Combat veterans have higher rates of posttraumatic stress disorder (PTSD), depression, and generalized anxiety relative to the general population (Ramchand et al., 2015). They also have an elevated risk of developing PTSD and other mental health conditions such as depression, generalized anxiety, and substance use disorders compared to non-deployed veterans (Goodson et al., 2011). Moreover, diagnostic comorbidity seems to be the rule rather than the exception, with 53% of post-9/11 combat veterans meeting diagnostic criteria for more than one disorder (Shi et al., 2023). Unfortunately, these conditions tend to be associated with increased physical health morbidity and dysfunction, chronic pain, pulmonary disease, neurological, gastrointestinal, cardiovascular, musculoskeletal, and pulmonary problems (Wachen et al., 2013). These conditions are also associated with reduced occupational performance and loss of productivity, damaged relationships and social connections, and a lower quality of life (Hershenberg et al., 2018; Raines et al., 2021; Wachen et al., 2013). According to the National Health and Resilience in Veterans Study, younger male veterans (77%) are at higher risk of developing PTSD (Fogle et al., 2020).
Several manualized treatments have been shown to be efficacious in treating combat-related PTSD and associated conditions. The treatments that have the most empirical support for this population are Prolonged Exposure Therapy (PE) and Cognitive Processing Therapy (CPT) (Moshier et al., 2024). PE is a behavioral-based treatment conceptually rooted in emotional processing theory, which contains the following components: (1) Psychoeducation, (2) Breathing retraining, (3) In-vivo exposure to trauma reminders, and (4) Imaginal exposure to trauma memories (Foa & Rothbaum, 1998). PE is typically delivered in 9 to 12 90-minute sessions. CPT is theoretically and conceptually rooted in cognitive theory (Resick et al., 2008). Key components include writing an impact statement, identifying “stuck points,” and cognitive therapy techniques to address overaccommodated and assimilated trauma-related thoughts and beliefs. Five trauma-specific themes addressed throughout the protocol are trust, esteem, safety, power/control, and intimacy (Resick et al., 2008). CPT is typically delivered in 12 60-minute sessions (Resick et al., 2017). Both treatments are well-established, with extensive empirical support from numerous randomized controlled trials (RCTs) and effectiveness studies. For instance, Eftekhari and colleagues (2013) examined 1,200 veterans who underwent PE and found large effect size reductions in symptoms (Cohen, 1988).
In a sample of 26,189 veterans who completed CPT between 2001–2017, 9,181 were found to have clinically meaningful improvement at some point in the study (Holder et al., 2020). Additionally, a multi-site, head-to-head randomized study of PE and CPT among 916 veterans found that both treatments resulted in large symptom reductions (PE Standardized Mean Difference [SMD] = 0.99 vs CPT SMD = 0.71). These findings are bolstered by meta-analytic findings that show large treatment gains across multiple studies, with researchers finding large effect sizes for both PE and CPT (Bisson et al., 2013; Jonas et al., 2013; Powers et al., 2010; Raines et al., 2024). As a result, PE and CPT are considered front-line treatments for PTSD and recommended as front-line treatments by the Department of Veterans Affairs (VA), Department of Defense (DoD), and American Psychological Association (APA) as clinical practice guidelines for the treatment of PTSD (American Psychological Association [APA], 2017; US Department of Veteran Affairs [VA] 2023). In addition to reduced symptom burden, veterans also enjoy improved relationship functioning and intimacy (Van Woudenberg et al., 2023), improved occupational functioning (Schnurr & Lunney, 2012), less healthcare utilization (Tuerk et al., 2013), and greater overall quality of life (Goodson et al., 2013). Indeed, for many veterans, a successful course of PE or CPT can be life-changing.
