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Erbes, C. R., Polusny, M. A., MacDermid, S., & Compton, J. S. (2008). Couple therapy with Combat Veterans and their partners. Journal of Clinical Psychology, 64(8), 972–983. https://doi.org/10.1002/jclp.20521 :
"may feel overwhelmed and isolated. As partners get to know one other again, theymust renegotiate how to communicate with one another, make decisions together,divide up tasks and assign roles within the family, deal with ﬁnances, raise children,and once again rely upon one another.As difﬁcult as this transition may be, it can be complicated by disruptions in thesoldiers’ postdeployment mental health. Although it is important not to under-estimate the resilience of soldiers, partners, and families to the stresses of combat anddeployment (Bonanno, 2004), extant evidence suggests that returning soldiers reportsubstantial rates of mental health concerns including PTSD, depression, anxiety, andsubstance abuse (Hoge et al., 2004). A recent population-based survey found thatrates of these mental health problems as well as interpersonal conﬂicts weresigniﬁcantly higher among National Guard/Reserve soldiers compared to activecomponents soldiers following their return from Iraq (Milliken, Auchterloine, &Hoge, 2007). Concerns about interpersonal conﬂicts increased at least fourfoldamong National Guard/Reserve soldiers during the 6 months following theirdeployment.There is unequivocal evidence of the robust association between mental disordersand marital distress (e.g., Jacobson, Holtzworth-Munroe & Schmaling, 1989;Whisman, Uebelacker, & Bruce, 2006). Numerous studies have also demonstratedthat veterans suffering from PTSD are more likely to report lower couplesatisfaction, be divorced or be considering divorce, engage in intimate partnerviolence, and report difﬁculties with childrearing (Galovski & Lyons, 2004).In this context, it is not surprising that requests for treatment for relationshipdistress are among the most common in mental health agencies providing care formilitary service members (Department of Defense Task Force on Mental Health,2007). In addition to alleviating conﬂict in relationships and enhancing socialsupport by partners, couple therapy may also facilitate returning service members’coping with traumatic events. Indeed, greater social support has been identiﬁed asone of the strongest correlates of lower rates of PTSD, a ﬁnding that is particularlyrobust for combat trauma (Brewin, Andrews, & Valentine, 2000). Postdeploymentfactors such as negative social interactions, negative life events, and psychosocialstressors such as divorce can substantially erode social support and increase the riskof PTSD (Brewin et al., 2000). Posttraumatic stress disorder symptoms have alsobeen shown to predict deteriorating social support over time, underscoring thedisorder’s corrosive impacts on social functioning and family members (Guay,Billette, & Marchand, 2006). Thus, interventions targeting couple relationships canboth ameliorate relationship distress and facilitate recovery. In the remainder of thisarticle, we describe and illustrate couple therapy for returning soldiers and theirpartners using PTSD as an exemplar.Avoidance and Relationships in Combat-Related Posttraumatic Stress DisorderWe ground our conceptualization and treatment of PTSD in a relational contextbased on experiential avoidance. Experiential avoidance occurs when individualsengage in efforts to alter the frequency or experience of distressing internal events,such as thoughts, feelings, memories, or bodily sensations (Hayes, Wilson, Gifford,Follette, & Strosahl, 1996). This includes cardinal symptoms of PTSD, such asavoiding external and internal trauma reminders, as well as a wide range of problembehaviors that function to reduce distressing internal experiences associated with thetrauma (Polusny & Follette, 1995). Other examples include social withdrawal,974 Journal of Clinical Psychology: In Session, August 2008Journal of Clinical Psychology: In Session DOI: 10.1002/jclpsubstance use, and dissociation. Avoidance impedes emotional processing oftraumatic events and hinders exposure to experiences that challenge erroneousassociations between trauma reminders and fear or anxiety. In this way, avoidanceplays a role in the development and maintenance of PTSD symptoms (Foa &Rothbaum, 1998). Chronic, pervasive experiential avoidance has also been shown tolead to increased distress and impairment in individual functioning over time (Marx& Sloan, 2005).Experiential avoidance is likely to alter interpersonal processes and tends to exertnegative consequences on couple satisfaction and intimacy (Leonard, Follette, &Compton, 2006). Avoidance behaviors, such as distancing from others, emotionalnumbing, or being excessively involved in productive (e.g., work) or nonproductive(e.g., video games) activities to cope with trauma-related symptoms, are thought tobe particularly harmful to relationship functioning. The lack of emotionalinvolvement and expression arising from such behaviors may reduce opportunitiesfor closeness and intimacy, validation, and effective communication. It is notsurprising, therefore, that the avoidance cluster of PTSD symptoms contributes tolower couple satisfaction even after controlling for other PTSD symptoms (Galovski& Lyons, 2004).The hyperarousal symptoms of irritability and anger also detract from couplefunctioning. Posttraumatic stress disorder has been associated with increased risk forintimate partner violence, and even nonviolent anger and hostility can lead toreduced communication, ineffective problem solving, and decreased social support(Sherman, Zanotti, & Jones, 2005). We conceptualize anger as a form of experientialavoidance when angry outbursts function to increase emotional distance or whenanger serves as a ‘‘secondary emotion’’ overlying primary but distressing emotions,such as sorrow or fear.To summarize, experiential avoidance can lead one to (a) engage in acts thatreduce internal discomfort in the short term, but (b) serve to distance a person fromtheir interpersonal relationships (especially couple relationships), and (c) deprive aperson from opportunities to confront future discomfort, thereby hinderingrecovery. Couple therapy provides a useful venue in which to identify and confrontexperiential avoidance as it affects the relationship and also as it plays out in asoldier’s broader life.Integrative Behavioral Couple Therapy for Posttraumatic Stress DisorderThe development of couple therapy for treating PTSD remains in its infancy.Although several treatments have been proposed (e.g., Johnson, 2002; Leonard etal., 2006; Sherman et al., 2005), only one pilot study on cognitive–behavioral coupletherapy (Monson, Schnurr, Stevens, & Guthrie, 2004) and another on adjunctivebehavioral family therapy (Glynn et al., 1999) have provided outcome data thus far.The lack of demonstrated efﬁcacy of couple therapy as a primary treatment forPTSD has led to recommendations that currently it be viewed only as an adjunctiveintervention (Riggs, 2000).Integrative behavioral couple therapy, developed by Jacobson and Christensen(1996), was initially designed to improve efﬁcacy and relapse rates associated withtraditional behavioral couple therapy (Jacobson & Margolin, 1979). In contrast tothe traditional treatment, IBCT includes an emotional acceptance component that isparticularly useful for targeting the experiential avoidance endemic to PTSD.Although change strategies continue to be used (e.g., behavior exchange,975Couple Therapy With Combat VeteransJournal of Clinical Psychology: In Session DOI: 10.1002/jclpcommunication/problem-solving), the primary emphasis in IBCT is to help partnersaccept (and even embrace) aspects of each other and their relationship that havecome to be viewed as intolerable and insoluble.From an IBCT framework, acceptance includes letting go of the struggle tochange each other, but is not to be confused with resignation or living withunacceptable behavior (e.g., abuse, explosive outbursts, or marked social avoidance).Acceptance in IBCT is a process to help couples to use their differences as a means ofenhancing understanding and intimacy instead of driving them apart. Integrativebehavioral couple therapy promotes acceptance as a pathway towards problemresolution (when a problem improves as the struggle to eliminate the problem stops)or circumvention (so that the problem no longer prevents intimacy and other valuedactivities). The balance between acceptance and change strategies characteristic ofIBCT serves as an ideal platform to target both the relationship and individualproblems faced by couples when a partner has PTSD. Integrative behavioral coupletherapy has a strong empirical base, showing efﬁcacy in treating relationship distress(Christensen et al., 2004; Jacobson, Christensen, Prince, Cordova, & Eldridge, 2000).We conceptualize IBCT for PTSD as operating through several mechanisms.First, it reduces conﬂict and increases intimacy between a soldier and his or herpartner, which, in turn, reduces the individual distress of both. This may, in and ofitself, promote recovery from trauma-related symptoms, and at the very least, shouldreduce stress in a soldier’s life and enhance social support. Second, IBCT fostersacceptance, tolerance, and expression of primary emotions such as fear or sadnessthat often underlie the chronic anger associated with PTSD. Emotions of this kindare often cut off or minimized by soldiers suffering from the disorder. Theacceptance fostered through IBCT is seen as the functional opposite of experientialavoidance (Leonard et al., 2006). Third, IBCT is a behavioral approach that includesskills acquisition and generalization strategies to improve communication andproblem-solving skills. Finally, IBCT’s emphasis on intimacy and increased positiveactivities (through behavioral exchange) fosters relational exposures that mayencourage soldiers to confront situations, feelings, and conversations that they haveavoided; an avoidance which ironically maintains PTSD symptoms.In couple therapy, it is important to distinguish the ‘‘broad’’ exposure we discusshere from traditional trauma-focused exposure work used in individual therapy forPTSD. Individual exposure-based therapy for PTSD makes use of intensive andextended periods of revisiting traumatic memories and associated feelings to reducethe anxiety and arousal and facilitate cognitive processing of the memory (e.g., Foa& Rothbaum, 1998). It may be helpful, on a case-by-case basis, to facilitatedisclosure of trauma events within a couple context (Leonard et al., 2006; Shermanet al., 2005); however, we do not advocate systematic exposure work in a couplecontext. It may not be therapeutic to encourage disclosure of traumatic experiencesin couple therapy, particularly combat events in which the soldier was an activeparticipant. Further, the therapist cannot control a partner’s (perhaps entirelylegitimate) reactions to a soldier’s disclosure of traumatic events, and thus may notbe able to provide a safe, corrective environment for trauma disclosure. Finally, weare not convinced that formal exposure is required for every soldier suffering fromPTSD. When targeting experiential avoidance, exposure work can be quite broadand can include exposure to any stimuli that are avoided, including things such asleaving the house, sharing an intimate moment, or having a difﬁcult conversation.The application of IBCT to enhance exposure involves current life events andrelationships, not necessarily past traumatic memories.976 Journal of Clinical Psychology: In Session, August 2008Journal of Clinical Psychology: In Session DOI: 10.1002/jclpWe will now highlight salient points of our IBCT adaptation to the military servicemember population. The intervention is divided into assessment and treatmentphases, with the ﬁrst few sessions (typically 1–2 conjoint and an individual meetingwith each partner) making up the assessment phase. The primary focus of thisassessment, adapted from Jacobson and Christensen’s (1996) original manual,include seven areas:1. Level of distress2. Level of commitment to the relationship3. Conﬂict areas4. What makes the conﬂict a problem5. The individual and relationship strengths that keep the couple together6. Deployment-related issues (e.g., how has the couple dealt with the stress ofdeployment and reintegration; what roles have been altered since deployment)7. PTSD-related issues (e.g., how PTSD symptoms affect the relationship)The next session is used as a feedback session to provide couples with informationgathered during assessment, including the initial formulation of couple problems. Theformulation is a cardinal feature of IBCT and is provided in this early session to begina dialogue about relationship themes. The formulation attempts to put words to theprocess or controlling variables that underlie most of the relationship conﬂicts andindividual frustrations, and is intended to help couples join together against acommon problem instead of continuing to attempt to change each other inunproductive ways. The formulation also contains basic education about PTSDsymptoms and experiential avoidance tailored to the speciﬁc presentation of thesoldier and the couple. By incorporating this education in an individualized contextwe attempt to enhance retention and comprehension of the information provided, butalso to facilitate acceptance and change of PTSD-related behaviors within the couple.Like standard IBCT, the content of treatment varies session to session and isfocused on emotionally relevant topics. Sessions most often focus on recentinteractions that were successful or difﬁcult, differences between partners, how one’sbehavior effects the other, and planning for upcoming events. Generally, thedominant emphasis in IBCT is to facilitate a collaborative stance characterized bymutual understanding and emotional acceptance between partners. Although theorder and relative emphasis of acceptance versus change