression and those with neither disorder. Veterans seeking mental health 
treatment reported worse health status than Veterans not in treatment. However, those who had 
received mental health treatment in the past were similar in health status to those who did not seek 
mental health treatment, suggesting that receiving mental health treatment may alleviate some of the 
negative effects of PTSD on health.13  
  
Dr. Spiro continues to focus his research on the effects of trauma over the lifecourse. His is 
currently funded by the National Institute on Aging to examine the lifespan outcomes of military 
service. This project has formed a national multidisciplinary panel of experts to advise project 
progress and has created a website to provide researchers with information about military service 
variables in publically available longitudinal datasets that can be used to address relevant research 
questions. A book that portrays the long-term effects of military service on aging using data derived 
from these datasets is under development.  
Effective Mental Health Treatments for Older Veterans with PTSD, Adaptation of   
Interventions, and Family Functioning among Older Veterans with PTSD – Dr. Joan Cook  
  
Dr. Joan Cook is an Associate Professor in the Department of Psychiatry at Yale School of 
Medicine and a Research Affiliate of the VA’s National Center for PTSD. She has written extensively 
about the state of the literature and the need for additional research that examines assessment and 
treatment of older adult trauma survivors and Veterans with PTSD. She has described the limited 
research on treatment for PTSD in older adults, and has noted that supportive and cognitive-
behavioral group interventions have been successfully applied in this population. She has also 
outlined several issues for consideration when working with older adults, such as the 
appropriateness of exposure therapy, issues regarding conducting traditional psychotherapy in 
traumatized Veterans with moderate to severe cognitive impairment, the effects of aging-related 
physical health and role changes, and adjustments to the pace and modality of treatment.58  
  
Dr. Cook has conducted research examining differences between older Veterans with PTSD 
and those without PTSD. Among a sample of older World War II former Prisoners of War (POWs), 
Cook and colleagues found that those with PTSD reported more relationship problems, issues with 
adjustment, and communication difficulties than did former POWs without PTSD.59 Further, Dr. Cook 

  
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has detailed the need to focus interventions on improving functioning and quality of life and 
decreasing disability among older Veterans with PTSD in contrast to only examining symptom 
improvement.32 In a study she conducted involving a supportive/cognitive behavioral group 
intervention for older combat Veterans with PTSD, pre-post Posttraumatic Stress Disorder Checklist 
symptom changes were not significant. However, participants and their family members reported 
significant improvement in the Veterans’ interpersonal functioning, coping skills, and social 
interactions. Thus, suggestions for future research on interventions with older Veterans emphasized 
the importance of focusing on some of these types of outcomes: symptom management, 
stabilization, initiation and maintenance of new activities, improvement in interpersonal relationships, 
perceptions of improvement, and reduction of maladaptive coping strategies such as social isolation. 
Additionally, reports of family members and clinicians (in addition to Veteran self report) were 
acknowledged as essential.  
  
Dr. Cook has also conducted research identifying barriers to mental health providers’ 
adoption of evidence-based psychological treatments. Cook and colleagues surveyed over 1,600 
North American psychotherapists via an internet survey to determine perceived barriers to 
implementing a new clinical intervention. Themes that emerged included: clinician attitudes, client 
characteristics, contextual or institutional factors, training issues, and other issues. The barrier most 
often cited was insufficient time for training, learning, and practicing new treatments.60 Knowledge of 
such barriers and potential solutions to these barriers will help to guide the development and future 
implementation of the intervention protocols designed in the current study.  
Implementation of Interventions with Older Veterans within the Geriatric Mental Health  
Clinic of VA Boston Healthcare system – Dr. Jennifer Moye  
  
Dr. Jennifer Moye has expertise in geropsychology, implementation of interventions with 
older Veterans, and research methodology. Dr. Moye founded the Geriatric Mental Health Clinic at 
VA Boston and has subsequently recruited geropsychologists to direct clinical services and training 
programs. VA Boston is one of the leading programs in geropsychology training. Dr. Moye has 
taught psychotherapy with older Veterans to interns and fellows for more than 20 years, and 
received the APA Society for Clinical Geropsychology distinguished mentorship award for her work 
in teaching others. Dr. Moye has participated in a number of projects focused on mental health 
treatment in complex geriatric populations including a 9-site randomized trial of mental health 
outreach and treatment for under-treated Veterans and a 5-site randomized trial of care 
management for older Veterans with dementia. She has received VA RR&D funding to study 
interacting emotional and physical concerns in older cancer survivors including an observational 
cohort study and a randomized clinical trial. This work focuses in particular on the interaction of 
combat-related PTSD and late life stressors including cancer. Dr. Moye’s recent published work in 
this area has integrated qualitative and quantitative methods to describe quality of life issues in these 
older veterans including  PTSD/anxiety, posttraumatic growth, values/goals, and coping or meaning 
making.61,62 Dr. Moye has also written about the diagnosis, prevalence, course, risk and protective 
factors, assessment, and treatment of Veterans with  PTSD in the setting of medical illness.63 In this 
paper, the authors described how various aspects of cognitive behavioral therapy, such as cognitive 
restructuring, relaxation training, psychoeducation, and pharmacological management are all helpful 
components of treatment. 
Intervention Outcome Research within the National Center for PTSD – Dr. Denise Sloan 
  
Dr. Denise Sloan has expertise in clinical trial research and methodology, treatment for 
PTSD, and protocol development. In a randomized clinical trial, Dr. Sloan and colleagues evaluated 
a brief (5 session) written exposure therapy intervention for PTSD.64 Participants were 46 adult 
survivors of motor vehicle accidents who met diagnostic criteria for PTSD and were randomized to a 
written exposure or a wait list condition. Assessments were conducted at baseline, 6 weeks and 3 
months post-intervention. Between group differences were large (g = 3.5 and 2.2) at 6 week and 3 
month follow-up assessments, respectively, indicating that the written exposure group displayed 
larger reductions in PTSD symptoms than the no treatment group.  

  
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Dr. Sloan recently conducted a meta-analysis examining the efficacy of group treatments for 
PTSD.65 Sixteen studies were included in the meta-analysis; among studies comparing group 
treatment for PTSD against a comparison condition (e.g., supportive therapy), there was a small 
significant effect size (d = .24). Within-group effect sizes ranged from small to very large. Effects for 
groups of men were smaller than for women or mixed-gender groups, and studies with combat 
Veterans displayed smaller effect sizes than did studies with other trauma populations (e.g., MVA). 
Dr. Sloan and colleagues emphasize the importance of measuring other aspects of change, such as 
social functioning, in addition to PTSD symptomatology.  Dr. Sloan is currently the PI on two 
randomized controlled trials. One study is examining the efficacy of a cognitive behavioral group 
treatment for PTSD compared to a support group control. The other study explores whether a brief 
treatment for PTSD is equally efficacious in comparison to a more intensive, evidence-based 
treatment for PTSD.  
Focus Group Development, Facilitation, and Analysis – Dr. Dawne Vogt 
  
Dr. Dawne Vogt has multiple areas of research expertise; of particular importance to this 
project, she focuses on risk and resilience factors for PTSD as well as issues related to interpersonal 
functioning and resilience in Veterans. Dr. Vogt has nearly 20 years of experience designing, 
implementing, and analyzing data from focus groups with Veteran participants, and is well-suited to 
provide consultation on this aspect of the current project.  
  
 
(4)  Work Proposed 
Although some studies have demonstrated efficacy for improving psychosocial functioning 
among Veterans with PTSD50 and well-being among Veterans48, there have not been any rigorous 
studies to our knowledge that demonstrate improvement in these areas for older Veterans with 
partial or full PTSD and reduced quality of life. In addition to functional domains described above, 
there are several areas of psychosocial functioning (e.g., problems related to stress, activity 
limitations, and depression), that may be beneficial to include in a therapeutic intervention for older 
Veterans. The purpose of this project is to develop an intervention to improve psychosocial 
functioning and quality of life for older Veterans with partial and full PTSD. This project will develop 
a group protocol geared toward restoring older Veterans to better, fuller functioning. Focus groups 
will be conducted with older Veterans with PTSD to gain additional understanding of functional 
impairments and preferences for the proposed intervention modules.  
 Proposed Intervention 
The intervention protocol will be developed following consultation with an expert panel. The 
intervention will be modified following focus groups with older Veterans with PTSD, and this revision 
will be approved by the expert panel. Each module in the intervention protocol will present didactic 
information, provide skills training, and will utilize role plays to facilitate rehearsal and skill 
application and generalization. Between-session work will be assigned, and participants will be 
provided with feedback. Based on the research reviewed above, we will incorporate several topic 
areas into the intervention. For example, the intervention protocol will contain modules that provide 
anger management strategies, communication skills, and education about interpersonal 
relationships and social support. In addition, psychoeducation about behavioral activation and 
stress management (discussion of common sleep problems and sleep hygiene techniques, 
relaxation strategies, as well as the benefits of exercise and healthy diet changes) will be included. 
All modules will be based on manuals used within the PTSD Clinic at VA Boston Healthcare 
System, with additional modifications included based on supporting literature, such as applicable 
components of TMT. These modules will be enhanced with information and examples relevant for 
older Veterans. Veterans will be taught about the ways in which disability and decreased autonomy 
can influence thoughts and perceptions as well as mood – which in turn affects the experience of 
stress, depression, and verbal and nonverbal communication. The connection between such aging-
related changes and interpersonal functioning will be reviewed. Another modification will involve a 
discussion about coping with common aging-related stressors, such as bereavement, caretaking an 

  
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ill family member, and increased medical problems. The ramifications that experiencing these 
stressors have on each intervention domain will be reviewed and discussed as applicable.  
Support Group Control Condition 
The support groups will be process-oriented in nature with core elements manualized to 
facilitate consistency of the intervention. In particular, group leaders will facilitate a check-in with the 
group, and the agenda will be open to topics brought in by group members. The group therapists 
will intervene by inviting group feedback, noting similarities among group members, and 
summarizing key points. Group sessions will be the same length as the intervention sessions, and 
group members will be given between-session assignments. In this way, the dose will be kept as 
consistent as possible between the two conditions. 
Completion of the proposed project will provide data to support the potential efficacy of the 
intervention protocol (compared to support group controls) and serve as pilot data for a VA Merit 
application that involves a more rigorous randomized clinical trial (RCT) of the intervention.  
 