Manualized evidence-based practice (EBP) for PTSD shares several common therapeutic ingredients. These similarities include: (1) Psychoeducation, (2) Emotion regulation skills training, (3) Trauma memory processing (imaginal exposure), (4) Cognitive restructuring, and (5) Work on emotions (Schnyder et al., 2015). Interestingly, these ingredients appear in most forms of psychotherapy, including other treatments for PTSD. Thus, it should not be unexpected that many other treatment approaches have shown to be effective. Case in point, eye movement desensitization (EMDR) has a large base of treatment outcome studies—including several meta-analyses—that show EMDR to be an effective treatment approach (Forman-Hoffman et al., 2018; Goodson et al., 2011; Watts et al., 2013). In a recent network meta-analysis (NMA) conducted by Yunitri and colleagues (2023), comparing the different psychotherapies on adults with PTSD found that “CPT and EMDR were consistently in the upper quartile as the most effective therapies for improving PTSD symptoms at immediate post-treatment, short-term and long-term follow-up” (p. 6384). Further, in light of their findings, they suggest EMDR be recommended as a first-line treatment for PTSD.
Likewise, Narrative Exposure Therapy (NET), which has several different formats—but all include written accounts of traumatic events—has also accumulated significant evidence as an effective treatment for PTSD (Raeder et al., 2023). For example, Sloan and colleagues (2023) compared written exposure therapy to PE among 178 veterans and found no significant differences between written exposure and PE in treatment outcomes. Another modality with evidence for treating PTSD is Cognitive-Behavior Therapy (CBT). In one of the few community-based outpatient studies with combat-related PTSD, veterans received general CBT. Results of the study found that 69% experienced a clinically significant change in PTSD symptoms—as evidenced by greater than 15 on the Clinician-Administered PTSD Scale for the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (Zembia et al., 2014). While these three modalities have been highlighted in the current discussion, a large and growing number of treatments for PTSD continue to garnish evidence, albeit with considerable variation in the quality of such. A review of the literature reveals the growing body of scholarship, but is not limited to, Present Centered Therapy (Division 12 of the American Psychological Association [APA], 2016), Skills Training in Affective and Interpersonal Regulation (Jackson et al., 2019a), Acceptance and Commitment Therapy (Pohar & Argáez, 2017), Stress Inoculation Training (Jackson et al., 2019b), Behavioral Activation (Etherton & Farley, 2022), Mantra-based mediation (Boremann et al., 2013), Meta-Cognitive Therapy (Simons & Kursawq, 2019), and Safety Behavior Elimination (Goodson & Haeffel, 2022). This suggests that evidence exists for a growing number of non-standard EBPs.
Despite the efficacy of standard EBPs for PTSD, these treatments are not without limitations. For instance, PE and CPT both suffer from high participant dropout rates, with some as high as 55% (Schnurr et al., 2022). Watts et al. (2014) found that of 1,924 veterans who started PE or CPT in PTSD clinics, the median number of completed sessions was 5 of the recommended 12. Moreover, combat veterans who have an elevated risk for developing PTSD and other mental health conditions, such as depression, generalized anxiety, and substance use disorders, compared to non-deployed veterans, are less likely to complete an EBP for PTSD (Goodson et al., 2011). Factors that increase dropout from EBPs for PTSD are trauma-focused, history of traumatic brain injury (TBI), and younger age (Berke et al., 2019). Also, high levels of distress in exposure-based therapies may be overwhelming for some combat veterans (Najavitis, 2015). Most trauma therapies focus on a single “index event,” which may be less appropriate for combat veterans with multiple traumas. Other factors associated with dropout from PE and CPT are higher symptom severity, poor treatment buy-in, male gender, low levels of social support, service-connected disability, therapist training, distress associated with imaginal exposure, and exacerbation of symptoms (Goodson et al., 2017; Harpaz-Rotem & Rosenheck, 2011; McLane et al., 2019; Schottenbauer et al., 2008; Zafert et al., 2005; Zayfert & Black, 2000). Complicating the picture, not all veterans respond to EBPs for PTSD. For instance, Hoge and Chard (2018) estimated that 20–30% of individuals who complete treatment do not experience significant symptom reductions and remain highly symptomatic.