strategies varies betweencouples, acceptance interventions are required in the standard IBCT protocol andoften dominate treatment.Treatment adherence and dropout tends to be a problem with younger returningveteran populations, and this has led to the modiﬁcation of standard IBCT in at leastﬁve ways. First, length of treatment is typically shorter than standard IBCT, withmost veterans receiving from 12–14 sessions instead of 24–26 sessions. Second, wehave also found it useful to incorporate elements of motivational interviewing(Miller & Rollnick, 2002) and values clariﬁcation (Hayes, Strosahl, & Wilson, 1999)in early phases of the treatment. By eliciting ‘‘change talk,’’ discussing pros and consfor change, and elaborating core values we try to clarify treatment goals and enhancetreatment retention. Third, assessment and feedback sessions with this populationalways include education about trauma and trauma reactions. Fourth, throughouttreatment the identiﬁcation and blocking of experiential avoidance as it manifests incouple interactions is a primary focus. Fifth, an increased emphasis is placedon behavioral exchange and activity scheduling during treatment to increase977Couple Therapy With Combat VeteransJournal of Clinical Psychology: In Session DOI: 10.1002/jclpinvolvement with shared and individual activities. These strategies are incorporatedto circumvent experiential avoidance and are tailored in a gradual exposure processto match the unique needs of each couple.Case IllustrationPresenting ProblemMike and Kimberly presented for couple therapy 8 months following Mike’s returnfrom Iraq where he had been deployed for the previous 15 months. Kimberly initiallywas concerned that Mike wouldn’t stick with treatment and gave him anultimatum—psychotherapy or separation—before he phoned for the appointment.Mike ﬁnally agreed to 12 weeks of couple therapy after ‘‘losing his temper’’ during arecent argument. Kimberly spent several nights at a friend’s house and refused tocome home unless Mike was willing to get help. Mike was evaluated by an outpatientintake team and diagnosed with PTSD of moderate severity. He was referred forcouple therapy after stating that his primary concern and motivation for treatmentwas his marriage.Mike and Kimberly, in their mid-twenties, met through mutual friends whileattending community college. Mike, the youngest of an intact urban family with fourchildren, had worked fulltime as an electronics technician and had been slowlyaccumulating college credits when he enlisted in the National Guard. Kimberly, whowas an only child, was taking courses, working as a bank teller, and living with herparents to save money. The two ‘‘hit it off’’ right away and seemed to want the samethings in life—interesting careers, a nice house, and children. They were dating fornearly 2 years when Mike was notiﬁed that he would be deployed to Iraq. Heproposed to Kimberly soon after, and they planned a simple wedding 4 months later.Together, they had enough money saved to buy a small home, and Mike wasdeployed shortly after they were able to move into it. At the time of Mike’sdeployment, neither Mike nor Kimberly had any history of signiﬁcant physical orpsychological disorders.Assessment and FeedbackAssessment was conducted over the course of two conjoint sessions and oneindividual session with each partner. Mike and Kimberly shared a variety of strongemotions during sessions and appeared to be struggling primarily over intimacy andcloseness in their marriage. Kimberly tearfully stated that she just wanted ‘‘the old’’Mike back. She complained that he didn’t seem like himself, he never wanted tospend time together, and they didn’t talk as much now as they did when he wasthousands of miles away. When she expressed her feelings or pressed him, Mike gotirritated, said ‘‘mean things,’’ and sometimes looked at her with ‘‘hate’’ in his eyes.Kimberly said Mike’s deployment was hard on her in many ways, but she was ableto cope by staying in touch with him and staying busy with school, friends, andwork. She couldn’t wait for him to come home, and she described the ﬁrst severalweeks as a ‘‘perfect’’ reunion. At ﬁrst they were together all of the time, they talkedinto the nights, celebrated with friends and family, and Kimberly had fun showingMike all of the projects she had completed in their new home.Once things settled down, Kimberly was back into her routine and Mike was hiredas a tech on a new project at his old company. Kimberly began to worry more andmore about him over the next several weeks when Mike started to become978 Journal of Clinical Psychology: In Session, August 2008Journal of Clinical Psychology: In Session DOI: 10.1002/jclpincreasingly ‘‘moody’’ and ‘‘insecure.’’ He started to complain about his job andseemed to dread going to work. He didn’t want to do anything, wasn’t interested insex, and wanted to stay home most of the time. Mike played videogames on thecomputer late into most nights and increased his alcohol intake. Frustrated,Kimberly felt justiﬁed in spending time with her friends (a group of similar-aged,mostly single men and women) although she knew that this would displease Mike.Mike’s excessive alcohol use led to increased friction with Kimberly. Ultimately,Mike missed several days of work and was ﬁred from his job—the trigger for theheated argument that brought them to treatment. Kimberly reported that she hadtried everything she could to make things right between them: she tried talking withhim, giving him space, planning fun things to do, being ﬂirtatious, and everythingelse she could imagine. When nothing worked she eventually demanded that he get ajob and stop acting like a child. Kimberly felt that no matter what she did, Mike justseemed farther away, less interested, more sarcastic.Mike agreed that he needed to decrease his drinking and work on a career plan,but he saw things differently. He felt that Kimberly wanted too much from him; shewanted to talk ‘‘constantly’’ and usually about petty matters. He was amazed at howmuch she changed while he was gone, and he privately shared irritation about thefriends she made (especially male) and the money she spent on furniture and homedecorations while he was deployed. Plus, he felt that she just didn’t seem tounderstand how ‘‘stupid’’ and unattractive it was to worry about material things—hefelt this was trivial in comparison to the state of the world. Mike acknowledged thatlife was really different in Iraq and that he had seen some ‘‘pretty bad stuff.’’ Heendorsed sleep problems, intrusive thoughts, and described himself as detached,tense, and unable to have fun. This was especially true when Kimberly ‘‘needled’’him to get a job, do a project, or go out with her. Sometimes he just wanted to yell‘‘shut up,’’ but found that videogames and a few drinks helped. Sometimes, like thenight of their big ﬁght, he was actually afraid that he might hit her just to stop herfrom talking. Mike said that this really shook him up, and he decided then and therethat he didn’t want to lose the best thing in is life—thus he agreed to get help. Mikeshared feelings of guilt about how often Kimberly was crying, and he started to thinkthat she was right, he was no longer the man she married.During the feedback session, the therapist presented an initial formulation of theinteraction patterns of Mike and Kimberly’s conﬂict and the role of PTSD in theirrelationship.Despite the fact that you’ve lived separate lives over the past year and ahalf because of Mike’s deployment, I see you both being committed toeach other and eager to make things work. The two of you have beenthrough a difﬁcult relationship strain (deployment), and one primaryfactor that we have to consider is that Mike is experiencing symptoms ofposttraumatic stress disorder (PTSD) that are affecting your interactions.The conﬂict that you are experiencing now centers on Kimberly wantingMike to resume married life together now that you are home, to be openand available—emotionally, physically, and with your time. She wantsyou be her partner and to collaborate together to build your home,ﬁnances, and family together as you had planned. From Kimberly’sperspective, it’s a bit like the pause button has been lifted and your livesare on ‘‘play’’ again—which makes a lot of sense since Kimberly has beentaking care of day to day tasks and waiting for your return. However,979Couple Therapy With Combat VeteransJournal of Clinical Psychology: In Session DOI: 10.1002/jclpfrom Mike’s perspective, the lives that are ‘‘playing’’ are changed infundamental ways as a function of his experiences as a soldier in Iraq.The tricky thing is that Mike’s experiences have brought PTSD into yourlives, and this makes knowing what kind of relationship he wants andneeds even more difﬁcult. So both the long separation and the disorderitself make relating to each other difﬁcult. One classic symptom of PTSDis a strong desire to avoid things that are associated with the traumaticevents, and oftentimes, the desire to avoid spreads to other areas likeavoiding feelings, people, and activities. For you Mike, it seems thatwhen Kimberly asks you to be there for her, you often feel pressured,overwhelmed, and frustrated. You don’t really know how to talk aboutwhat you are experiencing, you aren’t a good actor, and you’re fearfulthat you might hurt Kimberly in some way if you are honest abouteverything you are thinking and feeling. So instead, you make jokes, getangry, space out on the computer, or drink. Kimberly, you wind upfeeling sad, rejected, and unloved—and after some time you startedfeeling resentful and angry. You fell back on your old coping strategies(those that helped when Mike was in Iraq), and you have been workinghard and hanging out with your friends. When this happens, Mike feelsinsecure about your commitment, guilty, and sad—feelings that makehim tend to pull back and withdraw even more. Can you see a viciouscycle in play?Course of TreatmentIn the sessions that followed, Mike and Kimberly were provided with informationabout PTSD, empirically supported treatments, and the role of avoidance inmaintenance of the disorder. Sessions focused on building a collaborative set bylabeling the PTSD symptoms and validating the experience of both partners, helpingthem to unite around the ways PTSD had affected their interactions. Kimberly’sanger toward Mike decreased quickly as she better understood what he was goingthrough, and Mike began to talk more about his private experiences. Mike explainedthat he sometimes felt that he was going ‘‘crazy.’’ He hated being in public withKimberly because he couldn’t shake the feeling that he needed to be ready in casesomething happened—he needed to be on guard, to defend himself and protect her(resulting in distraction, detachment, tension, and frustration). As Mike wasincreasingly genuine about his experience, Kimberly was less judgmental andcommunicated more understanding. The couple began to see some of their problemsas part of the PTSD that they could treat through exposure. During sessions, Mikeand Kimberly were encouraged to slow down and to notice a full range of feelingsand thoughts. Outside of sessions, Mike and Kimberly began to do small, but tenderthings for each other and began to tackle a mutually derived hierarchy of activitiestogether (e.g., having a date during the day, having a date at night, having friendsover, going out with friends).Later sessions focused on difﬁcult interactions that occurred through the week,especially those characterized by anger. Mike and Kimberly slowly began tounderstand themselves and each other more fully and their mutual efforts helpedthem to take risks together in session. Several sessions focused on making the privateemotions and thoughts associated with anger and frustration more public—starting980 Journal of Clinical Psychology: In Session, August 2008Journal of Clinical Psychology: In Session DOI: 10.1002/jclpto have the real conversations they had been avoiding. Mike eventually shared howworried he was that Kimberly may not have been faithful during his deployment. Heknew that other wives had cheated on his friends, and he had a hard time dealingwith his sexual feelings during deployment. Kimberly told Mike how good it felt tohear this because she thought he was not attracted to her and didn’t love heranymore. She was able to look him in the eyes, hold his hand, and reassure him thatshe had not and did not want to be with anyone other than him—he continued to bethe man that she wanted as her husband. Over the next several weeks, Mike andKimberly became sexually intimate again and steadily seemed to be more acceptingand loving. Mike started to talk about his interests and career goals, and Kimberlywas able to listen and be collaborative.Outcome and PrognosisBy the end of 13 weeks of treatment, Mike and Kimberly both said their relationshipwas considerably stronger, that they had fewer arguments, and that they werespending considerably more time together. Mike was more open to leaving the houseand engaging in social activities, and spent less time on the computer or drinking. Hestill had some intrusive symptoms of PTSD (particularly some nightmares about hisIraq experiences) and was considering pursuing individual therapy to address these.Clinical Issues and SummaryThe composite case of Mike and Kimberly illustrates the use of acceptance-basedcouple therapy both in terms of couple interactions (as Mike and Kimberly came tounderstand and accept changes each had made through the deployment) andindividual experiences (as Mike, in particular, had to confront and acceptuncomfortable feelings in and outside of sessions). As is often the case,acceptance-based interventions led to some speciﬁc change strategies (such asactivity scheduling). We have found the application of IBCT to couple distress withPTSD to be valuable. There remains, however, the need for controlled research toassess the efﬁcacy of this and other couple-based treatments for ameliorating coupledistress with returning soldiers"