Research Design and Methods:  
Design Overview: The purpose of this project is to develop an intervention to improve 
psychosocial functioning and quality of life for older Veterans with PTSD. This project will develop, 
implement, and evaluate a group protocol geared toward restoring older Veterans to better, fuller 
functioning. This project adds to the existing knowledge by testing a program of resources (the 
group protocol) with a unique population: older Veterans with PTSD. The developed group protocol 
will be compared against a support group intervention for Veterans (see Table 1 for a timeline of 
proposed research activities).  
 
This project will be completed over several phases (see Figure below).  
 
 
 
 
Phase IA (Develop Protocol):  
Consult with the expert panel to review the initial intervention plan and to further assess areas of 
dysfunction and impairment for older Veterans with PTSD. Areas identified using this process will 
further inform protocol development. In this phase, the intervention protocol and finalization of 
assessment measures will take place, guided by expert panel suggestions. The protocol will be a 
brief (~10 session) group-based intervention designed to improve psychosocial functioning and 
quality of life. Components of the group intervention for Veterans with PTSD include likely domains 
of psychosocial functioning such as anger management, communication skills, social activity, 
interpersonal relationships, stress management and behavioral activation. Typical cognitive-
behavioral interventions for improving anger management skills include psychoeducation about 
anger and the anger response, differences between aggressive, assertive, and passive behaviors, 
presenting the rationale for and demonstration of how to monitor anger levels, and relaxation skills 
training. Communication skills training often involves education about verbal and non-verbal 
communication, active listening, and use of “I” statements. Regarding interpersonal relationships, 
techniques for improving communication strategies, with loved ones in particular, may be included, 
as well as didactic information about the importance of social support and increasing engagement in 
social activities. Some interventions have successfully included sessions in which facilitators 
encourage and assist group members in problem-solving barriers to engaging in social activities.26 In 
the stress management module, areas such as sleep hygiene, relaxation, exercise, and dietary 
changes will be included. The behavioral activation module will include information about increasing 
Phase IA
• Consult expert  
panel 
• Develop  
protocol 
Phase IB
• Conduct focus groups 
• Revise intervention 
protocol 
• Consult expert panel 
Phase II
• Conduct pilot groups 
• Revise protocol
  
 
Phase III 
• Conduct intervention 
& support groups
• Consult expert panel 
• Merit submission

  
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motivation for behavior change, goal-setting, and strategies for engaging in activities and decreasing 
depression. The VA Office of Patient Centered Care and Cultural Transformation has developed 
“Components of Proactive Health and Well-being” to illustrate how each area of self-care is 
connected. Materials from these approaches will be modified for use in the current study. The use of 
psychosocial self-report assessment measures will be supplemented with ratings indicative of 
psychosocial functioning, such as use of anger management strategies, monitoring of 
communication and relaxation techniques used, weekly social activity ratings, and time spent with 
friends and relatives.  
Procedure: Using the areas identified by the expert panel, the initial group intervention 
modules will be modified. Educational materials to be included in the intervention will be developed 
(using existing manualized components as a starting point). A facilitator manual will likely be 
developed, as well as handouts for participants to be given at each session and between-session 
assignments. 
 
Phase IB (Development and Facilitation of Focus Groups):  
The research team will finalize the focus group guide (see attached), review recruitment strategies, 
and design the focus group sessions. Focus groups allow the researcher to understand the focal 
concept(s) from the perspective of the population being studied.66 The PI will conduct two focus 
groups with older Veterans with PTSD to obtain feedback on the group intervention developed. 
Specifically, Veterans will provide feedback on each proposed module, for their thoughts about the 
content of the modules, and for their opinion about the most effective mode of delivering the 
material. Information learned from focus groups will be used, along with feedback from the expert 
panel, to inform revision of the intervention protocol. 
Procedure: Two focus groups will be held at VA Boston Healthcare System and facilitated by 
the PI and  a trained research technician. Six to 10 Veterans will be recruited for each focus group. 
Veterans recruited by flyer or word of mouth will call and express interest in the study and receive a 
return call. All potential focus group participants will be administered the Primary Care PTSD Screen 
for DSM-5 (PC-PTSD-5)67 over the telephone. Note: this is a change from the original protocol, 
which indicated that potential participants would be administered the PTSD module of the 
Structured Clinical Interview for DSM Disorders (SCID)68. This change was made because it 
was determined that a PTSD screen would be sufficient for focus group participants, and to 
reduce participant burden. In addition, the PC-PTSD-5 has demonstrated excellent diagnostic 
accuracy and compares with a structured diagnostic interview67.  Veterans who meet eligibility 
criteria will be invited to participate in a focus group. Focus group participants will receive a $75 
compensation for time and travel (i.e., up to two hours in a focus group and completing assessment 
measures plus travel to and from the VA Boston facility). Focus groups are expected to last 
approximately 1.5 to 2 hours, including informed consent. Veterans will be consented as a group, 
with the option of being consented on an individual basis if requested (we will have another room an 
RA could take the individual Veteran for consent). Veterans will be given the opportunity to ask 
questions before signing the consent form.  During the focus group visit, participants will complete 
self-report measures of demographics, PTSD symptomatology (the Posttraumatic Stress Disorder 
Checklist-5)69, and psychosocial functioning (the Inventory of Psychosocial Functioning)70 (see 
attached measures).The facilitators will begin by assuring Veterans that their participation is 
confidential and that their names will not be used in any subsequent scientific presentations or 
publications. Participants will be asked not to use their names to protect the anonymity of their 
responses. Focus groups will be audio-recorded to facilitate data analysis and interpretation. 
Potential participants will be informed of the intent to audio-record the focus groups when they are 
contacted for the telephone screening. Potential participants who do not agree to be audio-recorded 
will be excluded from the study. Once the focus groups have been conducted, each participant will 
be contacted by telephone to ask if they have any additional comments that they did not feel 
comfortable sharing with the group.  

  
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Data Analysis Plan: Several different approaches can be taken to analyze focus group data, 
and the choice depends on the goals of the analysis.71 While some researchers develop a transcript 
of focus groups and use a popular qualitative data analysis package, such as QSR International’s 
NVivo 10 program72, simple coding of transcripts is an economical alternative for a smaller study 
such as this one.73 Therefore, we will apply a general inductive approach74 that involves developing 
a transcript of each focus group and coding themes identified in this transcript. For the purposes of 
this study, the themes are content areas covered within the proposed intervention modules. Two 
individuals, one of whom was physically present during the focus groups and another research 
assistant, will listen to the recordings and review the transcripts of each focus group and identify 
themes. Separate coders (research assistants) trained by the PI will be provided with these themes 
and their definitions and will be told that they may or may not have been discussed during the focus 
group. Coders will listen to the recordings once and review the transcripts twice. First, they will 
simply listen to the recording and read the transcript to become familiar with the flow of the 
conversation and the topics that were raised. On the second review of the transcript, coders will 
mark up the transcript each time they see an identified theme, thus documenting where it was 
discussed. Coders will also be instructed to mark up the transcript if they identify additional themes 
not included among the previously identified list. Next, the coders will meet to discuss their review of 
the recordings and transcripts. To the extent that coders are in agreement on examples of identified 
themes, quotes relevant to each of the key constructs will be compiled. Disagreements regarding 
which themes quotes fit into will be resolved through discussion between the coders. In the event 
that an agreement cannot be reached, the PI will meet with the coders to assist in resolution. As 
recommended by focus group experts68, newly nominated themes and ongoing refinements of 
conceptualizations of key themes will be incorporated in the subsequent focus group. The 
information in the final compilations will be used to inform the revision of the intervention protocol. 
Once coding of focus group transcripts has been completed, we will be able to address our research 
questions. After the transcripts are marked up by the coders, each sentence identified will be sorted 
by the theme it represents. Information gleaned from review of these materials will be used to a) 
assist us in determining what existing content will be most important to include and emphasize in 
intervention modules; b) identify additional content to address in intervention modules; and c) 
provide examples within the modules to increase face validity of the intervention. Finally, we will 
identify any areas of difference between themes identified by the Veterans compared to those 
identified by the expert panel that were included in the proposed intervention protocol.  
 
Phase II (Conduct Pilot Groups, Revise Protocol):  
Activity 1: Conduct two pilot intervention groups for older Veterans with PTSD. These groups will be 
used to pilot all study procedures and measures, and to identify any changes needed. Additionally, 
the pilot groups will be used to collect feasibility and pilot data prior to Phase III. This phase will also 
provide information about how best to minimize drop out; strategies deemed to be useful will be 
implemented in Phase III.  
Activity 2: Revise Veteran intervention protocol as indicated by pilot data, as well as by group 
member and facilitator feedback.  
Recruitment and Participant Characteristics:  
• 
Veteran participants will be recruited from: a) flyers posted at each VA Boston Healthcare 
System campus, b) flyers and information given to clinicians within the PTSD clinics and 
the Geriatric Mental Health Clinic, c) contacting Veterans in the PTSD clinic whom have 
stated an interest in research, and d) a volunteer roster of Veterans who have previously 
sought services through the National Center for PTSD and the PTSD clinic and agreed to 
participate in future studies.  
• 
Approximately 10 participants will be recruited (target group membership is 8 participants) 
per group.  
Inclusion/Exclusion Criteria: See human subjects document.  