Furthermore, these modalities are time-intensive to learn, creating a training burden for clinicians. For example, standard PE training courses are 4 days. This is followed by 6 months of weekly consultation calls (both group and individual). CPT training is typically 3 days, followed by 6 months of weekly group consultation calls. In addition, clinician attrition is a significant problem (Ackland et al. (2023). Mental health professionals trained in PE and CPT often express dissatisfaction with the highly structured nature of EBPs for PTSD, which results in less favorable perceptions and less usage of these modalities (Borah et al., 2017). The US Veteran Health Administration (VHA) is the largest mental health care system in the country and has carried out widespread and systematic training and implementation of PE and CPT over the past 20 years. Likewise, many corresponding studies have demonstrated the effectiveness of these treatments (Eftekhari et al., 2013; Goodson et al., 2017; Karlin et al., 2010). However, treatment outcome studies have little bearing on veterans’ decision to seek treatment, and a growing number of veterans are seeking treatment outside the VA healthcare system (Lawson, 2014). Some of the reasons why veterans do not seek mental health care from the VA include: (1) long wait lists, (2) concerns about stigma associated with mental health conditions, (3) discharge status requirements, (4) difficulty navigating the complexities of the VA healthcare system, and (5) service connection concerns (i.e., not wanting documented improvement of symptoms) (Burnam et al., 2009; Reisman, 2016).
Unfortunately, the effectiveness of community-based treatments at non-VA clinics for combat veterans has received less attention, and little is known about community providers’ practice when it comes to treating veterans with PTSD (Finley et al., 2018). Finley and colleagues (2018) found that community providers employed a variety of psychotherapeutic approaches when treating PTSD. This is not surprising as community providers tend to be more generalist in practice, without the same need for extensive disorder-specific EBPs as provided by the VA. These factors have led some researchers to suggest that non-VA providers may not be adequately prepared to treat combat-related PTSD effectively (Reisman, 2016). However, this conclusion may represent a lack of existing evidence instead of clinical ability and points to the need for additional research. Given that some veterans are reluctant to seek mental health treatment at the VA, store-front civilian outpatient facilities may be a viable alternative (Botero et al., 2020).
Given the high dropout rate of veterans in these manualized approaches (Najavits, 2015; Schnurr et al., 2022) and reticence to seek mental health treatment at the VA (Ouimette et al., 2011), an evaluation of short-term non-manualized treatment of combat veterans in a community-based clinic is warranted. While the manualized protocols have a significant body of literature supporting their efficacy and are time-intensive to learn, a study evaluating the clinical outcomes among masters-level clinicians under the supervision of an experienced supervisor at a community clinic is needed. The treatment interventions in the present study were not protocol-driven and were investigated guided by the following research question: Will short-term non-manualized treatment in a community-based clinic have reductions in PTSD, depression, and anxiety among combat veterans?
Method
Study Design
The participants in this study—combat veterans (N = 68), were all voluntary treatment-seeking and were treated at a nonprofit mental health agency in the greater Dallas/Fort Worth area that specializes in the treatment of veterans, first responders, and their families. The participants could have been referred by other community partners or the VA itself, as sometimes there were long wait times at the local VA clinics from 2015–2017 or referrals from other community partners in the same geographical area. The clinically focused nonprofit agency Stay The Course, which later merged with One Tribe Foundation, was established by the spouse of a combat veteran who identified the lack of culturally competent mental health providers between 2015–2017 in the greater Dallas/Fort Worth metropolitan area. In the early years of Stay The Course, the clinical providers used the PCL-5, BAI, and BDI-II for 2 years. After that, the standard protocol switched to the PHQ-9 and the GAD-7. The agency administered these self-report assessments at baseline and the end of treatment, and as such, there are only two data points in this study. The clinicians used these assessments for internal evaluation of their clients throughout treatment and for internal secondary data analysis that is continually analyzed by the second author (WNP) of this study.