Monk, J. K., Oseland, L. M., Nelson Goff, B. S., Ogolsky, B. G., & Summers, K. (2017). Integrative intensive retreats for veteran couples and families: A pilot study assessing change in relationship adjustment, posttraumatic growth, and trauma symptoms. Journal of Marital and Family Therapy, 43(3), 448–462. https://doi.org/10.1111/jmft.12230:
"We assessed a brief, systemic retreat-style intervention that was developed to address concerns about the utilization of services for veterans coping with traumatic stress. A total of 76 dyads (N = 152) were assessed before and after a 4-day retreat, which included psychoeducation, group and conjoint therapeutic sessions, and recreational relaxation components. Overall, participants reported a reduction in trauma symptoms, but only support persons experienced a significant increase in posttraumatic growth from pretest to posttest. Both veterans and their romantic partners reported an increase in relationship adjustment after the retreat. Opportunities to address the needs of this population by removing barriers to treatment and reducing feelings of isolation, as well as implications for similar treatments are discussed.

Prolonged exposure to combat makes military personnel particularly vulnerable to posttraumatic stress disorder (PTSD; American Psychiatric Association, 2013) and other trauma-related diagnoses (Hoge, Milliken, & Auchterlonie, 2006). These experiences are compounded by the fact that service members and their families must also navigate the challenges of deployment and reintegration (e.g., Knobloch & Theiss, 2011). Thus, many military couples and families report poor functioning and high levels of distress in the wake of these unique stressors (e.g., Allen, Rhoades, Stanley, & Markman, 2010; Lester et al., 2010). While there are numerous treatment options available to military personnel and their family members, the majority of these resources go unused and many lack a systemic, family focused orientation, which has been shown to be beneficial (see MacDermid Wadsworth et al., 2013).

To address these issues, researchers, practitioners, and service members designed a systemic retreat-style intervention program for military trauma survivors (Bruner, 2014; Monk, Ogolsky, & Bruner, 2016). In particular, the Veteran Couples Integrative Intensive Retreat model (VCIIR; Bruner, 2014; Monk et al., 2016) adopted a community-based approach to treatment and provided psychoeducation to veterans and their partners. These weeklong retreats used a strengths-based focus to reduce the stigma associated with seeking mental health services and equipped participants with adaptive coping mechanisms for the distress associated with past trauma and deployment experiences (Bruner, 2014, for more information on the VCIIR model). To further enhance the accessibility and feasibility of these retreat-style intervention programs, the VCIIR model was shortened into a 4-day format for the present study. The revised Integrative Intensive Retreats (IIR) reflect this change, and a change in the inclusion of dyads beyond romantic couples. Brief treatments are important in order to open-up reluctant populations to exploring treatment, as there are higher drop-out rates for longer treatments (Imel, Laska, Jakupcak, & Simpson, 2013), indicating they may be less desirable.

Although workshops and retreat-style treatments have become popular in military communities (see Walsh, 2013), few studies have investigated these programs. In fact, many scholars (e.g., Bobrow, Cook, Knowles, & Vieten, 2013; Davis et al., 2012) argue that more research and attention on retreat interventions is vital. The present study examines the impact of the brief IIR model on veterans’ and their partners’ relationship adjustment, as well as the effects of the retreat on PTSD symptoms and posttraumatic growth for all participants. Not only is this important information for evaluating efficacy, but this investigation is also salient because it is one of the first studies to follow both system members through a retreat-style program, which can provide needed insight for future interventions.

Systemic Influence of Trauma on Military Couples and Families
Combat-related trauma often is associated with both poor intrapersonal outcomes (e.g., PTSD, depression, substance abuse disorders) as well as interpersonal challenges (see Monson, Taft, & Fredman, 2009; Nelson Goff, Crow, Reisbig, & Hamilton, 2007). In addition to trauma related distress, deployment and reintegration stressors, more generally, are also associated with significant impairments in individual and relational well-being (e.g., Knobloch & Theiss, 2011). Due to the widespread and pervasive impact of trauma and distress on all domains of functioning, not only are trauma survivors affected, but their family members, romantic partners, and peers may also be affected, through secondary traumatic stress (Nelson Goff & Smith, 2005; Salston & Figley, 2003).

Secondary Traumatic Stress and Interpersonal Distress
Among military service members, some have found that roughly 35–45% of returning soldiers and their partners meet criteria for one or more mental health disorder (e.g., Kim, Thomas, Wilk, Castro, & Hoge, 2010; Milliken, Auchterlonie, & Hoge, 2007). Trauma is theorized to have a unique systemic impact on relationships in the form of secondary traumatic stress (i.e., secondary traumatization, vicarious traumatization; see Arzi, Solomon, & Dekel, 2000; Lev-Wiesel & Amir, 2001). According to theorists (e.g., Salston & Figley, 2003), individual survivors’ symptoms are communicable and therefore have the potential to “infect” those persons with whom they maintain consistent contact as a contagion effect. Although a secondary individual may not have directly experienced a traumatic episode, through intimate contact with the trauma survivor, the other member of the system may begin to manifest symptoms that parallel those of the survivor. Recent modifications to the PTSD diagnostic criteria (American Psychiatric Association, 2013) now state that individuals who learn of “traumatic event(s) that occurred to a close family member” or experience “repeated or extreme exposure to aversive details of the traumatic event(s)” (p. 271) can be vulnerable to developing PTSD themselves. Symptomatology in the second individual can potentially further affect the survivor's symptoms, consequentially reinforcing the cyclical nature of distress, and damaging both individual and relational functioning (Nelson Goff & Smith, 2005; Oseland, Gallus, & Nelson Goff, 2016).

Of particular concern is the research suggesting that secondary traumatization contributes to decreased relationship satisfaction and distress among couples coping with trauma (e.g., Allen et al., 2010; Arzi et al., 2000; Monk & Nelson Goff, 2014; Nelson Goff et al., 2007). The interpersonal paradox of trauma (Schwerdtfeger & Oseland, 2013) can enhance distress and shape the recovery process for veterans and their partners (Monson et al., 2009, 2012). Furthermore, the association between PTSD and relational challenges is more potent among military personnel than their civilian counterparts, highlighting the need for treatment approaches that consider the interdependent factors that shape trauma recovery in military personnel (Taft, Watkins, Stafford, Street, & Monson, 2011). Thus, it is pivotal that other members of the system are included in the healing process (see also MacDermid Wadsworth et al., 2013; Nelson Goff & Smith, 2005; Riggs, 2000).

Although some scholars suggest that most distress incurred by partners of service members is more attributable to general distress than secondary trauma (e.g., Renshaw et al., 2011), traumatic symptoms can still create distressing interactions within family systems. Moreover, in addition to (a) providing added support to service members and (b) providing assistance to partners or support persons who may also need services, treating others in an individual's system may cut down on interference from partners (Knobloch & Theiss, 2011) and other disruptions that could inhibit progress. In fact, according to systems theory, feedback or change-back messages from system members who do not attend therapy or do not understand the treatment process may undermine progress. This disruption can occur because any change in treated individuals may bring about new reactionary patterns of interaction within their environment (see MacDermid Wadsworth et al., 2013; Ohye et al., 2015). In addition, others within the service members’ environment often report desiring insight into their loved one's experiences postdeployment (e.g., Fischer et al., 2015), which creates added incentive to include other members from the veterans’ support system (see also Sautter, Armelie, Glynn, & Wielt, 2011).

Toward More Systemic Treatment
Traditionally, individually focused cognitive-behavioral therapies such as Cognitive Processing Therapy (CPT) and Cognitive-Behavioral Therapy (CBT), among other variations of this approach, have been used to treat combat and trauma-related diagnoses (Cahill, Rothbaum, Resick, & Follette, 2009). These cognitive-behavioral treatments are effective; however, given the interpersonal and recursive nature of trauma, a systems approach may be beneficial (see MacDermid Wadsworth et al., 2013). For example, a primary trauma survivor's symptoms of hyperarousal, intrusive reexperiencing, and avoidance could negatively affect his or her partner's (or support person's) resulting symptomatology. Consequently, the partner's resulting symptoms could, in turn, influence the primary survivors’ coping methods (Nelson Goff & Smith, 2005; Oseland et al., 2016). When focusing only on individuals, treatment may lack a holistic, bidirectional scope and discount social supports that could enhance survivors’ recovery (e.g., Herman, 1997; Johnson & Williams-Keeler, 1998; Matsakis, 2004; van der Kolk, 2007).

Recently, Monson and colleagues (e.g., Monson et al., 2012; Shnaider, Pukay-Martin, Fredman, Macdonald, & Monson, 2014) and Sautter, Glynn, Cretu, Senturk, and Vaught (2015) have had promising results conducting randomized controlled trial studies on conjoint clinical interventions for veterans and their partners. A family systems-oriented approach to treating combat-related trauma is important for military personnel and their families because traumatic stress responses can be buffered by strong marital and social bonds (e.g., Herman, 1997; Matsakis, 2004; van der Kolk, 2007). Furthermore, veterans are at risk for dropping out of mental health services (see Luedtke, Davis, & Monson, 2015; Najavits, 2015), but romantic partners and family members can be strong sources of support for veterans in treatment (see Sautter et al., 2011). In fact, many military personnel suggest that they would prefer services that were family focused (Khaylis, Polusny, Erbes, Gewirtz, & Rath, 2011; see also Fischer et al., 2015). Despite the evidence for the advantages of systems-oriented treatments, this approach has not been fully integrated into military and veteran services (MacDermid Wadsworth et al., 2013). Moreover, to address concerns about long-term treatment (see Imel et al., 2013), as well as a need for a sense of community belonging (see Monk et al., 2016), brief community-based workshop and weekend retreat formats are often used to promote resilience in military personnel and their family members (Walsh, 2013). This adoption of more brief and systemic approaches to treatment could be more desirable for this population and, thus, increase attendance and retention.