  
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Procedure: Veterans recruited by flyer or word of mouth will call to express interest in the study 
and receive a return call. Veterans obtained via the PTSD clinic (who have indicated interest in 
research) will be called. Research staff will also mail recruitment letters to Veterans who have 
received care in the VA Boston Healthcare System or have an appointment scheduled in relevant 
clinics (e.g. Behavioral Medicine, Audiology, Pain, Physical Therapy) as indicated in the electronic 
medical records system, and have been identified as over age 60. Veterans recruited from the roster 
will receive a letter describing the study and a postcard that can be returned if participants do not 
wish to be contacted or if they are interested in learning more about the study. Those Veterans who 
indicate interest or who do not return the postcard may be called and screened to see if they are 
eligible to participate. A HIPAA waiver has been submitted to collect PHI (month/year of birth, name, 
and last 4 of SSN will be asked during the screening call) prior to completion of ICF and HIPAA. If 
potential Veteran participants are interested in the study and meet preliminary eligibility criteria 
during the screening call, they will be invited to attend an in-person appointment with the PI or a 
trained research staff member. Research staff will access CPRS to identify exclusionary criteria, 
such as current treatment for PTSD, diagnosis of a psychotic disorder or currently experiencing 
psychotic symptoms, being hospitalized for suicidal ideation or psychosis within the past year, or 
having a diagnosis of dementia or other severe cognitive disorder. At the baseline appointment, 
Veterans will be administered the PTSD questions from the SCID along with additional assessment 
measures. The PI will review all assessment materials and make a determination of eligibility. 
Veterans who are eligible to participate in the pilot intervention groups will be contacted by telephone 
to schedule appointments.  
Two pilot intervention groups with Veterans will be conducted during this phase. Groups will be 
audio-recorded. The PI will train and work with a psychology trainee or research staff to facilitate 
groups in this study phase. The PI will train all group facilitators via mini-workshops prior to 
conducting groups in which all intervention materials will be reviewed and discussed. Several 
assessment measures will be completed at the start of each session (see Assessment section). At 
the end of each session, Veterans will complete satisfaction ratings and provide feedback. Group 
facilitators will also provide ratings and feedback at the end of each session.  
The intervention developed as part of this project is conceptualized as being the first stage in a 
stepped care approach. As such, Veterans will be recruited from the PTSD and Geriatric Mental 
Health Clinics if they are: new patients, established patients who have declined or dropped out of 
more structured trauma-focused therapy, have partial PTSD, or if they are deemed inappropriate for 
trauma-focused therapy due to health impairments. Following post-group assessments, if any 
participants are still reporting significant symptoms and distress and indicate interest, they may be 
referred to other groups within one of the VA clinics or to trauma-focused  EBPs such as Prolonged 
Exposure or Cognitive Processing Therapy or other EBPs (e.g., CBT for Insomnia). Veterans will be 
provided with descriptions of a variety of evidence-based treatment options, and will be given 
referrals as appropriate. Veterans’ attitudes about mental health treatment and readiness to change 
will be examined before and after group participation.  
Groups will be conducted during regular business hours. Dr. Pless Kaiser (the PI) is a licensed 
clinical psychologist, and will be available during screening calls, baseline and follow-up 
assessments, and during group sessions in case of a clinical emergency. If needed, the PI will be 
contacted to conduct a risk assessment with a patient, and if it is determined that immediate care is 
needed, will walk the participant down to urgent care. The PI will also have referral information and 
important resources (e.g., the Veteran’s crisis line, suicide prevention coordinator numbers) 
available. In the event that the PI is not available to provide clinical coverage, another licensed 
provider will be asked to provide coverage.  
For each group session attended we will provide compensation ($10) for travel expenses, as is 
consistent with attendance at clinical appointments for service-connected conditions through VA. 
Starting with the second pilot group, a booster or follow-up session will be scheduled for 1 to 3 
months following the end of the 9-session group. The purpose of this session is to check-in with 

  
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group members, discuss treatment gains and current symptoms, and to provide referrals and 
resources as appropriate. Veterans will also receive $10 for attending this session.  
Research Questions:  
• 
Is the intervention feasible as conducted with older Veterans with PTSD? 
• 
Are Veterans satisfied with the intervention? 
• 
Do Veterans comply with assignments (e.g., monitoring forms)? 
Data Analysis Plan: Baseline demographics (e.g., age, race, service era) will be summarized. To 
evaluate feasibility, we will descriptively examine recruitment and retention characteristics, such as 
ease of recruitment, number of sessions attended by participants, and study attrition. Secondly, we 
will examine compliance and satisfaction measures, such as participant and clinician ratings and 
participant feedback to gain a better understanding of the effectiveness of the groups in facilitating 
change and teaching group members about included concepts. Participant commitment will be 
evaluated by monitoring session attendance, compliance with assignments, and level of participation 
in group sessions. Participants’ open-ended comments provided at the end of each session will be 
coded and categorized into themes, which will then be used to inform changes to the protocol as 
appropriate. 
 
Phase III (Conduct Groups to Compare Intervention against Support Group):  
Activity 1: The PI will provide training to group facilitators, compare the revised intervention 
protocol for older Veterans with PTSD against a support group control, and conduct three groups 
with the revised intervention protocol and three support groups, both among older Veterans with 
PTSD. Outcomes will be compared between intervention and support groups. 
Activity 2: After the groups are completed, the group intervention protocol will be revised 
according to group member and facilitator feedback. The expert panel and mentors will be consulted 
prior to final revision of the protocol. 
Activity 3: Following data analysis, a manuscript detailing the results of the study will be 
prepared. In addition, final revisions will be made to the intervention protocol according to group 
member and facilitator feedback, expert panel suggestions, as well as lessons learned in this phase 
of the study. To evaluate the utility of the intervention in preparing Veterans for trauma-focused 
therapy, utilization of mental health treatment will be assessed at the six month follow-up.  
Finally, data collected as part of this study will be used as pilot data (including effect size 
estimates for power calculations) in the development of a possible VA Merit award submission to 
conduct a RCT of the group intervention.    
Recruitment and Participant Characteristics:  
• 
For both the intervention and support groups, recruitment of Veteran participants will be 
conducted in the manner used in Phase II.   
• 
For all groups, approximately 14 participants will be recruited (target group membership is 10 
participants per group).  
Inclusion/Exclusion Criteria: For both the intervention and support groups, inclusion/exclusion criteria 
for Veteran participants will be the same as used in Phase II of this study. In addition, participants of 
Phase II will be excluded from participation in Phase III. 
Procedure: This procedure will be the same as followed in Phase II. Those Veterans who are 
eligible to participate will be randomized in groups of 3 (block randomization) to participate in either 
an intervention group or a support group. Three intervention groups and support groups will be 
conducted during this phase. All groups will be conducted by doctoral level psychologists or 
psychology trainees or research staff who the PI will have trained. Given that this is a small study, 
there is a limited number of available group facilitators, and therapeutic allegiance effects are not 
expected, group facilitators will conduct either intervention groups or support groups. All groups will 
be audio recorded. Several assessment measures will be completed at the start of each session. At 
the end of each session, Veterans will complete satisfaction ratings and provide feedback. Veterans 
in both conditions (intervention and control) will be given between-session assignments that will be 
collected. Fidelity to the intervention and support group protocols will be monitored by a doctoral 

  
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level psychologist who is not part of the study team and is familiar with cognitive-behavioral 
interventions for PTSD. Each group session will be digitally recorded, and the monitor will listen to a 
randomly selected sample (20% of the sessions) and complete a fidelity monitoring form. Group 
facilitators will also provide ratings and feedback at the end of each session. Following the last 
session, Veteran participants will be asked to complete post-group assessment measures. Veterans 
will be asked to complete follow-up assessments at one month and six months, either via postal mail 
or in person.  
Consistent with the recruitment method followed in Phase II, Veteran participants for both the 
intervention and support groups will be recruited from the PTSD and Geriatric Mental Health Clinics 
if they are new patients, if they are established patients but have declined or dropped out of more 
structured trauma-focused EBPs, if they have partial PTSD, or if they are deemed inappropriate for 
trauma-focused therapy due to health impairments or other reasons. The same procedure will be 
followed as in Phase II after the six month follow-up. Specifically, Veterans will be presented with 
descriptions of a variety of evidence-based treatments, including trauma-focused EBPs, and 
provided with referrals should they request them. Attitudes toward treatment and readiness for 
change will also be assessed. In addition, the VA electronic medical records will be reviewed to 
document enrollment and completion of mental health treatment at the six month follow-up.  
Groups will be conducted during regular business hours. Dr. Pless Kaiser (the PI) is a licensed 
clinical psychologist, and will be available during screening calls, baseline and follow-up 
assessments, and during group sessions in case of a clinical emergency. If needed, the PI will be 
contacted to conduct a risk assessment with a patient, and if it is determined that immediate care is 
needed, will walk the participant down to urgent care. The PI will also have referral information and 
important resources (e.g., the Veteran’s crisis line, suicide prevention coordinator numbers) 
available. In the event that the PI is not available to provide clinical coverage, another licensed 
provider will be asked to provide coverage.  
For each group session attended we will provide compensation ($10) for travel, a practice that is 
consistent with VA policy to reimburse for travel expenses for VA appointments for service-
connected conditions. 
After the final session, a booster or follow-up session will be scheduled for 1 to 3 months 
following the end of the 9-session group. The purpose of this session is to check-in with group 
members, discuss treatment gains and current symptoms, and to provide referrals and resources as 
appropriate. Veterans will also receive $10 for attending this session. 
 
 
Procedures implemented during the Coronavirus Pandemic 
 
In light of the current COVID-19 pandemic, we will be transitioning all study-related in-person procedures to 
a virtual telehealth format, as follows: 
 
Procedure 
 
Recruitment 
Veteran recruitment will remain the same as described above in Phase III for in-person groups. 
 
Obtaining Consent & Baseline Appointments 
Veterans who indicate interest in the study will receive a screening call from a study staff member. A 
revised HIPAA waiver has been submitted to allow the collection of PHI (month/year of birth, name, 
email, and last 4 of SSN) during the screening call, prior to completion of the combined ICF/HIPAA. 
This is different from the previously approved HIPAA waiver, as we are collecting each Veteran’s 
email address in order to send them the link to the video appointments, as well as replacement study 
materials as needed (please see page 18). If potential Veteran participants are interested in the 
study and meet preliminary eligibility criteria during the screening call, they will be sent an envelope 

  
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in the mail with a cover letter, the ICF/HIPAA document, and all baseline measures except the SCID. 
A pre-addressed, stamped envelope will be included to facilitate return of all documents to study 
staff. It will be emphasized over the phone during the screening call that participants should not 
begin the baseline measures until they have completed the informed consent documents with study 
staff.   
 