Participants
Participants’ average age was (M = 40.71, SD = 11.39). Most of the sample size was male (85.3%; n = 58), with most participants identifying as White (72.1%; n = 49). The average length of service in years was (M = 8.81, SD = 6.25). Most participants served in the US Army (47.1%; n = 32) and the US Marine Corps (26.5%; n = 18). The first deployment locations were in support of the Global War on Terrorism (GWOT) (78.0%; n = 53), the first Persian Gulf War (17.6%; n = 12), and Vietnam (4.4%; n = 3). Of the 43% (n = 29) that had at least two combat deployments, 82.8% (n = 24) were in support of the GWOT, and 17.2% (n = 5) were in support of the first Persian Gulf War. Of the 16% (n = 11) that had at least three combat deployments, 72.7% (n = 8) were in support of the GWOT, and 27.3% (n = 3) were in support of the first Persian Gulf War. Of the 9% (n = 6) that had at least four combat deployments, 83.3% (n = 5) were in support of the GWOT, and 16.7% (n = 1) were in support of the first Persian Gulf War. Lastly, one participant had five deployments, and one had six deployments supporting the GWOT (Table 1). Only veterans over the age of 18 who were forwardly deployed, agreed to complete an intake assessment, and complete six sessions were considered for this study.
Table 1
Demographics of Sample.
| CHARACTERISTIC | SAMPLE (N= 68) |
|---|---|
| Age (Years) | |
| Mean | 40.71 |
| Median | 36.50 |
| SD | 11.39 |
| Range | 48 |
| Time in Service (Years) | |
| Mean | 8.81 |
| Median | 6.41 |
| SD | 6.25 |
| Range | 22.5 |
| Gender | |
| Male | 58 (85.3%) |
| Female | 10 (14.7%) |
| Ethnicity | |
| White | 49 (72.1%) |
| African American | 10 (14.6%) |
| Hispanic | 8 (11.8%) |
| Asian | 1 (1.5%) |
| Military Branch | |
| Air Force | 8 (11.7%) |
| Army | 32 (47.1%) |
| Navy | 9 (13.2%) |
| Marine Corps | 18 (26.5%) |
| More than one | 1 (1.5%) |
| Number of Deployments | |
| One | 40 (58.8%) |
| Two | 17 (25.0%) |
| Three | 3 (4.4%) |
| Four | 6 (8.8%) |
| Five | 1 (1.5%) |
| Six | 1 (1.5%) |
Procedure
Data for the current study were collected from 2015–2017 at Stay The Course, which provides services to veterans, first responders, and their families. In the agency’s early years, most clinical services were conducted by interns under the supervision of licensed professionals (i.e., Licensed Professional Counselor-Supervisors or Licensed Clinical Social Worker-Supervisors), and they had the autonomy to use the modality of their preference. For this study, the sample was treated by two new clinicians working under the supervision of two fully licensed and experienced clinicians. During the time of this study, the primary modalities used at the agency were CBT, EMDR, and narrative exposure (e.g., written account of trauma, not narrative exposure therapy) (T. Sherrill personal communication, June 26, 2024). After the clients completed their baseline assessments, they were assigned to available clinicians. After that, the clinicians had the autonomy (under the guidance of their clinical supervisor) to use the aforementioned modalities, and after six sessions, the clients were reassessed.
The clinicians who treated the veterans in this study and their supervisors were culturally competent in military culture. They had served themselves or had family members (e.g., the program founder is married to a combat veteran) who served and have strong ties to the veteran community. This is crucially important because providers who take a holistic approach to learning and identifying how the client and family system are impacted by military service have better clinical outcomes (Meyer et al., 2016; Meyer et al., 2018). Cultural competency can also help build rapport with the client (Stubbe, 2020). Further, a qualitative examination of military cultural competency clinicians and clinical students found that the following five categories are important: (1) asking about a client’s previous military service affirms their value, (2) promotes provider comfort with veteran clients, (3) produces understanding of the cultural stigma that the veterans may face, (4) reduces an “intimidation factor” that they may have had if they have no first-hand exposure to the military, and (5) several specific specialties such as PTSD, TBI, and intimate partner violence (Isserman & Martin, 2021). Furthermore, those with military cultural competency have a deeper understanding that increases their ability to assess for military sexual trauma (Isserman & Martin, 2021) and gender and sexual orientation (Atuel & Castro, 2018). This study was approved by the Stephen F. Austin State University Institutional Review Board (AY 2023–0062).