Although there are some guidelines to systemic psychotherapy with veteran trauma survivors and their partners, few studies have evaluated the effectiveness of couple- or family focused interventions (see Monson et al., 2012; Sautter et al., 2011, 2015; Schumm, Fredman, Monson, & Chard, 2013; for notable recent exceptions). In addition, empirical literature often addresses the negative impact and impairment from combat trauma (see Schnurr, Lunney, Bovin, & Marx, 2009; for a review) with little focus on the potential resilience or posttraumatic growth (Tedeschi & Calhoun, 1995, 1996) that can occur. Due to the benefits of treatment and the support provided within the couple relationship, the potential for positive outcomes also needs to be addressed in research (see Renshaw & Campbell, 2016). To address these shortcoming, we evaluate a brief systemic retreat-style treatment for veterans and their partners or primary support persons.

The Present Study
The purpose of this pilot study was to examine the impact of a brief systemic veteran retreats model on participants’ reports of relationship adjustment, PTSD symptoms, and posttraumatic growth. The original VCIIR retreat model spanned 7-days. The modified IIR approach is a 4-day, brief systemic version of the retreat. Studies have shown that brief interventions have higher retention rates (Imel et al., 2013); thus, we wanted to assess if the abbreviated 4-day retreats could successfully reduce trauma-related distress for veterans and their support persons. In addition, given these retreats are meant to provide new perspectives and skills while also encouraging coping and hope, posttraumatic growth (Tedeschi, Park, & Calhoun, 1998) was also measured to assess positive change. Specifically, we hypothesized that: Veterans and their romantic partners will report significantly higher posttest relationship adjustment scores compared to their pretest scores after participating in the retreat intervention (H1). Similarly, veterans and their primary support persons will report significantly higher posttest posttraumatic growth scores compared to their pretest scores after participating in the retreat intervention (H2). Veterans and their primary support persons will also report significantly lower trauma symptom scores compared to their pretest scores after participating in the retreat intervention (H3).

Method
Participants
The sample included 76 dyads, which included veterans and a primary support person (N = 152 individuals) who attended one of the 4-day intensive integrative retreats. Dyads included 53 couples, six parent–child pairs, one sibling pair, and four dyads that were dual-military/veteran pairs (i.e., “battle buddies”). The remaining dyads were unspecified pairs. Of the couples, 14 indicated they were dual-military. Veterans ranged in age from 23 to 62 years (M = 38.59, SD = 8.82). Support persons ranged in age from 23 to 66 years (M = 40.63, SD = 10.32). With regard to gender, 62 (81.6%) veterans identified as male, 12 (15.8%) identified as female, and the remaining two veterans did not complete this question. Fifty-nine (77.6%) support persons identified as female, ten identified as male (13.2%), and the remaining seven did not answer this question. Approximately 5.3% of veterans identified as Native American, 2.6% Asian, 35.5% African American, 9.2% Hispanic/Latino/a, 40.8% White, 2.6% identified as “other,” and 3.9% of veterans did not answer this question. For primary support persons, about 3.9% identified as Native American, 25% African American, 10.5% Hispanic/latino/a, 50% White, 1.3% “other,” and 9.2% did not answer this question. For married couples, length of marriage ranged from 1 week to 31 years with a mean of 8.74 years (SD = 8.15). Regarding education, 57.9% of veterans reported some college and 23.7% completed college. For primary support persons, 39.5% reported some college and 25% completed college. Veterans reported incomes ranging from below $19,000 (n = 13, 17.1%), $20,000–$39,000 (n = 22, 28.9%), and $40,000–$59,999 (n = 20, 26.3%).

All veterans served after 9/11/01, but some had military experience pre-dating 2001. Among veterans, 69.7% were Army, 6.6% were Air Force, 11.8% were Marines, 14.5% were Navy, 15.8% were National Guard, and 6.6% were Reserve status. Most veterans were discharged or retired from the military (80.3%), 4% were currently Active Duty, 7% were current National Guard, and 7% were current Reserve members. Most primary support persons did not report previous military service; while 30.9% reported being discharged or retired for their military status, no primary support persons were currently serving in the military (Active Duty, National Guard, or Reserve). The average number of deployments for the primary veteran was 2.76 (SD = 2.01), while the average number of deployments for dual-military support persons was 3.33 (SD = 4.27). Most veterans reported that their highest military rank was an E5 (30.3%), followed by E4 (21.1%), and E6 (15.8%). Seven participants reported being officers. Among veterans or service members, 79.5% reported a PTSD diagnosis, whereas 27.1% of primary support persons reported a PTSD diagnosis.

Procedure
Participants took part in a 4-day community-based retreat focused on providing holistic care for veterans and their families. These retreats aimed to reduce symptoms of PTSD, improve overall relationship adjustment, and enhance posttraumatic growth by empowering participants, normalizing and validating experiences, reducing feelings of stigma and isolation, and promoting healthy coping (see Bruner, 2014). These retreats used a strengths-based approached while providing skills training and psychoeducation. Content of the psychoeducation sessions included information about trauma, practical skills in stress management, increased insight about the experience of veterans and partners, and how to provide support, which are all desired topics reported by this population (Fischer et al., 2015). The primary principles of the model include: (a) a focus on preparation and follow-up care by a multidisciplinary team of providers, (b) intergenerational interaction and peer support (i.e., veterans and support persons interacting with similar peers from a variety of eras to build a sense of supportive community), (c) focus on support system as a unit, (d) soldiers-saving-soldiers (i.e., service members interacting with others who have shared experiences) to promote normalization, bonding and understanding, and (e) community involvement to promote feelings of belonging, empowerment, inclusion, and welcoming (see Monk et al., 2016, for more detail on the core principles and a more detailed outline of the retreat schedule is provided as an online supplemental file).

Participants engaged in a variety of activities including group psychoeducation and therapeutic conjoint sessions. Within group sessions, in addition to receiving information about trauma and stress management, participants are encouraged to bond and share experiences to gain a sense of belonging and normalization. In couple or conjoint sessions, participants are encouraged to co-construct narratives with each other and to open up about intra and interpersonal distress in a safe environment. Similarly, complementary and alternative modalities (CAM; e.g., equine and art therapy), as well as therapeutic recreation (e.g., yoga, massage, and hiking; Monk et al., 2016) are also provided to inspire relaxation when not in more formal sessions. These alternative, recreational modalities have recently received empirical attention for their mental health benefits. For example, recreational activities such as hiking in nature compared to urban environments have been found to reduce symptoms of anxiety (Bratman, Daily, Levy, & Gross, 2015); and yoga as an augmentation to therapy has also been found to decrease depression symptoms (see Woolery, Myers, Sternlieb, & Zeltzer, 2004). The current retreat program included approximately 10 hr of group psychoeducation, 6 hr of CAM modalities, and approximately 3 hr of therapeutic recreation activities.

Between July 2013 and May 2015, eight retreats were held in three different locations in the U.S. (Florida, Georgia, and Illinois). Treatment fidelity was monitored in a number of ways: (a) by having consistency in staff leadership who oversaw the overall operation of the retreats, (b) providing consistency in content, activities, and the identified core components of the model, and (c) staff trainings for additional retreat facilitators. Each retreat accommodated 14–16 veterans and their primary support persons who were recruited from around the retreat locations. Participants were recruited through regional Veterans Affairs Hospitals, local military and veteran support organizations, colleges and schools, behavioral health providers, and word of mouth. Participating veterans must have served in the military, but could be from any branch of service and could be active duty, retired, or discharged status. They also were required to attend with a primary support person and have posttraumatic stress symptoms or a PTSD diagnosis from a primary care provider. All participants completed a thorough screening form and telephone interview prior to acceptance into the program. Participants were asked to complete a battery of pre- and posttest measures, in addition to postretreat program evaluations. University Institutional Review Board (IRB) approval was received for completion of the research protocol that is part of the retreat program.

Measures
Relationship adjustment
Relationship adjustment was assessed with the Dyadic Adjustment Scale (DAS; Spanier, 1976) in those who attended with a romantic partner. This 32-item self-report measure assesses perceived relationship quality of both partners. Total scores range from 0 to 151, with higher scores indicating greater relationship adjustment. Examples of items include: “How often have you discussed or considered divorce, separation, or terminating your relationship”; “How often do you and your partner “get on each other's nerves”“; and, “Do you and your partner engage in outside interests together?” Cronbach's alpha results for the current study were α = .93 for partners and .93 for veterans. A cut-score of 97.5 has been validated in previous studies to provide a potential threshold for relationship distress (see Funk & Rogge, 2007); thus, scores above this cutoff are indicative of nondistress, whereas scores below this threshold indicate potential relationship distress.

Traumatic stress symptoms
The PTSD Checklist (PCL; Weathers, Litz, Herman, Huska, & Keane, 1993) has been widely used to assess PTSD symptomatology. In response to the recently updated Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2013) and modifications to the diagnostic criteria of PTSD, an updated version of the measure, the PCL-5 (Weathers et al., 2013), has been developed. The PCL-5, used in this study, is a 20-item self-report scale based on DSM-5 criteria for PTSD. Total symptom severity scores range from 0 to 80; preliminary suggestions for the PCL-5 endorse scores of 33 or above being sufficient for a provisional diagnosis of PTSD (Weathers et al., 2013). It should be noted, however, that the PCL is not a clinical diagnostic instrument, though it can be used to monitor symptom change during and after treatment (Weathers et al., 2013), which was the intent in the current study. Veterans and primary support persons were asked to identify their most stressful experience and to respond to the items based on this self-identified experience, which is the recommended procedure for the PCL-5. In the current study, these experiences included reports of combat-related trauma, reports of previous violence, abuse, or sexual assault, and reports of the death of a friend or family member.

Because the PCL-5 is a newly revised assessment, there is limited information on the psychometrics of this measure. Blevins, Weathers, Davis, Witte, and Domino (2015) suggest that the PCL-5 is a valid and reliable instrument: internal consistency (α = .94), test–retest reliability (r = .82), convergent (rs = .74–.85), and discriminant (rs = .31–.60) validity were all adequate (Blevins et al., 2015). Cronbach's alpha results for the current study were α = .95 for veterans and .98 for support persons.

Posttraumatic growth
Posttraumatic growth was assessed using the Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1995, 1996). The PTGI was used in the current study to assess positive changes reported by participants during the retreat beyond anecdotal reports of progress. The PTGI is a 21-item self-report assessment designed to measure the positive changes after a traumatic experience. Participants were asked to indicate the degree to which they felt a change had occurred in their life as a result of their trauma (e.g., I have changed my priorities about what is important in life; I established a new path for my life; I have more compassion for others) using a 6-point Likert scale, from 0 (I did not experience this change as a result of my crisis) to 5 (I experienced this change to a very great degree as a result of my crisis). Total scores range from 0 to 105, with higher scores indicating greater posttraumatic growth. Cronbach's alpha results for the current study were α = .91 for veterans and .92 for support persons.

Results
For veterans, there was 18% missing data for the PTGI, 2% missing for the DAS, and 9% missing for the PCL at posttest. For primary support persons, there was 16% missing data for the PTGI, 2% missing for the DAS, and 21% missing for the PCL at post-test. Attrition analyses showed that there were no significant differences between participants who did or did not complete surveys at posttest. See Table 1 for means and standard deviations for variables of interest, as well as effect size estimates.