A telehealth appointment (using a platform such as VVC or Webex or telephone) will be scheduled 
with the Veteran to review the consent forms and surveys. Veterans will be given the opportunity to 
ask questions about study participation during the informed consent process. Participants will be 
reminded to put the signed consent documents and surveys in the pre-addressed, stamped 
envelope to be mailed back to study staff. At the end of the informed consent review call, a second 
appointment will be scheduled with the participant to complete the PTSD interview questions from 
the SCID. Participants will be reminded that the next appointment cannot be completed until the 
consent forms and survey documents have been received. If a session has been scheduled but the 
documents have not been received, the session will be rescheduled. The PI or a trained study staff 
member will conduct the PTSD interview questions from the SCID via telehealth (video or 
telephone). Participants will be given the opportunity to ask any questions they have before and after 
the completion of the SCID questions.  
 
Once the SCID is completed and all forms are reviewed by the study team, the participant will be 
informed if they are eligible to participate in the group sessions, and if so, will be added to the list for 
randomization to study condition. Veterans will be compensated $20 after completion of the SCID 
appointment. 
 
Group Sessions 
Groups will be conducted using a telehealth platform that has options for video and telephone-only 
participation (such as WebEx). Participants will be sent email invitations that contain links to join the 
sessions. Video sessions will start 10 minutes prior to the session start time, to provide participants 
enough time to work through any technological issues with study staff prior to the start of the 
sessions. Study participants will be asked to provide verbal consent to participating in the virtual 
telehealth sessions at the start of the first session, after being informed about the limits of 
confidentiality and important safety issues. The participants will be reminded of these issues at the 
beginning of the remaining sessions, but will not be verbally re-consented each week. Additionally, 
participants will be reminded that the session is being audio-recorded. The study PI, a licensed 
psychologist, or another licensed clinician will be available by phone following the sessions in case 
any of the participants indicate experiencing distress. Veterans will receive $10 per session that they 
attend. Payments will be mailed via check through the agent cashier at two timepoints: after session 
4, and after session 9.  
 
Prior to the start of group sessions, participants will be sent a package of all assessments to be 
completed in sessions, along with a pre-addressed, stamped envelope. Assessment measures will 
be clearly labeled with Veteran ID, session #, and whether the measure is to be completed at the 
start or at the end of the group session. During each session, group leaders will facilitate the 
completion of measures at the start and the end of each group session, and participants will be 
asked to indicate when they have finished measures and placed them in the included envelope to be 
returned at the end of the 9 weeks. Study staff will send replacement assessment measures as 
needed, through postal mail or e-mail.  
 
Post-Assessment and Follow-Ups 
Following the last session, Veteran participants will be asked to complete post-group assessment 
measures (which will be mailed to them). The follow-up booster session will also be conducted over 
a telehealth platform. Veterans will be asked to complete follow-up assessments at approximately 

  
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one month and six months via postal mail. Appropriate clinical referrals will be provided following the 
end of study participation.     
 
Technical Assistance 
 
Study staff may provide some technical assistance via telephone to participants at different 
points during their involvement in the study. Veterans who meet all telephone screening criteria 
other than “Has access to a home computer or device that will allow telehealth delivery of the 
intervention utilizing secure audio/video platforms (e.g. VVC, Webex) may receive assistance in 
connecting to secure platforms in order to determine if the home devices are sufficient to meet this 
criteria. Study staff may assist participants in connecting to complete the Informed Consent and 
baseline appointment process. Study staff may also assist participants prior to and following 
randomization to ensure that they are able to access the remote systems and utilize devices to 
participate in the group interventions. This assistance may include provision of telephone numbers 
and websites for VA technical support, methods to request VA-provided tablets, and trial sessions 
to work through potential issues (such as where to place cameras, how to maximize audio clarity, 
how to ensure privacy for the session, etc.). 
 
Use of Email 
 
Study staff may use e-mail to send remote access instructions or previously approved group 
handouts or measures to participants as needed (e.g. if postal mailing is delayed or participants ask 
for additional copies). Standard VA-approved language indicating that Veterans should not reply to 
these e-mails will be included in each e-mail. 
 
 
Research Questions:  
• 
Compared to support group participants, do intervention group participants experience 
greater increases in psychosocial functioning and quality of life and reductions in PTSD and 
depressive symptoms?  
• 
Are pre-post changes maintained at 1 and 6 month follow-up?  
 
Data Analysis Plan:  Baseline demographics (e.g., age, race, service era) will be summarized for 
each condition (intervention and support groups). Descriptive statistics will be presented for all 
outcome variables. Prior to analyzing the data, the adequacy of randomization will be checked and 
any factors that are unbalanced between groups will be controlled for in group comparisons. Data 
will be analyzed using SPSS and Mplus. Change in primary outcomes (psychosocial functioning and 
quality of life) will be evaluated from pre- to post-intervention and at 1 and 6 month follow-ups. We 
will also evaluate change in secondary outcomes (e.g., PTSD and depressive symptoms). 
Hierarchical linear modeling (HLM)72 may be used to evaluate changes in these measures over time. 
HLM is an optimal strategy for analyzing change over time, with strengths such as handling missing 
data efficiently, providing powerful and accurate estimation procedures, and modeling flexibility. We 
will account for missing data by using full information maximum likelihood estimation. Intent-to-treat 
analyses will be conducted, and completers will be compared against drop-outs to determine any 
group differences. For our primary and secondary outcomes, we will specify a random intercepts and 
random slopes model in which Time, Condition, and the Condition x Time interactions will be 
included as predictors. Time will be coded by assessment time point (baseline, post-group, follow-
ups) and modelled as a random effect to allow for individual differences in trajectories of change. We 
will examine between group effect sizes (e.g., Hedges g73) for the intervention compared to the 
support group at post-group and follow-up assessments. Additionally, we will look at the portion of 
each group (intervention versus comparison) who experienced reliable change on primary outcomes. 
Given the developmental nature of this study, results may be used to provide preliminary data for a 
subsequent trial. 
 

  
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Assessments and Participant Compensation: 
Focus group participants will be contacted by telephone after they have participated in order to 
collect individualized feedback and additional comments. Veterans who participate in the focus 
groups will be compensated $75 for their time and participation.  
All Veterans who participate in Phase II and Phase III (intervention group pilot testing and 
comparison of group intervention with support group) will complete a structured diagnostic interview, 
baseline assessments, satisfaction ratings of each session, and post-group assessments. Phase III 
participants will complete one and six month follow-up assessments. Participants will be 
remunerated for their time and inconvenience. Baseline assessments (including the SCID questions) 
are estimated to take about 90 minutes and participants will be compensated $20 for completion. 
Post-group and follow-up assessments are estimated to take 1 hour and participants will be 
compensated $35 for each assessment they complete (Phase III participants will receive $40 for 
completion of the six month follow-up). Additionally, all participants in Phases II and III will be 
remunerated $10 to cover travel expenses for each group session they attend. Thus, Veterans who 
participate in Phase II could receive up to $155 total and Veterans who participate in Phase III could 
receive up to $230 total.  
 
In case of a lapse between the time of baseline and the start date of the cohort, we may decide 
to reassess the participant and recomplete the baseline appointments. If the Veteran has a SCID 
lifetime rating, the SCID does not have to be recompleted; otherwise, both the SCID and the 
measures will be re-administered. In the event that this is the case, we will pay participants $20 for 
their recompletion of the baseline. 
 
Measures (see Table 2) 
Note: This proposal is being written after publication of DSM-5 but prior to the release of 
appropriately updated assessment measures. Revised versions of all assessment measures that are 
available at the time the study is conducted will be used. 
Phase IA: This is the protocol development phase. No participants will be enrolled or assessment 
measures collected during this phase.  
Phase IB: Prior to being invited to participate in the focus groups for Veterans, potential participants 
will be screened over the telephone with the PC-PTSD-5. 
 
All focus group participants will be contacted by telephone after attending the focus groups and 
asked several open-ended questions to gather feedback and allow participants a chance to share 
comments they may not have felt comfortable disclosing during the focus groups themselves.  
Phases II and III: Prior to being invited to participate in intervention and control groups, Veterans will 
attend an in-person appointment at VABHS. During this appointment, they will be administered the 
PTSD module from the SCID67 and several additional measures. 

  
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21 
 
 
 
Table 1. Timeline of Study Activities 
Year 1 
Year 2 
Year 3 
Year 4 
Year 5 
Activities by Quarters 
1 
2 
3 4 1 2 3 
4 
1 2 3 4 1 2 3 4 
1 
2 3 4 
Phase IA (Develop Protocol) 
1. Consult with expert panel 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2. Develop intervention protocol  
x 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3. Consult with mentors and with expert panel 
x 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
4. Finalize intervention protocol  
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Phase IB (Focus Groups) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
5. Consult with expert panel 
 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
6. Develop focus group guide 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
7. Recruit and screen participants for focus 
groups 
 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
8. Conduct focus groups 
 
 
 
 
x x 
 
 
 
 
 
 
 
 
 
 
 
 
 
9. Analyze focus group data 
 
 
 
 
 
 
x 
x 
 
 
 
 
 
 
 
 
 
 
 
 
Phase II (Pilot Intervention Protocol) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
10. Recruit and screen participants for 
intervention groups 
 
 
 
 
 
 
x 
x 
 
 
 
 
 
 
 
 
 
 
 
11. Conduct intervention groups 
 
 
 
 
 
 
 
x x 
x 
 
 
 
 
 
 
 
 
 
12. Consult with mentors and expert panel; 
revise protocol 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
 
 
 
 
 
 
 
13. Analyze pilot data 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
 
 
 
 
 
 
 
Phase III (Compare Intervention & Support 
Groups) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
14. Recruit/screen participants for groups 
 
 
 
 
 
 
 
 
 
 
x 
x 
 
 
 
 
 
 
 
15. Conduct intervention and support groups 
 
 
 
 
 
 
 
 
 
 
x 
x x x 
 
 
 
 
 
16. Conduct follow-up assessments 
 
 
 
 
 
 
 
 
 
 
 
 
x x 
x 
x 
 
 
 
17. Consult with mentors and expert panel; 
revise protocols 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
 
 
 