Measures
PTSD Checklist-5 (PCL-5)
Blevins et al. (2015) developed the PTSD Checklist-5 (PCL-5), which assesses PTSD symptoms and has been validated on a treatment-seeking sample of veterans (Ahmadi et al., 2023). It is a 20-item self-report assessment using a Likert scale (0 not at all to 4 extremely). Aggregated scores range from 0–80, with higher scores indicating greater PTSD symptoms. A summed score of 33 or higher is considered screening positive for probable PTSD (Bovin et al., 2016). We used an 8-factor configuration (e.g., internal intrusions, external intrusions, avoidance, negative affect, anhedonia, externalizing behaviors, anxious arousal, and dysphoric arousal) of the PCL-5 based upon a recent validation and network analysis (Gross et al., 2023). In this sample, Cronbach’s alpha of the PCL-5 at baseline was α = .95, and at session 6 was α = .97.
Beck Depression Inventory-II (BDI-II)
Beck et al. (1996) developed and validated the Beck Depression Inventory-II (BDI-II), which measures depressive symptoms. The BDI-II has 21 questions that have answers on a 4-point Likert scale. Aggregated scores range from 0–63, with higher scores indicating more depressive symptomatology. Summed score on the BDI-II is considered minimal (0–13), mild (14–19), moderate (20–28), and severe (29–63) depression (Beck et al., 1996). We used a 3-factor structure (e.g., cognitive, affective, and somatic) based on a previous validation in a veteran sample (Palmer et al., 2014). In this sample, Cronbach’s alpha of the BDI-II at baseline was α = .95, and at session 6 was α = .96.
Beck Anxiety Inventory (BAI)
Beck et al. (1988) developed and validated the Beck Anxiety Inventory (BAI), which measures anxiety symptoms. The BAI is a 21-item self-report assessment on a 4-point Likert scale with individual responses from 0 (not at all) to 4 (severely). Aggregated scores range from 0–63, with higher scores indicating higher anxiety symptoms. Summed scores on the BAI are considered minimal (0–7), mild (8–15), moderate (16–25), and severe (26–63) anxiety (Jackson et al., 2020). We used a 3-factor structure (e.g., subjective, somatic, and physiological) based on a previous validation in a veteran sample (Oehlert et al., 2020). In this sample, Cronbach’s alpha of the BAI at baseline was α = .94, and at session 6 was α = .93.
Data Analysis
Statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS) version 27.0. First, we verified a normal distribution of the data. There were no missing values. Next, we calculated the descriptive statistics for baseline and session 6 for all three assessments and the associated factor structure. After that, we conducted paired t-tests for the summed scores on all the measures and each factor for each measure and calculated the effect size with small (d = 0.2), medium (d = 0.5), and large (d = 0.8) along with the 95% confidence interval (CI; Cohen, 1988).
Results
There was a statistically significant reduction on PCL-5 scores from baseline (M = 42.29, SD = 19.25) to session 6 (M = 30.88, SD = 20.67), t(67) = 5.00, p < .001 d = .61, 95% CI [0.35, 0.86]. Using the 33-cutoff score on the PCL-5, at baseline (70.6%; n = 48) and at session 6 (42.6%; n = 29) screened positive for probable PTSD. There was a statistically significant reduction in BDI-II scores from baseline (M = 27.66, SD = 14.69) to session 6 (M = 17.53, SD = 14.23), t(67) = 6.67, p < .001 d = .81, 95% CI [0.53, 1.08]. Using the ranges identified by Beck et al. (1996) at baseline, 19.1% (n = 13) had minimal, 11.8% (n = 8) mild, 25.0% (n = 17) moderate, and 44.1% (n = 30) had severe depression. However, in session 6, 47.0% (n = 32) had minimal, 14.7% (n = 10) mild, 16.2% (n = 11) moderate, and 22.1% (n = 15) had severe depression. There was a statistically significant reduction in BAI scores from baseline (M = 25.49, SD = 15.41) to session 6 (M = 15.91, SD = 12.26), t(67) = 5.31, p < .001 d = .64, 95% CI [0.38, 0.90]. Using the ranges identified by Jackson et al. (2020) at baseline, 11.8% (n = 8) had minimal, 20.6% (n = 14) mild, 25.0% (n = 17) moderate, and 42.6% (n = 29) had severe anxiety. However, at session 6, 35.3% (n = 24) had minimal, 23.5% (n = 16) mild, 17.7% (n = 12) moderate, and 23.5% (n = 16) had severe anxiety. See Table 2 for descriptive statistics and the paired t-tests from baseline to session 6 for the aggregated scores and the factor of each assessment.