Table 1. Descriptive Information for Variables of Interest (N = 76 dyads, N = 53 romantic couples)
Variable	Pretest	Posttest	df	t	Effect size (r)
M	SD	M	SD
Primary veteran PCL	46.88	19.85	39.74	20.86	56	3.151**	.39
Support person PCL	34.65	24.24	25.63	20.66	39	3.136**	.45
Primary veteran PTGI	38.45	16.06	40.74	18.65	48	−0.782	.11
Support person PTGI	34.04	17.92	43.26	23.71	49	−3.668***	.46
Primary veteran DAS	97.92	21.98	101.80	21.84	38	−2.504*	.38
Support partner DAS	97.33	21.23	104.36	15.99	38	−3.575***	.50
Note.
*p < .05. **p < .01. ***p < .001.
Final models were run using Hierarchical Linear Modeling (HLM 7; Raudenbush, Bryk, & Congdon, 2010) to account for the dependence between dyad members. Missing values on items were handled using restricted maximum likelihood. A two-intercept model was used to estimate unique parameters for veterans and support persons simultaneously (Raudenbush, Brennan, & Barnett, 1995). We ran separate growth models for each of the three dependent variables in which we estimated intercepts and linear time slopes. An example equation for the two-intercept model analyses is as follows:

Level-1 Model:
urn:x-wiley:0194472X:media:jmft12230:jmft12230-math-0001
Level-2 Model:
urn:x-wiley:0194472X:media:jmft12230:jmft12230-math-0002
Hypothesis 1: Relationship Adjustment
To test Hypothesis 1, for those participants who attended with a romantic partner (n = 106), we assessed change in relationship adjustment from pretest to the postintervention assessment. First, models were run including controls (i.e., education level, age, income, veteran rank, and relationship length); however, these variables failed to reach significance so they were dropped from the final model for parsimony (see Table 2). There was a significant increase in relationship adjustment for veterans and partners from before to after the intervention. In addition to the average increase across the sample, at pretest, 45.2% of partners met the criteria (<97.5; see Funk & Rogge, 2007) for potential relationship distress; whereas only 35.4% were below the cut-off, indicating potential distress at posttest. Similarly for veterans, 56.5% met the criteria for potential relationship distress at pretest, compared to 42.2% at posttest. Thus, both veterans and their partners reported significantly higher posttest relationship adjustment scores compared to their pre-test scores after participating in the retreat intervention, which supports Hypothesis 1.

Table 2. Multilevel Model for Relationship Adjustment in Couples (N = 53 couples)
DAS	Unstandardized coefficient	SE	df	t-ratio	Effect Size (r)
Primary veteran baseline, γ10	97.53	2.93	52	33.25***	.98
Partner baseline, γ20	98.44	3.15	52	31.21***	.97
Primary veteran time, γ30	3.59	1.51	177	2.38*	.18
Partner time, γ40	7.30	1.95	177	3.74***	.27
Note.
Nonsignificant controls were removed for parsimony.
*p < .05. ***p < .001.
Hypotheses 2 and 3: Posttraumatic Growth and Trauma Symptoms
To test Hypotheses 2 and 3, we assessed posttraumatic growth in both veterans and support persons with the full sample (n = 152). Support persons reported a significant increase in post-traumatic growth scores following the intervention, controlling for education, income, age, veteran rank, and veteran PTSD diagnosis. Although veterans had an increase in mean PTGI scores, this increase failed to reach statistical significance. Thus, Hypothesis 2 was partially supported because only the partners or primary support persons reported significant increases in posttraumatic growth scores from pre- to posttest. See Table 3 with nonsignificant controls removed.

Table 3. Multilevel Model for Post-Traumatic Growth and Trauma Symptoms (N = 76 dyads)
Unstandardized coefficient	SE	df	t-ratio	Effect size (r)
PTGI
Primary veteran baseline, γ10	38.71	2.18	75	17.78***	.90
Support person baseline, γ20	34.21	2.33	75	14.70***	.86
Primary veteran time, γ30	0.77	2.78	231	0.28	.02
Support person time, γ40	8.34	2.38	231	3.51***	.23
PCL
Primary veteran baseline, γ10	47.30	2.31	74	20.48***	.92
Support person baseline, γ20	29.78	3.40	74	8.76***	.71
Primary veteran time, γ30	−6.95	2.18	226	−3.19**	.21
Support person time, γ40	−8.19	2.77	226	−2.96**	.19
PCL with significant control variable
Primary veteran baseline, γ10	27.95	3.69	73	7.58***	.66
Support person baseline, γ20	59.31	10.60	73	5.59***	.54
Primary veteran time, γ30	−7.37	2.19	221	−3.36***	.22
Support person time, γ40	−7.66	2.79	221	−2.75**	.18
Support person age γ50	−0.73	0.25	221	−2.91**	.19
Primary veteran PTSD γ60	23.78	4.20	221	5.66***	.36
Note.
Nonsignificant controls were removed for parsimony.
**p < .01. ***p < .001.
There was a significant decrease in trauma symptoms for both veterans and support persons from pretest to posttest. Prior veteran PTSD diagnosis was positively associated with posttest trauma symptoms, but was the only significant control in the model. See Table 3 for PCL models with and without the significant control variable for adjusted coefficient values. Weathers et al. (2013) proposed a cut-point of 33 as a reasonable indicator for a PTSD diagnosis until further psychometric studies can be conducted. At pre-test, 54.3% of support persons and only 22.7% of veterans were below the clinical threshold for PTSD (as a nondiagnostic indicator of not having PTSD), compared to 69.1% and 38.1% for support persons and veterans, respectively, at posttest. It is important to note, however, that the PCL cut-off score of 33 has not yet been fully evaluated and serves only as a descriptive point of reference, not as a definitive diagnosis in the present study. Thus, Hypothesis 3 was supported, as both veterans and their partners/primary support persons reported significantly fewer posttest trauma symptoms compared to their pretest scores after participating in the retreat intervention.

Discussion
This pilot study provides preliminary support for a brief systemic veteran retreats model. Specifically, we found that from pretest to posttest, veterans and romantic partners had a significant increase in relationship adjustment, veterans and support persons reported a decrease in trauma symptoms, and support persons reported an increase in posttraumatic growth. These findings not only replicate previous evaluations of the retreats model, in which a reduction in distress was found for both veterans and partners (Monk et al., 2016), but also extend the research on the model. In fact, compared to the initial assessment, the current study includes a shorter treatment (i.e., 4-days), more variation in support persons attending (i.e., beyond romantic couples), an updated measure of trauma symptoms, and includes measures of relationship adjustment and posttraumatic growth as potential benefits of participation. The additional assessments are important given, for example, the profound link between trauma, resilience, and relationship distress (e.g., Monson et al., 2009; Taft et al., 2011; see also Anderson, Amanor-Boadu, Stith, & Foster, 2013).

From a family systems perspective (e.g., Nelson Goff & Smith, 2005), incorporating another person from the veterans’ environments can be beneficial given the support they can provide (see Sautter et al., 2011). In addition, including another person from the system could provide awareness about the effects of trauma for both participants. This awareness may potentially reduce the likelihood of returning to homeostasis (i.e., pretreatment functioning) by reducing interference from partners, the transmission of distress (e.g., secondary trauma), or negative feedback within the system (e.g., Knobloch & Theiss, 2011; see also MacDermid Wadsworth et al., 2013). In fact, having a partner who does not attend treatment, for example, may disrupt recovery and progress if others in the system do not understand the experience of trauma or the change process (see Blount, Fredman, Pukay-Martin, Macdonald, & Monson, 2015). Furthermore, interacting with someone who experiences symptoms of trauma like angry outbursts, for example, may be distressing for other family members; thus, it can be helpful for others in the system to also receive direct assistance.

A 2011 Pew Research Center study found that post-9/11/01 veterans are having a significantly more difficult time than veterans who served in previous conflicts, and are more likely to suffer from posttraumatic stress (PTS). This risk was particularly present when service members had been exposed to combat trauma or were seriously injured, and were also plagued by marital or family problems while deployed (Morin, 2011). These and other current trends indicate a need for more community-based and systemic assistance to be available. The retreat program reviewed here is unique for several reasons, particularly because of the inclusion of empirical program research and because of the community-based, systemic focus, which may contribute to eliminating feelings of isolation that can accompany PTSD. There are a plethora of services and retreats provided for service members, military spouses, and military children, but often veterans and their families may be overlooked or limited in the types of services they can receive, or think that they can receive (see MacDermid Wadsworth et al., 2013). While there are many organizations that treat military personnel, there can be challenges to providing adequate services to veterans due to bureaucratic and governmental barriers as these programs are inundated with those in need. Brief community-based interventions may be a viable starting point for these overwhelmed service providers and show promise for attracting participants.

The current results suggest that improvements can be made for veterans when including a primary support person in their care and treatment can be beneficial even if it is brief. In fact, with many scholars calling for additional research in this area (e.g., Bobrow et al., 2013; Davis et al., 2012) and the fact that long-term treatments can have issues attracting and retaining participants (e.g., Imel et al., 2013), there are many benefits to brief formats. It is important, however, to advocate that clients continue to receive long-term services for progress monitoring after the retreats because brief programs are not a substitute for in-depth therapy in many cases. Nevertheless, retreat-style interventions have been shown to inspire participants to pursue additional treatment and services due to their positive experience (Davis et al., 2012). Thus, attracting participants through brief services may be beneficial in making them open to continued treatment, including couples- and family based PTSD interventions (see Blount et al., 2015; Monson et al., 2012; Sautter et al., 2011, 2015; Schumm et al., 2013).

Increasingly, local communities are being called on to provide support for the veterans and their families returning with combat-related injuries, both visible and invisible. For those veterans and families who do engage in services, it is important to gain an understanding of their experiences with both military and community-based services, as well as where they are most likely to receive assistance. It is salient to understand what additional individual and systemic factors may inhibit veterans and their families from seeking help. While there are studies investigating effective programs for returning veterans, the level of engagement in those services has not been fully addressed. Future research should explore retention efforts within similar programs for military families. The need to provide programs, like the retreat described here, that will assist with distress, the transition to civilian life, and reintegration into communities remains a critical and unmet need of today's post-9/11/01 veterans and families.

Clinical Implications
As a brief systemic intervention model, retreats can provide a unique holistic healing experience for veterans and their support persons. Removing barriers to connection while reducing feelings of isolation, as well as normalizing experiences and empowerment through community group interaction may help participants overcome the debilitating symptoms of distress (see Bobrow et al., 2013; Huebner, Mancini, Bowen, & Orthner, 2009; Monk et al., 2016; Walsh, 2013). Furthermore, because brief interventions are implicated in having better retention rates than long-term treatment programs (Imel et al., 2013), the shorter adaptation of the model may appeal to individuals less likely to seek help from other services.

A recent Institute of Medicine report indicated that “in spite of the variety of support services available on installations or in the community, family members—including spouses, partners, children, and parents—are often unsure of where to get information about PTSD, how to encourage a service member to seek treatment, and how to assist them with their treatments” (Institute of Medicine, 2014, p. 227). While there is a plethora of services available to veterans and families (i.e., both DoD and VA programs, as well as community-based services to assist with reintegration), these services are often not used or are underutilized by veterans and their families (Institute of Medicine, 2013). Moreover, many programs do not provide services for the military family as a unit or address any issues that are family based. Reports indicate that 40–50% or fewer service members diagnosed with a significant behavioral health problem actually seek or receive the services needed (Hoge et al., 2004); these numbers remained steady in a related study a decade later (Hoge et al., 2014).