 
18. Data analysis 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
x 
 
 
 

  
Version 5: 6/18/2021 
22 
 
Additional Measures to be Completed by Veterans at Baseline and Post-Group (Phases II and III), 
and at Follow-Up Assessments (Phase III):  
 
The Veterans Rand 12-item Health Survey (VR-12).76 The VR-12 is a 12-item scale that assesses the 
effects of physical and mental health on well-being, and is often used to assess quality of life. Item scores 
are used to compute two broad component scores: the physical component score (PCS) and the mental 
component score (MCS). The component scores are standardized T-Scores (M = 50, SD = 10) and the 
population standard for this measure was recently updated.77 
The Quality of Life Inventory (QOLI).78 The QOLI is a 32 item self-report measure that assesses life 
satisfaction across 16 life domains (e.g., health, work, recreation). For each domain, the respondent rates 
how important the domain is on a 0-2 scale and how satisfied he or she is in this area of life on a 7-point 
scale. Satisfaction scores on the measure are weighted based on the respondent’s rating of the importance 
of the life domain in order to achieve a total score. The measure was validated across a number of 
samples, including psychiatric inpatient and outpatient VA samples. Test-retest reliability was excellent 
over a one-month interval (r = .91) as was the internal consistency of the measure (alphas ranged from .86-
.89). The measure also demonstrated convergent and discriminant validity with other measures of life 
satisfaction. 
The Inventory of Psychosocial Functioning (IPF).79 The IPF is an 80-item self-report measure designed 
to assess multiple domains of functional impairment experienced by Veterans. Respondents rate how often 
they have acted a certain way over the past 30 days. Items are rated on a 7-point scale ranging from 0 
(“never”) to 6 (“always”). The IPF yields a total score and scores for seven subscales: romantic 
relationships, family, work, friendships and socializing, parenting, education, and self-care functioning. 
Respondents have the option to skip sections that do not apply to them. The IPF has excellent internal 
consistency reliability (overall alpha = .93) and the scale correlates with other self-report measures of 
quality of life and functional impairment, such as the QOLI (r = .59).   
 
Measures to be Completed by Veterans at Each Group Session: 
Phase II: Veteran participants will be asked to monitor or rate their use of various strategies at the 
beginning of each group session. For example, participants will be asked to report on social activities and 
time spent with friends and family and to rate their use of anger management strategies, coping skills, and 
relaxation strategies. Several additional behavioral ratings will also be administered. Participants will be 
asked about the number of nightmares, flashbacks, and hours slept the previous week. They will also be 
asked about frequency of anger outbursts and will provide a rating of their current distress. As a global 
process measure, participants will be asked to rate the extent to which they are doing better or worse than 
the previous session. Additionally, they will be asked to provide satisfaction ratings at the end of each 
group session. Satisfaction will be rated using several items (e.g., how relevant did today’s group feel to 
you?) with Likert-type response scales (e.g., 1 = not at all to 4 = very). In addition, Veteran participants will 
be given the opportunity to provide open-ended comments at the end of each session. Participant 
treatment engagement will be evaluated by monitoring session attendance, compliance with assignments, 
and level of participation in group sessions.  
Phase III: The measures used in this phase will be the same as used in Phase II, except that the scales 
used at baseline and post-group will also be administered at follow-up assessments (one and six months).  
 
Limitations to be Addressed in Current Study 
As with any study that evaluates a treatment outcome intervention, it is important to anticipate and 
attempt to minimize problems related to drop-out. For each of the group interventions (pilot, intervention, 
and support groups), several precautions will be taken to minimize drop-out. Group members will receive a 
schedule at the start of the group with the dates and times of each group session. Participants will also be 
given a binder in which to keep all group-related materials. The group schedule will be put in the front of 
this binder. At the end of each group session, all members will be given an appointment card with the 
details of the next group session date, time, and location (as well as contact information for group 
facilitators) on it. Additionally, participants will receive weekly reminder calls from one of the group 

  
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23 
 
facilitators. Finally, all group members will be given the option of receiving a mid-week telephone check-in 
with one of the group facilitators. Despite these measures, there will inevitably be some drop-out that 
occurs during the study. When this occurs, group facilitators will contact the Veteran to explore reasons for 
discontinuing their participation in the study. This information will be used to inform future phases of the 
study and future work. Full information maximum likelihood estimation techniques will be utilized when 
analyzing data and intent-to-treat results will be examined to account for the missing data due to drop-out.  
 
Limitations to be Addressed in Future Research 
The overall sample size for the current study is fairly small. However, this study will address questions 
of feasibility and satisfaction with/acceptance of the developed intervention protocol. Additionally, it will 
provide preliminary comparisons between the intervention protocol and support groups and provide effect 
size estimates and information about the group size needed for larger studies. The data gathered from this 
study will serve as pilot data for a larger randomized clinical trial to be conducted in the future.  
Another limitation of the current study is that it is focused on older male Veterans with PTSD. Future 
research may use the intervention protocol developed in the current study to test the effectiveness with 
other populations (such as with older women Veterans or with younger Veterans with PTSD).  

  
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Table 2. Assessment Measures 
 
Veteran Pilot Groups (Phase II) 
Veteran Intervention/Support Groups (Phase III) 
 
Domain 
 
Screening 
 
Baseline 
All Group 
Sessions 
Post-
Group 
 
Screening 
 
Baseline 
All Group 
Sessions 
Mid-
Group 
Post-
Group 
Follow Up 
Assessments 
Screening 
 
 
 
 
 
 
 
 
 
 
Structured Clinical Interview for DSM Disorders 
(SCID) – PTSD Questions only 
 
x 
 
 
 
 
x 
 
 
 
 
 
Primary Outcome 
 
 
 
 
 
 
 
 
 
 
The Quality of Life Inventory (QOLI) 
 
x 
 
x 
 
x 
 
 
x 
x 
The Inventory of Psychosocial Functioning (IPF) 
 
x 
 
x 
 
x 
 
 
x 
x 
Veterans RAND 12-item Health Survey (VR-12) 
 
x 
 
x 
 
x 
 
 
x 
x 
Additional Outcome 
 
 
 
 
 
 
 
 
 
 
Depression, Anxiety, Stress Scales (DASS-21) 
 
x 
 
x 
 
x 
 
 
x 
x 
Sense of Mastery 
 
x 
 
x 
 
x 
 
 
x 
x 
Posttraumatic Stress Disorder Checklist (PCL) 
 
x 
 
x 
 
x 
 
 
x 
x 
Beck Depression Inventory (BDI-II) 
 
x 
 
x 
 
x 
 
 
x 
X 
Other 
 
 
 
 
 
 
 
 
 
 
Endorsed and Anticipated Stigma Inventory 
(EASI) 
 
 
x 
 
 
x 
 
 
x 
 
 
 
x 
 
x 
University of Rhode Island Change Assessment 
Scale (URICA) 
 
 
x 
 
 
x 
 
 
x 
 
 
 
x 
 
x 
Satisfaction ratings 
 
 
x 
 
 
 
x 
 
 
 
Activity/Skills use monitoring forms 
 
 
x 
 
 
 
x 
 
 
 
Behavioral PTSD ratings 
 
 
x 
 
 
x 
 
 
x 
x 

  
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25 
k.  Human Studies Section   
 
(1) Risk to subjects 
 
(a) Human subjects involvement and characteristics. All participants included in the current 
study will be male Veterans. Focus groups with Veterans: Veterans who already receive 
care through VA Boston Healthcare System will be recruited as participants for this part 
of the study. Veterans from the community may also be recruited for this study. Two 
focus groups with Veterans will be held, each with up to 10 Veterans. Approximately 20 
Veterans will be recruited to participate in these focus groups. Veteran participants will 
be recruited from a) flyers posted at each VA Boston Healthcare System location, b) 
flyers and information given to clinicians within the PTSD clinics, the Geriatric Mental 
Health Clinic, and medical clinics, and c) word of mouth from other participating 
Veterans. Inclusion criteria: Veterans need to be male and at least 60 years old to be 
eligible to participate in the focus groups. Potential participants will be assessed with the 
PC-PTSD-5 prior to being invited to participate. Inclusion criteria include endorsement of 
a military-related criterion A event and a score of at least 3 on the PC-PTSD-5.  
Exclusion criteria: Veterans who are diagnosed with a psychotic disorder or have 
psychotic symptoms, have been hospitalization for suicidal ideation or psychosis within 
the past year, or have a diagnosis of dementia or other severe cognitive disorder. 
Women will be excluded from participation, since this study focuses on older male 
Veterans. Potential participants will also be excluded if they do not agree to be audio 
recorded. 
 
Pilot intervention groups for Veterans: Veterans who already receive care through VA 
Boston Healthcare System, as well as Veterans from the community may be recruited as 
participants for this part of the study. Two pilot intervention groups of up to 10 Veterans 
each will be conducted during this phase. Approximately 28 participants will be recruited 
for these groups. Veteran participants will be recruited from a) flyers posted at each VA 
Boston Healthcare System location, b) flyers and information given to clinicians within 
the PTSD clinics, the Geriatric Mental Health Clinic, and medical clinics, c ) contacting 
Veterans from the PTSD clinic who have expressed an interest in research, d) word of 
mouth from other participating Veterans, and e) a roster of Veterans who have sought 
services through the VA National Center for PTSD and have indicated consent to be 
contacted for other research studies. Inclusion criteria: Veterans need to be at least 60 
years old to be eligible to participate in the study. Potential participants will be assessed 
with the PTSD questions from the SCID prior to being invited to participate. Inclusion 
criteria include endorsement of a military-related criterion A event, at least one intrusion 
symptom (cluster B), one symptom of avoidance (cluster C), one symptom related to 
negative alterations in cognition or mood (cluster D), one symptom related to alterations 
in arousal or reactivity (cluster E), and report of impairment in functioning (cluster G; 
DSM-5). Exclusion criteria: Veterans who are in current treatment for PTSD, are 
diagnosed with a psychotic disorder or have psychotic symptoms, have been 
hospitalized for suicidal ideation or psychosis within the past year, or have a diagnosis of 
dementia or other severe cognitive disorder. Veterans will be asked not to join therapy 
groups or other interventions for the duration of their participation in the study. Potential 
participants will also be excluded if they do not agree to be audio recorded. 
 