Table 2
Paired Samples t-test (N = 68).
| MEAN (SD) INTAKE | MEAN (SD) SESSION 6 | MEAN DIFFERENCE | t | df | p | d | 95% CI | |
|---|---|---|---|---|---|---|---|---|
| PCL-5 | 42.29 (19.25) | 30.88 (20.67) | –11.41 | 5.00 | 67 | <.001 | .61 | [0.35, 0.86] |
| Internal | 5.81 (3.44) | 4.15 (3.28) | –1.66 | 4.32 | 67 | <.001 | .52 | [0.27, 0.77] |
| External | 4.26 (2.34) | 3.34 (2.38) | –0.93 | 3.06 | 67 | .003 | .37 | [0.12, 0.62] |
| Avoidance | 4.38 (2.56) | 3.24 (2.43) | –1.15 | 3.34 | 67 | .001 | .41 | [0.16, 0.65] |
| NA | 8.07 (4.69) | 5.99 (4.56) | –2.09 | 3.73 | 67 | <.001 | .45 | [0.20, .070] |
| An | 7.06 (3.66) | 5.00 (3.99) | –2.06 | 5.43 | 67 | <.001 | .66 | [0.39, 0.92] |
| EB | 3.37 (2.33) | 2.22 (2.24) | –1.15 | 4.00 | 67 | <.001 | .49 | [0.23, 0.74] |
| AA | 4.29 (2.50) | 3.29 (2.60) | –1.00 | 3.56 | 67 | <.001 | .43 | [0.18, 0.68] |
| DA | 5.04 (2.26) | 3.66 (2.53) | –1.38 | 4.97 | 67 | <.001 | .60 | [0.34, 0.86] |
| BDI-II | 27.66 (14.69) | 17.53 (14.23) | –10.13 | 6.67 | 67 | <.001 | .81 | [0.53, 1.08] |
| Cognitive | 11.46 (7.19) | 6.93 (6.07) | –4.53 | 5.88 | 67 | <.001 | .71 | [0.44, 0.98] |
| Affective | 5.41 (3.29) | 3.43 (2.93) | –1.99 | 5.68 | 67 | <.001 | .69 | [0.42, 0.95] |
| Somatic | 10.79 (5.64) | 7.18 (6.13) | –3.62 | 5.57 | 67 | <.001 | .68 | [0.41, 0.94] |
| BAI | 25.49 (15.41) | 15.91 (12.26) | –9.57 | 5.31 | 67 | <.001 | .64 | [0.38, 0.90] |
| Subjective | 9.37 (5.58) | 6.62 (5.09) | –2.75 | 4.02 | 67 | <.001 | .49 | [0.24, 0.74] |
| Somatic | 9.65 (7.20) | 5.07 (5.05) | –4.57 | 5.31 | 67 | <.001 | .64 | [0.38, 0.90] |
| Physiological | 2.41 (1.98) | 1.44 (1.53) | –0.97 | 4.13 | 67 | <.001 | .50 | [0.25, 0.75] |
[i] Note. PCL-5 – PTSD Checklist-5, Internal = Internal Intrusions (PCL-5 questions 1–3), External = External Intrusions (PCL-5 questions 4–5), Avoidance = Avoidance (PCL-5 questions 6–7), NA = Negative Affect (PCL-5 questions 8–11), An = Anhedonia (PCL-5 questions 12–14), EB = Externalizing Behaviors (PCL-5 questions 15–16), AA = Anxious Arousal (PCL-5 questions 17–18), DA = Dysphoric Arousal (PCL-5 questions 19–20); BDI-II = Beck Depression Inventory-II, Cognitive = Cognitive factor (BDI-II questions 1, 2, 3, 5, 6, 7, 8, 9, 14), Affective = Affective factor (BDI-II questions 4, 10, 12, 13), Somatic = Somatic factor (BDI-II questions 11, 15, 16, 17, 18, 19, 20, 21); BAI = Beck Anxiety Inventory, Subjective = Subjective factor (BAI questions 4, 5, 9, 10, 14, 16, 17), Somatic = Somatic factor (BAI questions 1, 2, 3, 6, 8, 11, 15, 19, 20), Physiological = Physiological factor (BAI questions 12, 13).