For many veterans and their families, barriers to obtaining care are numerous and seemingly insurmountable, often involving felt stigmatization, limited resources, ineffective treatments, or lack of recognition of the seriousness of the problems (Hoge et al., 2014; Kim et al., 2010). Thus, the level of impairment and distress experienced by all family members may result in long-term negative effects when services are not sought or received. The current retreat program described here is not intended to replace PTSD treatment, but to augment or provide a bridge to services that address the impact of combat-trauma and deployment stress. It is critical that clinicians and scholars provide additional insight that will contribute to the development of improved community-based systems of care for veterans and their families.

Given the appeal and benefits of including others from the family system (see Fischer et al., 2015; Khaylis et al., 2011), incorporating the veterans’ close system members to raise awareness and support could be a promising approach. In fact, the IIR model provides a framework for the systemic modalities that may be beneficial for decreasing distress for veterans and those in their support system. For example, including interaction with other veterans and partners in group discussion facilitated by a trained practitioner can potentially decrease feelings of isolation and provide a sense of normalization (see Monk et al., 2016, for more information on clinical modalities).

Limitations
As with any study, our findings should be viewed in the context of their limitations. First, we did not utilize a randomized control condition due to funding constraints for this pilot project. A strong next step for assessing the IIR model would be the inclusion of a control group to assess treatment effects explicitly. Nevertheless, case studies of one couple through an intervention (e.g., Blount et al., 2015; Fredman, Monson, & Adair, 2011; Luedtke et al., 2015) and small sample evaluations without control groups (e.g., Monson et al., 2011; Sautter, Glynn, Thompson, Franklin, & Han, 2009; Schumm et al., 2013) still provide important, initial insight into treating military couples. Moreover, a longitudinal follow-up was not conducted to assess progress maintenance. In a previous evaluation of the model, researchers conducted an assessment with a follow-up 6-months after the posttest, which provided support for maintaining trauma symptom reduction (Monk et al., 2016). The current study, however, does not provide evidence that other benefits (i.e., relationship adjustment and post-traumatic growth) are sustained over-time. Although a request to complete a follow-up online survey was sent to all participants through email, less than 10% of participants completed the follow-up assessments; thus, the follow-up was not included in the current analyses due to potential bias in the findings. In order to examine the application of skills learned and the maintenance of retreat outcomes across time, future studies should collect complete longitudinal data, which could inform revisions to the current intervention. Similarly, despite the fact that there were no significant differences between those who did and those who did not complete posttest surveys, there were a number of incomplete surveys at posttest, which reduced the strength of our analyses.

Nevertheless, there was little attrition in the retreats themselves (only two veteran couples left the retreat prior to completion), even though some participants did not complete posttest measures. Thus, by adopting more brief and systemic approaches to treatment, professionals may be able to increase attendance and retention rates among veterans and their families. This is encouraging considering that retreats may be a catalyst for seeking longer term services later (see Davis et al., 2012). Furthermore, although most veteran participants and several primary support persons reported having a current PTSD diagnosis prior to the retreat, a clinical interview was not conducted to determine diagnostic status. This limitation makes it unclear if previous diagnoses of trauma were maintained across treatment because assessment of symptoms only provides limited information about the participants’ experiences. Although a reduction in distress symptoms is promising, future research would benefit from thorough diagnostic interviews before and after the retreat interventions.

Conclusion
A potential way to address systemic distress and enhance posttraumatic growth is by incorporating support persons, such as intimate partners or family members, into veterans’ interventions (see Sautter et al., 2011). With the need for more short-term treatments (see Imel et al., 2013), and the desire for treatments to be family focused (Khaylis et al., 2011), this retreat model can provide a helpful brief service to veterans and their support systems. By providing psychoeducation, skills training, complementary and alternative modalities, and a welcoming sense of community, this systemic retreat model could promote symptom management, enhanced growth, and reduced psychological and interpersonal distress. Although further assessment is needed, particularly the comparison to a waitlist control group, the results of this pilot program suggest that this retreat model is a promising intervention for military veteran families."



Lindstrom, C. M., Cann, A., Calhoun, L. G., & Tedeschi, R. G. (2013). The relationship of Core Belief Challenge, rumination, disclosure, and sociocultural elements to posttraumatic growth. Psychological Trauma: Theory, Research, Practice, and Policy, 5(1), 50–55. https://doi.org/10.1037/a0022030 :
"The relationship of challenge to core beliefs, rumination, disclosure, and some sociocultural elements to posttraumatic growth (PTG) were explored. Participants were college students enrolled in psychology classes who reported having experienced a stressful event within the past 2 years and who completed measures in groups. Findings suggested that challenge to core beliefs was the main predictor of PTG, and that a very large proportion of the sample had encountered themes of PTG in their sociocultural contexts.
KEYWORDS:

posttraumatic growth, rumination, core beliefs, trauma

Traumatic events are rather common (Norris & Slone, 2007), and most research on their impact has focused on the development of posttraumatic problems (Joseph, Linley, & Harris, 2005). However, over the past 30 years, there has been growing interest in the experience of positive change in the aftermath of trauma. The idea that positive change can be found after a traumatic event is age-old, but the systematic study of these changes is more recent (Joseph, Yule, & Williams, 1993; Park, Cohen, & Murch, 1996; Tedeschi & Calhoun, 1995).
Posttraumatic growth (PTG), the experience of positive change as a result of the struggle with a major life crisis (Calhoun & Tedeschi, 1999), has been reported by people who have experienced a wide range of events, including cancer (e.g., Cordova, Cunningham, Carlson, & Andrykowski, 2001; Weiss, 2004; Cordova et al., 2007), sexual assault (e.g., Grubaugh & Resick, 2007), combat (e.g., Maguen, King, King, & Litz, 2006), natural disasters (e.g., Cryder, Kilmer, Tedeschi, & Calhoun, 2006), and HIV/AIDS (e.g., Milam, 2004). PTG has been reported on at least five dimensions: Relating to Others, New Possibilities, Personal Strength, Spiritual Change, and Appreciation of Life (Morris, Shakespeare-Finch, Rieck, & Newbery, 2005; Tedeschi & Calhoun, 1995, 1996). Relating to Others includes the realization of how good and supportive people are as well as a sense of increased closeness in relationships. New Possibilities is the experience of new options that had previously not been considered, and it can include the discovery of a new life path. Personal Strength is the realization of oneself as being stronger than was previously thought. Spiritual Change is illustrated by a greater understanding of spirituality and increased faith in a higher power. Appreciation of Life can entail a revision of life priorities and a new appreciation for how precious life is. Earlier research focused on the occurrence and prevalence of PTG. More recently, the focus has shifted to seeking to assess what contributes to the process of growth and why the experience of growth varies across individuals.
One of the factors hypothesized to be important for setting the stage for subsequent PTG is the occurrence of events that present a challenge, that shake, or that shatter the core beliefs that comprise the person's assumptive world (Janoff-Bulman, 1992; Linley & Joseph, 2004; Parkes, 1971; Tedeschi & Calhoun, 1995, 2004). The assumptive world is a “general set of beliefs and assumptions about the world, that guide actions [and] help understand the causes and reasons for what happens” (Tedeschi & Calhoun, 2004). Previous research has indicated that the amount of PTG reported is correlated with the degree of challenge to one's core beliefs about the world and one's place in it (Cann et al., 2010). The challenge to the assumptive world is assumed to lead to cognitive processing of the event in the form of repeated thought about what happened.
The term rumination has been used, by some but not all scholars, to denote exclusively negative and intrusive thinking (e.g., Lyubomirsky & Nolen-Hoeksema, 1995; Nolen-Hoeksema & Morrow, 1993). However, rumination, as the word is used here, follows the original meaning of the term, to mean repetitive thinking (Watkins, 2008). Rumination can be intrusive, when unwanted thoughts invade the person's cognitive world. Rumination can also be a thoughtfully reflective (Nolen-Hoeksema & Davis, 2004), deliberate, and purposeful reexamining of the event and related issues (Calhoun, Cann, Tedeschi, & McMillan, 2000). As Martin and Tesser (1996) have suggested, rumination can include reflecting on events, trying to understand them, reminiscing, and trying to find solutions to life problems. Although intrusive rumination tends to occur for most, if not all, trauma survivors, deliberate rumination, where the person decides, consciously and explicitly, to think about something, can also occur. This deliberate kind of rumination may be more conducive to PTG than is the kind of intrusive thinking that is typical after a highly stressful event, because the presence of more deliberate and of less-intrusive rumination tends to be related to PTG (Affleck & Tennen, 1996; Calhoun et al., 2000). Deliberate rumination, in this context, can involve thinking about possible positive repercussions of the event, for example, “I think this event helped me realize I am much stronger than I had thought'” and it may also involve deliberate and conscious attempts to remind oneself of benefits experienced as a result of being forced to face a very difficult situation (Affleck & Tennen, 1996; Folkman, 2008).
In contrast, intrusive rumination is unwanted thinking that happens without the person wanting it and it is likely to be distressing. The thought may be experienced as an annoyance or worse. Although intrusive rumination is likely for most trauma survivors soon after the event, PTG is theorized to occur for individuals who move away from intrusive rumination and enter into more deliberate ruminative processing as time since the event increases (Tedeschi & Calhoun, 1995, 2004).
Another factor that may affect the process of PTG is self-disclosure about one's reactions to the highly stressful event. The general psychological benefits of disclosure are well-documented (Lepore & Smyth, 2002; Niederhoffer & Pennebaker, 2009; Pennebaker, 2003). There is also some indication that disclosure may be related to the amount of growth reported. For example, a study with cancer patients found that disclosure about their illness was positively associated with stress-related growth (Henderson, Davison, Pennebaker, Gatchel, & Baum, 2001). A study with Japanese university students found that those who had told others about their experience with a highly stressful event and who experienced mutual disclosure reported more PTG than those who did not (Taku, Tedeschi, Cann, & Calhoun, 2009). These previous findings suggest that disclosure may be related to growth, but previous studies have not examined the specific content of disclosure and its relationship to growth. It seems likely that disclosure of growth themes will be more likely to be related to PTG than disclosure of negative posttraumatic experiences. However, little is known about this aspect of the process of development of growth.
Sociocultural influences have also been proposed as an important component to the development of PTG (Weiss & Berger, 2010). One of the influences proposed as an important covariate of PTG is the degree to which themes of growth are culturally available to the individual who has experienced a traumatic event. The degree to which people are exposed to cultural themes that growth can come from the struggle with a traumatic event has been hypothesized to impact the degree to which they will report PTG (Calhoun & Tedeschi, 2006; Calhoun, Cann, & Tedeschi, 2010). Exposure to growth themes, both through the broader culture (e.g., TV, Internet, and newspapers) and through one's more proximate social network (e.g., friends or family reporting positive changes resulting from difficult experiences), may contribute to the experience of PTG. If themes of PTG are available to persons who are coping with a major stressor, they may be more likely to report growth.
The current study was designed to examine the relationship of threat to core beliefs, rumination, disclosure experiences, and exposure to cultural themes of growth to posttraumatic growth.
Method