Comparison condition - Intervention and support groups for Veterans: Veterans who 
already receive care through VA Boston Healthcare System, as well as community-
based Veterans who do not use the VA, may be recruited as participants for this part of 

  
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26 
the study. Three intervention groups of up to 14 Veterans each, as well as three 
comparison support groups will be conducted during this phase. Approximately 84 
participants will be recruited for these groups. Veteran participants will be recruited from 
a) flyers posted at each VA Boston Healthcare System location, b) flyers and information 
given to clinicians within the PTSD clinics, the Geriatric Mental Health Clinic, and 
medical clinics, c) contacting Veterans seen in the PTSD clinic who indicated interest in 
research d) word of mouth from other participating Veterans, and e) a roster of Veterans 
who have sought services through the VA National Center for PTSD and have indicated 
consent to be contacted for other research studies. Inclusion criteria: Veterans need to 
be at least 60 years old to be eligible to participate in the study. For both intervention 
and support groups, participants (who will be assessed with the PTSD questions from 
the SCID prior to being invited to participate), must endorse a military-related criterion A 
event, at least one intrusion symptom (cluster B), one symptom of avoidance (cluster C), 
one symptom related to negative alterations in cognition or mood (cluster D), one 
symptom related to alterations in arousal or reactivity (cluster E), and report of 
impairment in functioning (cluster G; DSM-5). Exclusion criteria: Veterans who are in 
current treatment for PTSD, are diagnosed with a psychotic disorder or have psychotic 
symptoms, have been hospitalization for suicidal ideation or psychosis within the past 
year, or have a diagnosis of dementia or other severe cognitive disorder. Veterans will 
be asked not to join therapy groups or other interventions for the duration of their 
participation in the study. Potential participants will also be excluded if they do not agree 
to be audio recorded. In addition, Veterans who participated in the pilot phase of the 
study will be excluded from participating in the comparison condition phase. 
 
(b) Sources of materials.  
Focus group participants will provide data in the form of audio recordings that will be 
transcribed, demographic information, and responses to survey measures. Veterans 
participating in the pilot intervention groups and the comparison condition (intervention 
and support groups) will provide data in the form of self-report assessment measures 
collected during and after group participation. Veteran participants will be recruited using 
data from a roster of Veterans who have sought treatment through the VA National 
Center for PTSD or PTSD clinic. This roster is an electronic database maintained by the 
VA National Center for PTSD – Behavioral Science Division. Participant entry into the 
database is done on a voluntary basis and written consent for future contact has already 
been established. 
 
(c) Potential risks. The potential psychological, physical, social or other risks to Veterans 
who participate in the proposed study are minimal. Veteran focus group participants will 
be discussing domains of psychosocial functioning that they view to be problematic for 
themselves or for other Veterans. Additionally, Veterans who participate in the 
intervention groups will be asked to complete psychological and psychosocial 
assessment measures and discuss areas of difficulty for them. There is a slight chance 
that Veterans discussing these issues may experience some psychological discomfort 
when reflecting on such experiences. Dr. Pless Kaiser (the PI), as a trained clinical 
psychologist, will be able to provide thorough assessment in the event of a participant’s 
adverse reaction to focus group participation. In addition to Dr. Pless Kaiser, another 
licensed clinical psychologist will be available during each of the focus groups. If a 
Veteran becomes distressed and it is clinically appropriate, the Veteran will be allowed to 
leave the group and speak with the available  psychologist. If clinically appropriate, the 
Veteran will participate for the remainder of the focus group and Dr. Pless Kaiser will 
speak with him individually as the group is over  to assess distress and any other clinical 

  
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27 
needs. Appropriate intervention and/or referral for treatment can be provided, if needed. 
No other known physical, social or legal risk associated with participation in the proposed 
research project is identified. 
 
(2)  Adequacy of Protection from Risks 
 
(a) Recruitment and informed consent.  
Issues related to recruitment and obtaining informed consent are relevant to the proposed 
study. For recruitment details, see the above section. For the focus groups, informed 
consent will be obtained by Dr. Pless Kaiser or a trained research technician prior to the 
start of the focus group. For Veterans who participate in an intervention or support group, 
informed consent will be obtained by Dr. Pless Kaiser, a psychology trainee, or trained 
research technician at the assessment session held prior to the start of the groups. 
Informed consent will be obtained from all study participants prior to participation, 
according to the guidelines established by the Institutional Review Board (IRB) at VA 
Boston Healthcare System. Following the completion of the informed consent form, the 
consent form will be given to the research technician for photocopying for the participant 
copy. All participants who decline the study or do not meet study criteria will be given 
appropriate feedback and referrals for other treatment as needed (e.g., to one of the 
psychology clinics at VA Boston Healthcare System).   
 
(b) Protection against risk. The primary risk associated with the proposed study includes 
psychological distress resulting from increased focus on psychosocial problems during 
the assessment, focus group, and/or intervention sessions. To address this potential risk, 
Dr. Pless Kaiser, a trained clinical psychologist, is in a good position to provide further 
evaluation of a participant’s distress. This evaluation may include contact with a 
participant’s current healthcare providers, including mental health professionals, if 
needed. Dr. Pless Kaiser will also be in a good position to make referrals for further 
evaluation and/or treatment, and to ensure that such consults are placed on the 
participant’s behalf. Study staff will immediately report any serious adverse events to Dr. 
Pless Kaiser, and she will, according to standardized procedures, report them to the IRB 
within the required timeframe. In addition, all participants will be provided with Dr. Pless 
Kaiser’s contact information, and encouraged to establish contact at any time during the 
study as needed. All other incidents (e.g., theft of loss of data), will be reported in 
accordance with VA policy. Efforts will be made to protect confidentiality. Focus group 
members will be asked not to discuss information about other individuals in the group 
outside of the group setting. Participants will be asked not to state their names when 
speaking in order to protect confidentiality on the audio recordings of the focus group 
sessions. Study staff will immediately report any serious adverse events to the PI. The PI 
will, according to standardized procedures, report them to the IRB within the required 
timeframe. The confidentiality of the data that is gathered from participants (audio 
recorded group sessions, telephone screen data, survey measures) will be protected 
through secure storage of such media in a locked cabinet in Dr. Pless Kaiser’s office that 
is kept locked when unattended. Data will be de-identified by removing all individually 
identifiable (all 18 HIPAA identifiers) prior to data analysis. The PI will provide members 
of the research team with de-identified datasets as needed. Once research staff are no 
longer working on the study, they will be removed from the protocol. All information kept 
electronically, including digital recordings of focus groups, will be kept behind the VA 
firewall on a secure server in a restricted access computer file. Records will be destroyed 
in accordance with the VA Record retention schedule 
(www1.va.gov/VHAPUBLICATIONS/RCS10/rcs10-1.pdf).  Records will be destroyed, 

  
Version 5: 6/18/2021 
28 
when applicable, in a manner in which they cannot be retrieved. Additionally, all 
information will be de-identified for the purposes of analysis and dissemination of 
findings.  
  
(3)   
Potential benefits to subjects and others 
 The proposed study is consistent with the overall mission of the VA, which assures that 
all persons cared for in the VA healthcare system can reliably count on prompt and 
appropriate treatment of psychological distress. The proposed study seeks to develop, 
implement, and evaluate a psychosocial intervention for older Veterans with PTSD. The 
efficacy of the intervention developed will be compared to support group controls. The 
intervention has the potential to reduce problems related to psychosocial functioning and 
PTSD, and to improve quality of life for older Veterans with PTSD symptoms. This 
intervention will address the missions of the VA and the VA National Center for PTSD 
and directly address the care of older participants with PTSD symptoms, a high priority 
problem within the VA. 
 
In addition, this study will provide valuable research data on interventions that are 
effective with older Veterans with PTSD, an understudied population. Aging in the 
context of PTSD is a high priority research area within the VA National Center for PTSD. 
The data collected during the course of this study will help to inform the future 
development and refinement of the intervention protocol to help improve psychosocial 
functioning and quality of life among older Veterans with PTSD symptoms. Thus, there is 
substantial potential for the proposed study to benefit Veterans who participate in the 
current study as well as to indirectly help others who experience psychosocial problems 
related to PTSD. 
 
(4)     Importance of knowledge to be gained 
Given the aging of our Nation’s Veterans, it is important to develop and provide 
interventions that will help those with partial and full PTSD manage their symptoms and 
improve their lives. One area that is affected by PTSD symptoms and will be targeted by 
the intervention developed in the proposed study is psychosocial functioning. There are 
several evidence-based trauma-focused interventions for PTSD, such as Prolonged 
Exposure and Cognitive Processing Therapy. There is some evidence to suggest that 
these interventions are helpful for older Veterans. However, not all Veterans engage in or 
are offered these types of interventions (for various reasons), and among those who do, 
some do not improve and others drop out. Thus, additional types of interventions designed 
to reduce symptoms and enhance quality of life and functioning are needed for this 
population. The intervention to be developed may be able to serve as a pre-treatment 
intervention, increasing readiness for change and attitudes toward treatment among older 
Veterans. The focus groups conducted as part of this study, in concert with 
recommendations from the expert panel, will guide the revision of the development 
intervention. Thus, this study will produce an intervention informed by the perspectives of 
Veterans with PTSD, will be used in future phases of the study to test the effectiveness of 
the intervention.  
 