Discussion
The purpose of this study was to explore the effectiveness of clinical services provided to combat veterans with PTSD in a civilian outpatient treatment facility to answer the following research question: Will short-term non-manualized treatment in a community-based clinic have reductions in PTSD, depression, and anxiety among combat veterans? Results suggested that the combat veterans experienced reductions in PTSD, depression, and anxiety symptoms. Effect sizes indicated that reductions in PTSD and anxiety symptoms were medium in magnitude, and reductions in depression were large in magnitude. Given the high dropout rates that plague trauma-focused treatments such as PE and CPT, these preliminary results are of interest, and they may suggest that briefer, less structured approaches can be efficacious for combat veterans while increasing treatment retention. Overall, this study provides preliminary support for the use of community-based interventions for combat-related PTSD, depression, and anxiety.
Our results are consistent with previous research that examined the effectiveness of brief treatments for PTSD. For example, in a randomized pilot study assessing a three-session heart rate variability biofeedback intervention among veterans with PTSD, Schuman et al. (2023) found significant decreases in depression and PTSD-related intrusions compared to the wait-list control. In a study at an urban VA Medical Center in Richmond, Virginia, Polak et al. (2019) sought to identify any adjunctive treatments that could influence retention in the intensive outpatient substance abuse program. They found that those who completed four sessions of transcending self-therapy (TST) were twice as likely to complete the substance abuse program compared to those who did not. Similar to the present study, Polak et al. (2019) also found significant reductions in depression as measured by the BDI-II and the PCL-5. However, they did not conduct analyses on the associated factor structure of each assessment. In a treatment-seeking sample of military spouses, researchers found that six sessions did not significantly reduce generalized anxiety and depression while also not significantly increasing resilience (Prosek et al., 2023). One variable not controlled for in that study was the PTSD symptoms in their significant other, who is a veteran. Longitudinal research has shown veteran PTSD-related avoidance increases new onset depression in military spouses by 62% (Walter et al., 2021). Bonn-Miller et al. (2021) investigated the short-term impact of cannabis on veterans and found that there were no significant differences between those who used cannabis or the placebo.
Our statistical significance decreases in PTSD, depression, and somatic anxiety are also consistent with short-term accelerated resolution therapy (ART) when participants had between one to five individual therapy sessions (Kip et al., 2012). In an RCT study of ART, combat veterans getting treatment for PTSD had a mean number of sessions (M = 3.7) and significantly reduced PTSD, depression, and somatic anxiety compared to those in the control group who received attention control (Kip et al., 2013). Additionally, a study exploring the effectiveness of a five-session intervention investigating the reconsolidation of traumatic memories (RTM) protocol found a significant decrease in aggregated PTSD scores from baseline to the end of treatment (Gray & Bourke, 2015). Taken together, the present study of combat veterans adds to a growing body of literature suggesting that brief treatments may reduce PTSD, depression, and anxiety symptoms.