Participants
Participants were recruited via an online system at a large public university in the Southeastern United States. They were undergraduate college students enrolled in introductory psychology courses who participated for course credit. Originally, 213 students participated in this study, which was identified as requiring personal reactions to a highly stressful event experienced in the past 2 years. However, 84 participants were excluded from the analyses. Exclusion criteria were as follows: if event occurred more than 2 years before, if event did not meet criteria for a traumatic event as defined by the DSM-IV-TR (American Psychiatric Association, 2000), and if the event was rated as less than 4 on a 7-point scale of stressfulness. The final sample of 129 participants included 87 (67.4%) women and 42 (32.6%) men. Participants ranged in age from 18 to 47 years (M = 20.29, SD = 3.73) and included 87 (67.4%) Caucasians, 23 (17.8%) African Americans, 9 (7%) Asians, 5 (3.9%) Native Americans, 4 (3.1%) Latinos, and 1 person did not list their ethnic identification. Almost all participants (N = 127) were single. The most commonly reported traumatic events were death of a family member (43 participants, 33.3%), death of a close friend (26 participants, 20.2%), serious accident (16 participants, 12.4%), sexual assault (8 participants, 6.2%), and other (16 participants, 12.4%), which included, for example, life-threatening illness of a family member, suicide of a loved one, and unplanned pregnancy.
Procedure
Measures were administered to participants in groups of up to 10; they were asked to read the informed consent form and were given an opportunity to ask questions. Participants were asked to focus on a highly stressful event they had experienced in the past 2 years. Completion of measures took approximately 10–15 min. Order of presentation of measures was counterbalanced to control for order effects.
Measures
Stressfulness of the event
Stressfulness of the event was assessed with two separate items. One asked for a rating of stressfulness at the time of the event (How stressful was the event for you at the time it happened?) and the other for a rating of current stressfulness (How stressful is the event for you now?). Responses were made on 7-point Likert scales ranging from 1(not at all stressful) to 7 (extremely stressful).
Core Beliefs Inventory (CBI)
The CBI (Cann et al., 2010) is a nine-item measure that assesses the degree to which a traumatic/stressful event causes people to reevaluate their assumptive worlds, including beliefs about themselves, other people, the future, and the world. Items were rated on a 6-point scale ranging from 0 (not at all) to 5 (to a very great degree). Scores can range from 0 to 45 (M = 28.06, SD = 9.19). The CBI has been shown to have good internal reliability (α = .82) (Cann et al., 2010) and acceptable test-retest reliability (.69). In the current study, the reliability for the CBI was α = .84.
Rumination scale
The Rumination Scale is a 24-item measure assessing intrusive and deliberate rumination both “two weeks after” the event and in the past 2 weeks (α = .93 for intrusive items, α = .80 for deliberate items); the present scale is based on items used in a previous study (Calhoun et al., 2000). There are 12 distinct items, with six assessing intrusive rumination (e.g., Thoughts about the event came to mind and I could not get rid of them, I could not keep images or thoughts about the event from entering my thoughts) and six assessing deliberate rumination (e.g., I thought about the event and tried to figure out how I could make sense out of what happened, I deliberately thought about how the event had affected me). Participants respond to the same six deliberate and intrusive rumination items separately for each of the two time points.
Self-disclosure about the event
Two items were used to assess disclosure of consequences of the event: “Sometimes, did you actually discuss negative consequences of this event with your friends or family?”, and “Sometimes, did you actually discuss with your friends or family, positive things that came from your struggle with this event?” (Yes = 1, No = 2).
Sociocultural context
The sociocultural context was assessed using a 7-item measure developed for this study. The items assessed the availability of PTG themes in both the proximate (e.g., I have known several people who experienced really tough situations and saw benefits in their experience) and distal culture (e.g., I have seen TV shows or movies where people who faced really tough losses changed for the better because of that). Items are rated from 0 (strongly disagree) to 5 (strongly agree). Responses to the items were summed to obtain a total score to indicate overall exposure to growth themes (possible range of scores is 7–35; M = 27.56, SD = 3.40). Internal consistency was only marginally acceptable (α = .65).
Posttraumatic Growth Inventory (PTGI)
The PTGI (Tedeschi & Calhoun, 1996) is a 21-item inventory that assesses five domains of growth. Items are rated on a 0 (I did not experience this change) to 5 (I experienced this change to a great degree) scale, and scores can range from 0 to 105 (M = 60.07, SD = 19.27). The scale has acceptable test-retest reliability, scores are not correlated with social desirability, and responses on the scale tend to be corroborated by others (Shakespeare-Finch & Enders, 2008; Tedeschi & Calhoun, 1996; Weinrib, Rothrock, Johnsen, & Lutgendorf, 2006; Wild & Paivio, 2003).
Results

Correlations between the major variables were conducted, and there were significant correlations between challenge to core beliefs (M = 28.06, SD = 9.19) and stressfulness of event at the time it happened (M = 6.43, SD = .72) (r = .22, p < .05); soon after event intrusive rumination (M = 13.56, SD = 4.04) (r = .24, p < .01); deliberate rumination soon after event (M = 10.46, SD = 3.35) (r = .37, p < .01); recent intrusive rumination (M = .6.70, SD = 5.39) (r = .38, p < .01); recent deliberate rumination (M = 6.86, SD = 4.29) (r = .44, p < .01); and PTG (M = 60.07, SD 19.27) (r = .58, p < 01). See Table 1.
TABLES AND FIGURES
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Table 1. Descriptive Statistics and Zero-Order Correlations Among Focal Variables
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The mean sociocultural context scores were quite high, with very limited variability (M = 27.56, SD = 3.40; minimum = 15, maximum = 35). Sociocultural context scores were not significantly correlated with any of the other variables of interest. Items assessing exposure to growth themes were generally rated highly, suggesting that growth is a common theme in the sociocultural contexts of the present participants. Total scores ranged from 15 to 35, and means on individual items (rated on 1–5 scales) were generally high, ranging from 3.69 to 4.29, indicating that respondents generally saw themes of growth as quite common in their sociocultural contexts.
To examine the effect of disclosure about the event, participants were divided into two groups, based on whether they had, or had not, discussed with others consequences of their struggle with the trauma; disclosure of positive consequences from the struggle were considered separately from negative consequences of the event. Participants who had discussed positive consequences of their traumatic experience reported more deliberate rumination soon after the event (M = 11.10, SD = 3.05) than those that had not discussed positive consequences of the trauma (M = 9.40, SD = 3.58, t(126) = 2.86, p < .01), and less current stress associated with the event (M = 3.51, SD = 1.61), than those who did not discuss positive consequences of the event (M = 4.23, SD = 1.49, t(127) = 2.53, p < .05). There were no differences between the two groups on total scores on the PTGI.
Those who discussed negative consequences of the trauma differed from those who did not only on deliberate rumination soon after the event; those who reported having discussed negative consequences scored higher on deliberate rumination soon after the event (M = 10.97, SD = 3.11) than those that did not (M = 8.64, SD = 3.61, t(126) = 3.38, p < .01). There were no differences between the two groups on total scores on the PTGI.
A stepwise regression analysis was conducted to assess the impact of several variables of interest on total PTG. Based on theoretical models of growth (Calhoun et al., 2010; Janoff-Bulman, 1992) and on previous findings (Cann et al., 2010), degree of challenge to core beliefs was entered first and predicted 34% of the variance in PTGI score (R2 = .34, F(1, 125) = 63.31, p < .001). In the next step, intrusive and deliberate rumination soon after the event were entered separately and, together, predicted an additional 6% of variance (R2 = .40, F(3, 123) = 27.53, p < .01), a significant change (change in R2 = .07, F change = 6.73, p < .01). In the third step, discussing negative and positive consequences of the trauma were entered separately and, while not significant, predicted an additional 2% of variance (R2 = 42%, F(5, 121) = 17.48, p < .001). Finally, recent intrusive and deliberate rumination were entered separately and, together, predicted an additional 2% of variance (nonsignificant change), resulting in an overall 44% of variance being predicted by the model [R2 = .44, F(7, 119) = 13.23, p < .001]. See Table 2.
TABLES AND FIGURES
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Table 2. Hierarchical Multiple Regression Predicting Posttraumatic Growth
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Discussion

The current study was perhaps the first to directly assess the relationship of specific proximate and distal sociocultural factors to self-reported PTG. Although no relationship was found between self-reported exposure to cultural themes and growth, the very limited range of scores, with the possibility of ceiling effects, may have influenced this finding. What was surprising was the very large proportion of participants who reported at least some cultural exposure to themes of growth. Ninety-eight percent, for example, reported having heard or read stories of people who had experienced positive changes as a result of their struggle with very difficult events, and the mean score on the sum of items assessing exposure to growth themes was approximately 28 of a total possible score of 35. These findings may be the most interesting of this cross-sectional study, because they indicate that themes of PTG are readily available to almost all people in the present sample. A needed next step is an assessment of the degree to which these findings are representative of other places in North America in particular, and the world more generally.
The current study provides additional support for the important relationship between challenges to core beliefs and PTG. Present findings are congruent with both theoretical predictions (Calhoun & Tedeschi, 2006; Janoff-Bulman, 1989, 1992, 2006) and with recent empirical findings (Cann et al., 2010). Significant challenge to the assumptive world appears to be an important correlate of, and perhaps causal antecedent to, PTG. If a traumatic event does not present a challenge to previously held beliefs, the processes necessary to produce growth (e.g., rumination, self-disclosure, etc.) are unlikely to occur. The discomfort caused by the discrepancy between previously held core beliefs and new, contradictory information is purported to prompt the need to engage in these processes. However, longitudinal studies are needed to confirm that core beliefs challenge precedes growth.
The present study also provides some additional information on the possible impact of disclosure about a traumatic event. Disclosure about negative consequences was associated only with deliberate rumination recalled as having occurred soon after the event. However, participants who reported having disclosed about the positive impact of the struggle with the traumatic event reported more deliberate rumination soon after the event, and less current stress related to the event, than those who reported no such disclosure. One possible reason for these relationships is that higher levels of deliberate rumination may not only increase the likelihood of disclosure, but disclosure, especially disclosure that is socially accepted or reinforced, may, in turn, increase the likelihood of deliberate positive rumination about the stressful event. The finding that disclosure about positive consequences of the trauma is associated with less current stress is congruent with other findings on the effects of disclosure about traumatic experiences (Taku et al., 2009). Present findings suggest that it may be useful to further investigate the relationships between disclosure, especially disclosure about positive consequences of having to deal with a very difficult situation, the social and cultural responses to such disclosure, and PTG.
Unlike a previous study done on disclosure in Japan, there was no clear relationship between PTG and disclosure in the present findings; there are at least two possible reasons for this. One possible explanation is that disclosure may somehow be a more salient, impactful social action in Japan than it is in the United States. In addition, the present study assessed disclosure dichotomously and did not include any measure of the perceived responses to the disclosure, factors which may have moderated the effect of self-disclosure. Future studies should assess not only whether disclosure occurred, but also what the responses to disclosure were.
The findings from the regression predicting PTG indicate that the process by which growth occurs is complex and involves the interplay of many factors. Challenge to core beliefs, deliberate and intrusive rumination, both soon after the event and recently, and disclosure about positive and negative consequences of the trauma together predicted 44% of the variance in growth. A considerable amount of the variance of PTG is accounted for by the challenge to core beliefs, additional evidence that such threat to the assumptive world is an important element for understanding the process of PTG (Cann et al., 2010). The threat to the assumptive world likely sets in motion other processes, such as intrusive rumination and deliberate rumination, which may, in turn, have an impact on the degree of growth experienced and reported, as proposed models of PTG suggest (Calhoun & Tedeschi, 2006; Janoff-Bulman, 1992; Linley & Joseph, 2004).
This study has several limitations. One major limitation is its cross-sectional design, so the findings do not offer indication either of causality or of temporal sequence. A second limitation is that it was conducted with a sample of undergraduates from one region of the United States, and generalizations to other people, in other places, must be done with caution. A third limitation is that the assessment of self-disclosure and sociocultural context, although having face validity and at least minimally acceptable internal consistency, are not established measures and have not been used in other contexts.
In spite of its limitations, the present findings suggest that threat to the assumptive world and repetitive thought about the event are variables that need to be continued to be included in studies of the antecedents and causes of PTG. Perhaps, more importantly, however, these findings suggest it may be important to include an assessment of sociocultural variables in future studies of PTG. At least in this group of participants, themes of PTG were common components of their sociocultural contexts, a finding that suggests the importance of assessing such cultural elements in the study of both PTG and posttraumatic distress"