(5)  Resources  
 
(a)  Research Space: 
(1) The VA National Center for PTSD (NCPTSD) is a VA Center of Excellence for research 
and education on the prevention, understanding, and treatment of PTSD. The proposed 
research will take place in the Behavioral Science Division (BSD) of the NCPTSD, 

  
Version 5: 6/18/2021 
29 
located at the Jamaica Plain campus of the VA Boston Healthcare System (VABHS). 
The Jamaica Plain campus is conveniently located, with several public transportation 
alternatives (subway and bus lines) within a few blocks of the medical center. 
Additionally, parking is free for visitors, and there are shuttles that run from the medical 
center to other VA medical centers and outpatient clinics. Thus, the site of the proposed 
study is easily accessible for potential participants. BSD is under the direction of Dr. 
Terence Keane, Associate Chief of Staff for Research, Executive Director, and is well-
staffed by clinical psychologists, post-doctoral fellows, psychology interns, research 
technicians, and support staff.  The Principal Investigator (PI), Dr. Pless Kaiser, has a 
dedicated office for her ongoing program of research on the 12th floor of the VABHS 
medical center in BSD.  Space will be provided to the PI throughout the duration of the 
study. The PI’s office includes locked file cabinets which will be used to store screening 
forms, interview data, digital recordings of focus groups, and assessment forms. The 
Division’s office space includes networked computers and printers as well as duplication, 
fax, scanning, and mailing facilities.  Additional space will be made available to house 
research staff (i.e., the Research Technician) hired for the project. The NCPTSD also 
has office space and conference rooms that can be reserved and used for conducting 
focus groups with Veterans.     
 
(c) Other Research Resources:  
(d) 
The backbone of the NCPTSD computer operations is a fiber optic local area network for 
the more than 50 computer workstations in use by staff and support personnel. The LAN 
operates from a set of primary and secondary servers, running Windows operating 
systems that provide security, deliver a wide array of applications, and support large-scale 
file storage and backup. The LAN is directly linked to the cluster of servers that service 
VABHS, and is linked to the wider network of servers across the VA system. This 
nationwide VA network connects to a gateway onto the Internet, as well as to a mirrored 
FTP server that allows secure transfer of large files to/from outside computers. The 
system also provides secure remote access capabilities through a Virtual Private Network 
(VPN), which is used by NCPTSD staff to increase productivity and manage 
responsibilities while away from the worksite.  All of the NCTPSD workstations are recent-
vintage Windows-based PCs. Each year, the NCPTSD obtains 8-10 new computers with 
the latest available features and specifications to maintain technological currency.  Printing 
is predominately centralized through six high-speed laser and color printers. Windows-
compatible software of various types is available to all staff via the network.  Specific 
examples of the software include MS Office Suite (word processing, spreadsheets, 
database administration, graphics, and presentations), Adobe Illustrator and Photoshop for 
digital image manipulation, EndNote for reference and bibliography development, and 
Adobe Acrobat for PDF file manipulation.  Examples of available statistical packages 
include SPSS, SAS, LISREL, MPlus, EQS, AMOS, and HLM.  Staff have access to VA 
subscriptions to electronic databases for research, including PsycInfo service for literature 
searches and PsycArticles for full text electronic access to journals published by the 
American Psychological Association. Both of these resources can be accessed directly 
from the LAN and remotely via VPN.  In addition, through the NCPTSD’s affiliation with 
Boston University School of Medicine, there is electronic and physical access to journal 
articles, books, databases, and other references. The VA electronic library also provides 
full text on a wide array of journal articles and interlibrary loan is available.  
 
 
(n)  Publications/Presentations from Last Funding Period (as applicable).  None.  
 
 
(o)  Literature Citations (as applicable).   

  
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30 
1. United States Census Bureau. “Summary File.” 2010 American Community Survey. 
U.S. Census Bureau’s American Community Survey Office, 2013.  
2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental 
disorders (5th Ed.). Washington, DC: Author.  
3. Rosenheck. R. A., & Fontana, A. F. (2007). Recent trends in VA treatment of post-
traumatic stress disorder and other mental disorders. Health Affairs, 26, 1720-1727.  
4. Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2011). Prevalence 
and Axis I comorbidity of full and partial posttraumatic stress disorder in the United 
States: results from Wave 2 of the National Epidemiologic Survey on Alcohol and 
Related Conditions. Journal of Anxiety Disorders, 25, 456-465.  
5. Blake, D. D., Keane, T. M., Wine, P. R., Mora, C., Taylor, K. L., & Lyons, J. A. (1990). 
Prevalence of PTSD symptoms in combat veterans seeking medical treatment. Journal 
of Traumatic Stress, 3, 15-27.  
6. Glaesmer, H., Gunzelmann, T., Braehler, E., Forstmeier, S., & Maercker, A. (2010). 
Traumatic experiences and post-traumatic stress disorder among elderly Germans: 
Results of a representative population-based survey. International Psychogeriatrics, 22, 
661-670.  
7. Schnurr, P. P., Spiro, A., Vielhauer, M. J., Findler, M. N., & Hamblen, J. L. (2002). 
Trauma in the lives of older men: Findings from the Normative Aging Study. Journal of 
Clinical Geropsychology, 8, 175-187.  
8. van Zelst, W. H., de Beurs, E., Beekman, A. T. F., Deeg, D. J. H., & van Dyck, R. 
(2003). Prevalence and risk factors of posttraumatic stress disorder in older adults. 
Psychotherapy and Psychosomatics, 72, 333-342.  
9. Floyd, M., Rice, J., & Black, S. R. (2002). Recurrence of posttraumatic stress disorder 
in late life: A cognitive aging perspective. Journal of Clinical Geropsychology, 8, 303-
311.  
10. Kaup, B. A., Ruskin, P. E., & Nyman, G. (1994). Significant life events and PTSD in 
elderly World War II veterans. American Journal of Geriatric Psychiatry, 2, 239-243.  
11. Davidson, J. R., Kudler, H. S., Saunders, W. B., & Smith, R. D. (1990). Symptom 
and comorbidity patterns in World War II and Vietnam veterans with posttraumatic stress 
disorder. Comprehensive Psychiatry, 31,162–170.  
12. Yaffe, K., Vittinghoff, E., Lindquist, K., Barnes, D., Covinsky, K. E., Neylan, T., Kluse, 
M., & Marmar, C. (2010). Posttraumatic Stress Disorder and risk of dementia among 
U.S. veterans. Archives of General Psychiatry, 67, 608-613.  
13. Spiro, A., III, Hankin, C. S., Mansell, D., & Kazis, L. E. (2006). Posttraumatic stress 
disorder and health status: The Veterans Health Study. Journal of Ambulatory Care 
Management, 29, 71-86.  
14. Foa, E. B., Hembree, E. A., Cahill, S. P., Rauch, S. A., Riggs, D. S., Feeny, N. C., & 
Yadin, E. (2005). Randomized trial of prolonged exposure for posttraumatic stress 
disorder with and without cognitive restructuring: Outcome at academic and community 
clinics. Journal of Consulting and Clinical Psychology, 73, 953-964.  
15. Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y., & 
Stevens, S. P. (2006). Cognitive processing therapy for veterans with military-related 
posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74, 989-
907.  
16. Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. A. (2005). A 
multidimensional meta-analysis of psychotherapy for PTSD. American Journal of 
Psychiatry, 162, 214-227.  
17. Thorp, S. R., Stein, M. B., Jeste, D. V., Patterson, T. L., & Wetherell, J. L. (2012). 
Prolonged exposure therapy for older veterans with posttraumatic stress disorder: a pilot 
study. American Journal of Geriatric Psychiatry, 20, 276-280.  

  
Version 5: 6/18/2021 
31 
18. Schottenbauer, M. A., Glass, C. R., Arnkoff, D. B., Tendick, V., & Gray, S. H. (2008). 
Nonresponse and dropout rates in outcome studies on PTSD: review and 
methodological considerations. Psychiatry, 71, 134-168.  
19. Cook, J.M., Dinnen, S., Simiola, V., Thompson, R., & Schnurr, P.P. (2014). VA 
residential provider perceptions of dissuading factors to the use of two evidence-based 
PTSD treatments. Professional Psychology: Research and Practice, 45, 136-142.  
20. Becker, C. B., & Zayfert, C. (2001). Integrating DBT-based techniques and concepts 
to facilitate exposure treatment for PTSD. Cognitive and Behavioral Practice, 8, 107-122.  
21. Hamblen, J. L., Bernardy, N.C., Sherrieb, K, Norris, F. H., Cook, J. M., Louis, C. A., 
& Schnurr, P. P. (in press). VA PTSD clinic director perspectives: How readiness guides 
provision of evidence-based PTSD treatment. Professional Psychology: Research and 
Practice.  
22. Rosen, C., Adler, E., & Tiet, Q. (2013). Presenting concerns of veterans entering 
treatment for posttraumatic stress disorder. Journal of Traumatic Stress, 26, 640-643.  
23. Sheedy, C. K., & Whitter, M. (2009). Guiding Principles and Elements of Recovery-
Oriented Systems of Care: What Do We Know From the Research? HHS Publication 
No. (SMA) 09-4439. Rockville, MD: Center for Substance Abuse Treatment, Substance 
Abuse and Mental Health Services Administration.  
24. Substance Abuse and Mental Health Services Administration (SAMHSA). (2012, 
March 23). SAMHSA’s working definition of recovery updated. Retrieved December 10, 
2013.  
25. Kocsis, J. H., Schatzberg, A., Rush, J., Klein, D., Howland, R., Ginwesch, L., Davis, 
S., & Harrison, W. (2002). Psychosocial outcomes following long-term, double-blind 
treatment of chronic depression with sertraline vs placebo. Archives of General 
Psychiatry, 59, 723-728.  
26. Cattan, M., White, M., Bond, J., & Learmouth, A. (2005). Preventing social isolation 
and loneliness among older people: A systematic review of health promotion 
interventions. Ageing and Society, 25, 41-67.  
27. Sobel, D. S. (1995). Rethinking medicine: Improving health outcomes with cost-
effective psychosocial interventions. Psychosomatic Medicine, 57, 234-244.  
28. Bonanno, G. A. (2005). Resilience in the face of potential trauma. Current Directions 
in Psychological Science, 14, 135-138.  
29. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). 
Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General 
Psychiatry, 52, 1048-1060.  
30. Chopra, M. P., Zhang, H., Pless Kaiser, A., Moye, J. A., Llorente, M. D., Oslin, D. W., 
& Spiro, A., III (2014). PTSD is a chronic, fluctuating, disorder affecting the mental 
quality of life in older adults. American Journal of Geriatric Psychiatry, 22, 86-97.  
31. Schnurr, P. P., Friedman, M. J., Foy, D. W., Shea, T., Hsieh, F., Lavori, P. W., 
Glynn, S., … & Bernardy, N. C. (2003). Randomized trial of trauma-focused group 
therapy for posttraumatic stress disorder. Archives of General Psychiatry, 60, 481-489.  
32. Cook, J. M, & O’Donnell, C. (2005). Assessment and psychological treatment of 
posttraumatic stress disorder in older adults. Journal of Geriatric Psychiatry and 
Neurology, 18, 61-71.  
33. Van Orden, K. A., Stone, D. M., Rowe, J., McIntosh, W. L., Podgorski, C., & Conwell, 
Y. (2013). The senior connection: design and rationale of a randomized trial of peer 
companionship to reduce suicide risk in later life. Contemporary Clinical Trials, 35, 117-
126.  
34. Walters, R., Cattan, M., Speller, V. and Stuckelberger, A. (1999). Proven Strategies 
to Improve Older People’s Health. Eurolink Age, London.  