Among combat veterans, combat exposure is more closely associated with the PTSD intrusions cluster as opposed to the other three DSM-5 symptom clusters (Simons et al., 2020). In a cross-sectional directed acyclic graph using the 8-factor configuration of the PCL-5, internal intrusions started the cascade and had direct effects on external intrusions, negative affect, dysphoric arousal, and avoidance (Beattie et al., 2023). Our six-session study found that the clinical treatment reduced internal intrusions with a medium effect size, whereas the reduction in external intrusions had a small effect size. Over the course of CPT treatment, external intrusions predict longitudinal treatment change (Graziano et al., 2023). For example, there was an increase in intrusive memories, flashbacks, psychological reactions, and physiological reactions in CPT after sessions three and four (Moshier et al., 2024). However, when examining the change in the CPT network, ‘startle’ was only central to the network at mid-treatment and post-treatment (Graziano et al., 2023). This is crucially important because hyper-arousal symptoms can linger post-treatment on active duty servicemembers (Miles et al., 2022), and ‘startle’ is possibly a barometer among combat veterans that might be an indicator of PTSD-related fear reduction (Robison-Andrew et al., 2014). Not surprisingly, hyperarousal longitudinally predicts the maintenance of the other three PTSD symptom clusters among combat veterans (Doron-LaMarca et al., 2015).
Strengths and Limitations
The current study has several strengths. We carried out an efficacious study that allows generalizations of standard clinical care in naturalistic settings. We demonstrated clinically significant reductions in PTSD, depression, and anxiety symptoms among combat veterans without using manualized study protocols. This is likely more similar to care typically received outside of specialty clinics. Our findings suggest that non-manualized interventions are effective in treating PTSD and warrant additional research. Moreover, we found that significant treatment gains occurred in a small number of sessions. The current study also provided preliminary evidence that combat-related PTSD can be successfully treated in community-based clinic settings without extensive therapist training in evidence-based treatment protocols. An additional benefit and strength of the current study is that it presented the aggregated change on each measure and the associated factor structure. Our moderately sized sample, with its preliminary results on combat veterans, can generate or lead to hypotheses for testing on a larger sample.
The limitations of this study should be acknowledged when interpreting these results. First, some demographics of the study participants may limit generalizability as most participants were White males. Additionally, participants were deployed to different theaters supporting different military campaigns; 22% served in non-GWOT combat zones, which may have resulted in different types of trauma exposure. Second, there were limitations with our measurement procedures in the current study (i.e., PCL-5, BDI-II, and BAI). We collected no data on the level of combat trauma as it relates to different PTSD networks (Macia et al., 2020; Phillips et al., 2018).
Additionally, all the measures were self-reported and not diagnostic interviews (Rosencrans et al., 2024). Therefore, assessments relied on clients’ insights into their symptoms. There were also no measures of several constructs of interest, which included resilience, substance use, sleep, or suicidality. Third, two clinicians were interns working under the supervision of the full licensure of their clinical supervisor. This could be an issue because they might not be familiar with trauma-focused interventions, potentially reducing their efficacy. Also, we did not assess their level of clinical competency. Fourth, the nature of the intervention was not manualized as it is in PE, EMDR, and CPT. Because of this, the most significant limitation is that we could not have known the intervention modality for each client and clinical session. As we have seen, the TF-CBT canopy covers a wide swath of frameworks (Hoppen et al., 2023), and we cannot assess the content of session adherence ratings retrospectively. Finally, although the sample size was large enough for a parametric paired t-test, larger samples would allow for network analysis. Despite these limitations, this study provides preliminary evidence that short-term counseling at a civilian outpatient clinic can be efficacious for combat veterans.
Conclusion
This study provides preliminary evidence that combat veterans can get effective mental health treatment at an outpatient community clinic from masters-level clinicians. We found treatment gains (e.g., effect size) of medium magnitude for PTSD and anxiety symptoms and large magnitude for depression. The clinicians who treated these combat veterans are militarily culturally competent, likely aiding them in building rapport with the clients. These encouraging results can be of use to other community-based clinics that provide clinical services to combat veterans.
Acknowledgements
We would like to thank the combat veterans who have forwardly deployed to combat zones to protect our freedom from those who wish to take it.
Competing Interests
The authors have no competing interests to declare.