Russell, B., & Mussap, A. J. (2022). Rumination and threat-biased interpretation mediate posttraumatic stress and growth responses to military stressors. Military Psychology, 35(5), 451–466. https://doi.org/10.1080/08995605.2022.2127618:
"We examined the role of rumination and threat-biased interpretation in stress and growth responses to military stressors. Two online surveys were completed by 183 (survey 1) and 393 (survey 2) currently serving or retired military personnel. The surveys measured exposure to potential military stressors (exposure to combat, witnessing the consequences of war, and perceived moral injury), posttraumatic stress symptomatology (PTSS), posttraumatic growth (PTG), and personal wellbeing, with survey 1 including measures of rumination, and survey 2 including a measure of threat-biased interpretation. Path analyses revealed that indirect paths from both witnessing the consequences of war and experiencing betrayal to PTSS were mediated by intrusive rumination and threat-biased interpretation, and that indirect paths from both betrayal and transgressions by others to PTG were mediated by deliberate rumination and threat-biased interpretation. The results reveal the idiosyncratic nature of military stressors, their differential involvement with cognitions that underpin rumination about past events and interpretation of current events, and their relevance to posttraumatic stress and growth in military personnel.

KEYWORDS: Rumination, threat-biased interpretation, posttraumatic stress, posttraumatic growth, moral injury, personal wellbeing
What is the public significance of this article?—Military personnel are subject to occupational hazards that are potentially traumatic. This includes exposure to combat-related physical threats, witnessing and depravities of war, and experiencing transgressions and betrayals that can cause moral injury. These hazards are implicated in the high rates of posttraumatic stress disorder (PTSD) and posttraumatic stress symptomatology (PTSS) observed in this population. However, there is growing recognition that military experiences can also stimulate posttraumatic growth (PTG) and that this may have potential therapeutic benefits. We conducted two survey studies to better understand the cognitive processes that underpin PTSS and PTG associated with various types of military stressor. Participants were two groups of currently serving or retired military personnel. The first study examined the role of rumination about past stressors and confirmed that intrusive rumination about witnessing the consequences of war and experiences of betrayal are relevant to PTSS, whereas deliberate rumination about transgressions committed by oneself and experienced betrayals are relevant to PTG. The second study examined the role of threat-biased interpretation and found that such biases are associated both with transgressions and betrayals committed by others, and that both are relevant to increased PTSS and reduced PTG. In both studies, these cognitions were shown to be relevant to the personal wellbeing of participants. The results provide potentially important insights into the ways in which military stressors alter cognitions in ways that are relevant to psychosocial outcomes in military personnel and encourage attempts to develop cognitive theories that can explain both stress and growth responses in this population.

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Introduction
Psychological responses to military stressors
According to the DSM-5 (American Psychiatric Association, 2022), traumatic stressors can take the form of actual of threatened physical harm or injury, severe illness, or sexual violence experienced either personally, vicariously as a witness, or remotely and indirectly after the fact. Exposure to such stressors is common, with a lifetime prevalence rate in the civilian population of over 70% (Kessler et al., 2017).

In military personnel, exposure estimates are higher, with military personnel not only more likely to be exposed to traumatic stressors (Reger et al., 2019), but also more likely to be exposed to diverse types of stressor (Brownlow et al., 2018). These stressors often take the form of interpersonal physical trauma that is personally experienced (Kessler et al., 2017) or witnessed (VanBergen et al., 2020). Trauma results from deployment to conflict zones in which personnel are exposed to enemy fire, physical combat, and enemy mines, road-side bombs, and terrorist threats (Kelber et al., 2019). Stressors may also be encountered in the aftermath of armed conflict (Nordstrand et al., 2019), in the form of exposure to the death, injury, and physical suffering of combatants, as well as injury, hunger, and disease in civilians of war-ravaged communities. Such depravities are witnessed by combat personnel as well as medical staff, peacekeepers, and those involved in humanitarian operations (Karstoft et al., 2018). Military stressors can also take the form of exposure to transgressions that cause “moral injury” (Litz et al., 2009). This includes exposure to actions committed by self or by others that transgress one’s moral standards or professional code and can threaten one’s integrity, sense of purpose, duty, or sense of justice (Hall et al., 2022). Moral injury can also result from perceived betrayal by colleagues, superior officers, even people outside the military such as politicians or the public (Nash et al., 2013).

Military stressors are associated with mental health issues such as posttraumatic stress disorder (PTSD; Gerber et al., 2018). PTSD is characterized by widespread and maladaptive alterations to attention, judgment, perception, memory, and behavior (Bomyea et al., 2017). This includes intrusive reexperiencing in the form of rumination, flashbacks, and nightmares, avoidant behaviors and cognitions, negative and/or distorted attitudes, beliefs, and emotions, and arousal, hypervigilance and reactivity (American Psychiatric Association, 2022). PTSD in the military is also associated with serious behavioral problems such as physical aggression, substance abuse, self-harm, suicidal ideation, and attempted or completed suicide (Sheerin et al., 2018).

Traumatic stressors, including those encountered in the military, are also thought to stimulate a search for meaning and benefits-finding (Tedeschi & Calhoun, 2004). Posttraumatic “growth” (PTG) in the form of personal strength, relating to others, new opportunities, appreciation of life, and spiritual/religious change, have been reported in response to interpersonal threats in the form of sexual abuse, intimate partner violence, community violence and terrorism, natural disasters, serious injury, diagnosis with life-threatening or terminal illness, and bereavement (Zeligman et al., 2019). PTG is prevalent among civilian populations exposed to occupational trauma such as emergency services personnel (Ragger et al., 2019), and also in military personnel who have experienced or witnessed physical threats or in response to moral injury (Greenberg et al., 2021; Habib et al., 2018).

In the present paper we argue for research into military stressors that recognizes the diversity of these stressors and that accounts for both stress and growth responses to them. Our empirical approach was to explore the role of cognitions in mediating relationships between exposure to military stressors and responses to these stressors in the form of PTSS and PTG, and how these relationships are related to the personal wellbeing of military personnel. We focussed on two types of cognition, those involved in ruminating about past military stressors and those involved in interpreting current potential stressors.

The role of cognitions in posttraumatic stress in military personnel
Lifetime prevalence of PTSD for United States military veterans is 13.4% for women (compared to 8.0% for civilian women) and 7.7% for men (Lehavot et al., 2018). However, these estimates are variable and highly idiosyncratic (Murphy et al., 2020), depending on factors such as era of military service, military role, deployment duration, and the context of those deployments (Fonkoue et al., 2020; Forbes et al., 2019; Rona et al., 2007). Estimates are also complicated by concerns that PTSD may be over-diagnosed due to those seeking to profit from diagnosis, as well as under-diagnosed due to mental illness stigma in the military (see review by Gates et al., 2012). Furthermore, military personnel exposed to stressors but who do not meet the diagnostic criteria for PTSD may nonetheless experience subclinical levels of posttraumatic stress symptomatology (PTSS; Erickson et al., 2013).

Cognitive explanations of PTSD have focussed on risk and maintenance factors in the form of altered cognitions involved in rumination and anticipatory stress responses. Intrusive rumination is a diagnostic feature of PTSD (American Psychiatric Association, 2022). It takes the form of persistent uncontrollable thoughts about negative emotions and symptoms related to the original traumatic stressor (Nolen-Hoeksema, 1991), and because of this can re-expose victims of trauma to distress, prolong the psychological effects of the original stressor, and encourage avoidant coping at the expense of problem-solving strategies (Bomyea et al., 2017). Cross-sectional studies confirm associations between intrusive rumination, PTSS severity, and risk of PTSD in traumatized groups such as assault survivors, motor vehicle accident victims, diagnosis with serious or terminal illness, and emergency services workers (e.g.,; Brown et al., 2021). Associations between intrusive rumination and both PTSS and PTSD have also been observed in military personnel (Blackburn & Owens, 2016; Ramon et al., 2022). Although it could be argued that these associations merely reflect the fact that rumination is a symptom of PTSD, there is longitudinal research consistent with the idea that rumination is a contributing factor. For example, levels of intrusive rumination measured shortly after a exposure to a traumatic stressor predict subsequent PTSS (e.g.,; Seligowski et al., 2015; Szabo et al., 2017) and probability of developing PTSD (Kleim et al., 2007; Spinhoven et al., 2015).

Hyperarousal and hypervigilance are also diagnostic criteria for PTSD (American Psychiatric Association, 2022). They are problematic in their own right, for example, as risk factors for cardiovascular health (Chopko et al., 2021), but are also thought to be instrumental in maintaining PTSD by increasing psychophysiological reactivity to stimuli reminiscent of the original stressor and, perhaps more problematically, by creating negative biases in the way sufferers interpret and respond to future benign stimuli, scenarios, or events because of their perceived similarity to or association with the original traumatic stressor (Armour et al., 2017; Bomyea et al., 2017). Threat-biased interpretation is thought to undermine emotional regulation (Foa et al., 1989), interfere with adaptive inhibition of emotional responses to threats (M. Kimble et al., 2012), and lead to an overgeneralization of threat appraisals that can exacerbate and prolong arousal symptoms of PTSD (Boffa et al., 2018). As with intrusive rumination, there is evidence that biased responding to potential threats is not merely a symptom of PTSD but also both a response to military stressors and risk factor for PTSS/PTSD. Intensity of combat experienced during deployment has been found to predict post-deployment attention to threatening stimuli (Traynham et al., 2017) and, conversely, post-deployment hypervigilance has been associated with history of exposure to combat independently of one’s current PTSS levels (M. O. Kimble et al., 2013). Furthermore, longitudinal research with military personnel has shown that pre-deployment attentional avoidance of threatening stimuli predicts subsequent development of PTSD (Sipos et al., 2014) and PTSS post deployment (Beevers et al., 2011; Wald et al., 2013). Threat-biased interpretations are also thought exacerbate other symptoms of PTSD (e.g., intrusions are more likely to be misinterpreted as confirmation that the original threat is ongoing; Ehlers & Clark, 2000), and cause disruptions to psychosocial functioning, negative affect, and problems with psychological adjustment (Beck & Haigh, 2014).

The role of cognitions in posttraumatic growth in military personnel
PTG is conceptualized as the product of deliberate rumination in response to a threat, challenge, or disruption t
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