  
Version 5: 6/18/2021 
32 
35. Humphreys, K., Mankowski, E. S., Moos, R. H., & Finney, J. W. (1999). Do 
enhanced friendship networks and active coping mediate the effect of self-help groups 
on substance abuse? Annals of Behavioral Medicine, 21, 54–60.  
36. McFall, M. E., Wright, P. W., Donovan, D. M., & Raskind, M. (1999). 
Multidimensional assessment of anger in Vietnam veterans with posttraumatic stress 
disorder. Comprehensive Psychiatry, 40, 216-220.  
37. Gavlovski, T., & Lyons, J. A. (2OO4). Psychological sequelae of combat violence: A 
review of the impact of PTSD on the veteran's family and possible interventions. 
Aggression and Violent Behavior, 9, 477-501.  
38. Ray, S. L., & Vanstone, M. (2009). The impact of PTSD on veterans’ family 
relationships: An interpretative phenomenological inquiry. International Journal of 
Nursing Studies, 46, 838-847.  
39. Chemtob, C. M., Novaco, R. W., Hamada, R. S., Gross, D. M., & Smith, G. (1997). 
Anger regulation deficits in combat-related posttraumatic stress disorder. Journal of 
Traumatic Stress, 10, 17-36.  
40. Jakupcak, M., Conybeare, D., Phelps, L., Hunt, S., Holmes, H. A., Felker, B., 
Klevens, M., & McFall, M. E. (2007). Anger, hostility, and aggression among Iraq and 
Afghanistan War veterans reporting PTSD and subthreshold PTSD. Journal of Traumatic 
Stress, 20, 945–54.  
41. Teten, A. L., Miller, L. A., Stanford, M. S., Petersen, N. J., Bailey, S. D., Collins, R. 
L., Dunn, N. J., & Kent, T. A. (2010). Characterizing aggression and its association to 
anger and hostility among male veterans with post-traumatic stress disorder. Military 
Medicine, 175, 405–10.  
42. Forbes, D., Parslow, R., Creamer, M., Allen, N., McHugh, T., & Hopwood, M. (2008). 
Mechanisms of anger and treatment outcome in combat veterans with posttraumatic 
stress disorder. Journal of Traumatic Stress, 21, 142-149.  
43. Orth, U., & Wieland, E. (2006). Anger, hostility, and posttraumatic stress disorder in 
trauma-exposed adults: a meta-analysis. Journal of Consulting and Clinical Psychology, 
74, 698–706.  
44. Kulkami, M., Porter, K. E., & Rauch, S. A. (2012). Anger, dissociation, and PTSD 
among male veterans entering into PTSD treatment. Journal of Anxiety Disorders, 26, 
271-278.  
45. Forbes, D., Creamer, M., Hawthorne, G., Allen, N., & McHugh, T. (2003). 
Comorbidity as a predictor of symptom change after treatment in combat-related 
posttraumatic stress disorder. Journal of Nervous and Mental Disease, 191, 93–99.  
46. Rybarczyk, B., Lund, H.G., Garroway, A.M., & Mack, L. (2013). Cognitive behavioral 
therapy for insomnia in older adults: Background, evidence, and overview of treatment 
protocol. Clinical Gerontologist, 36, 70-93.  
47. Lewinsohn, P.M., Antonuccio, D.O., Breakenridge, J.S., & Teri, L. (1984). The coping 
with depression course: A psychoeducational intervention for unipolar depression. 
Eugene, OR: Castalia Publishing Company.  
48. Perlman, L., Cohen, J. L., Altiere, M. J., Brennan, J. A., Brown, S. R., Mainka, J. B., 
& Diroff, C. R. (2010). A multidimensional wellness group therapy program for veterans 
with comorbid psychiatric and medical conditions. Professional Psychology: Research 
and Practice, 41, 120-127.  
49. Frueh, B. C., Turner, S. M., & Beidel, D. C. (1995). Exposure therapy for combat-
related PTSD: A critical review. Clinical Psychology Review, 15, 799–817.  
50. Beidel, D. C., Frueh, B. C., Uhde, T. W., Wong, N., & Mentrikoski, J. M. (2011). 
Multicomponent behavioural treatment for chronic combat-related posttraumatic stress 
disorder: A randomized controlled trial. Journal of Anxiety Disorders, 25, 224-231.  

  
Version 5: 6/18/2021 
33 
51. Beck, R., & Fernandez, E. (1998). Cognitive behavioral therapy in the treatment of 
anger: A meta-analysis. Cognitive Therapy and Research, 22, 63–74.  
52. Gerlock, A. A. (1994). Veterans’ responses to anger management intervention. 
Issues in Mental Health Nursing, 15, 393–408.  
53. Taft, C. T., Creech, S. K., & Kachadourian, L. (2012). Assessment and treatment of 
posttraumatic anger and aggression: A review. Journal of Rehabilitation Research and 
Development, 49, 777-788.  
54. Taft, C. T., Walling, S. M., Howard, J. M., Monson, C. (2011). Trauma, PTSD, and 
partner violence in military families. In: S. MacDermid, S. Wadsworth, & D. Riggs, 
editors. Risk and resilience in U.S. military families (pp. 195-212). New York (NY): 
Springer.  
55. Eckhardt, C. I., Barbour, K. A., Davison, G. C. (1998). Articulated thoughts of 
maritally violent and nonviolent men during anger arousal. Journal of Consulting and 
Clinical Psychology, 66, 259–69.  
56. Silverstein, M., & Parker, M. G. (2002). Leisure Activities and Quality of Life among 
the Oldest Old in Sweden. Research on Aging, 24, 528-547.  
57. Spiro, A., III, Schnurr, P. P., & Aldwin, C. M. (1994). Combat-related posttraumatic 
stress disorder symptoms in older men. Psychology and Aging, 9, 17-26.  
58. Cook, J. M., O’Donnell, C., Moltzen, J. O., Ruzek, J. I., & Sheikh, J. I. (2005). Clinical 
observations in the treatment of World War II and Korean War veterans with combat-
related PTSD. Clinical Gerontologist, 29, 81-93.  
59. Cook, J. M., Riggs, D. S., Thompson, R., Coyne, J. C., & Sheikh, J. I. (2004). 
Posttraumatic stress disorder and current relationship functioning among World War II 
ex-Prisoners of War. Journal of Family Psychology, 18, 36-45.  
60. Cook, J. M., Biyanova, T., & Coyne, J. C. (2009). Barriers to adoption of new 
treatments: An internet study of practicing community psychotherapists. Administration 
and Policy in Mental Health and Mental Health Services Research, 36, 83-90.  
61. Hilgeman, M. M., Moye, J., Archambault, E., Billings, R. L., Karel, M. J., Gosian, J., & 
Naik, A. D. (2012). In the Veterans voice: Psychosocial needs after cancer treatment. 
Federal Practitioner, 29, 51S-59S. `  
62. Naik, A. D., Martin, L. A., Karel, M., Wachen, J. S., Mulligan, E., Gosian, J. S., 
Herman, L. I., & Moye, J. (2013). Cancer survivor rehabilitation and recovery: Protocol 
for the Veterans Cancer Rehabilitation Study (Vet-CaRes). BMC Health Services 
Research, 13, 93-103.  
63. French-Rosas, L. N., Moye, J., & Naik, A. D. (2011). Improving the recognition and 
treatment of cancer-related posttraumatic stress disorder. Journal of Psychiatric 
Practice, 17, 270-276.  
64. Sloan, D. M., Marx, B. P., Bovin, M. J., Feinstein, B. A., & Gallagher, M. W. (2012). 
Written exposure as an intervention for PTSD: A randomized clinical trial with motor 
vehicle accident survivors. Behaviour Research and Therapy, 50, 627-635.  
65. Sloan, D. M., Feinstein, B. A., Gallagher, M. W., Beck, J. G., & Keane, T. M. (2013). 
Efficacy of group treatment for posttraumatic stress disorder symptoms: A meta-
analysis. Psychological Trauma: Theory, Research, Practice, and Policy, 5, 176-183.  
66. Vogt, D. S., King, D. W., & King, L. A. (2004). Focus groups in psychological 
assessment: Enhancing content validity by consulting members of the target population. 
Psychological Assessment, 16, 231-243. 
68. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B.W. (2002). Structured Clinical 
Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition. (SCID-I/P) 
New York: Biometrics Research, New York State Psychiatric Institute.  

  
Version 5: 6/18/2021 
34 
70. Rodriguez, P., Holowka, D. W., & Marx, B. P. (2012). Assessment of posttraumatic 
stress disorder-related functional impairment: A review. Journal of Rehabilitation 
Research and Development, 49, 649-666.  
71. Kreuger, R. A., & Casey, M. A. (2009). Focus groups: A practical guide for applied 
research (4th Ed.). Thousand Oaks, CA: Sage.  
72. NVivo qualitative data analysis software; QSR International Pty Ltd. Version 10,  
2012.  
73. Frankland, J., & Bloor, M. (1999). Some issues arising in the systematic analysis of 
focus group interviews. In R. S. Barbour & J. Kitzinger (Eds.), Developing Focus Group 
Research: Politics, Theory, and Practice. London: Sage.  
74. Thomas, D.R. (2006). A general inductive approach for analyzing qualitative 
evaluation data. American Journal of Evaluation, 27: 237.