506055 research-article2013

JIV29610.1177/0886260513506055Journal of Interpersonal ViolenceWalter et al.

Article

Residential PTSD Treatment for Female Veterans With Military Sexual Trauma: Does a History of Childhood Sexual Abuse Influence Outcome?

Journal of Interpersonal Violence 2014, Vol. 29(6) 971­–986 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260513506055 jiv.sagepub.com

Kristen H. Walter,1 Amy Buckley,1 Jennifer M. Simpson,1 and Kathleen M. Chard1,2

Abstract This study examined whether a history of childhood sexual abuse (CSA) influenced treatment outcome among female veterans with an index trauma of military sexual trauma (MST) receiving residential treatment for posttraumatic stress disorder (PTSD). One hundred and ten female veterans, 61 with a history of CSA and 49 without, were compared on pre-treatment demographic and symptom measures, as well as treatment outcome, which were assessed with the Clinician-Administered PTSD Scale (CAPS), PTSD Checklist–Stressor Specific Version (PCL-S), and Depression Inventory–Second edition (BDI-II). Veterans received cognitive processing therapy (CPT) as the primary trauma-focused treatment. Study findings showed that these two groups did not significantly differ on pre-treatment variables or treatment outcome. Results suggest that CPT delivered in a residential treatment program was effective for female veterans with PTSD related to MST, with and without a history of CSA. 1Cincinnati 2University

VA Medical Center, Cincinnati, OH, USA of Cincinnati, OH, USA

Corresponding Author: Kathleen M. Chard, Cincinnati VA Medical Center, 3200 Vine Street, Cincinnati, OH 45220, USA. Email: [email protected]

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Keywords posttraumatic stress disorder, cognitive processing therapy, childhood sexual abuse, military sexual trauma, treatment outcome, veterans In recent years, female veterans have been seeking health care services from Veterans’ Affairs (VA) Health facilities at increasing rates. A recent study of 1.7 million U.S. female veterans (8% of the total veteran population) showed that over 11% have utilized VA services. In addition, female veterans are outpacing usage rates of other groups of veterans, with an estimated increase from 5.5% to over 10% service use within the past 5 years (Goldzweig, Balekian, Rolon, Yano, & Shekelle, 2006). In the past decade, the number of female veterans utilizing VA services has almost doubled, from 160,000 to almost 300,000, a growth rate that is considerably greater than the rate of male veterans (Frayne et al., 2010). Given these statistics, it is imperative that appropriate services for female veterans are available. One potential reason for the increased service utilization among female veterans may be due to the rise in treatment seeking for posttraumatic stress disorder (PTSD). In fact, recent data from the VA Office of Policy and Planning reported that the three most prevalent diagnoses for female veterans seeking health care were PTSD, hypertension, and depression, respectively (National Center for Veterans’ Analysis and Statistics, Office of Policy and Planning, Department of Veterans Affairs, 2007). In the general population, women are more than twice as likely as men to be diagnosed with PTSD, with lifetime rates of 10.4% for women compared to 5% for men (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Rates of PTSD are even higher for female veterans, with lifetime estimates of PTSD as high as 27% (Escalona, Achilles, Waitzkin, & Yager, 2004). Although the rates of PTSD in male and female veterans are comparable, due to the significantly higher proportion of male veterans reporting combat exposure, female veterans are significantly more likely than their male counterparts to report experiencing sexual assault (38%-64% vs. 4%-5%; Zinzow, Grubaugh, Monnier, Suffoletta-Maierle, & Frueh, 2007). It is estimated that 10% of women in the general population report experiencing one or more sexual assaults in their lifetime (Kilpatrick, Resnick, Ruggiero, Conoscenti, & McCauley, 2007; Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993), with rates significantly higher for female service members. For example, in a cross-sectional survey of over 500 female veterans, 26% reported being raped prior to joining the military and more than half (54%) indicated that they had experienced either physical or sexual assault prior to enlisting (Sadler, Booth, Mengeling, & Doebbeling, 2004). Female

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veterans also report experiencing higher rates of sexual assaults in adulthood compared to civilian women, with estimates from 38% to 64% for veterans and 12% to 32% for civilians (Zinzow et al., 2007). Similarly, in a sample of 270 female veterans, almost 39% reported experiencing adult non-militaryrelated sexual assault (Suris, Lind, Kashner, Borman, & Petty, 2004). In addition to high rates of civilian sexual trauma, women in the military also report high rates of sexual assault during their military service. The VA defines military sexual trauma (MST) as sexual harassment involving threat or sexual assault that occurred while the victim was in the military, regardless of gender, relationship to the perpetrator, or geographic location (Department of Veterans Affairs, 2004). In a review of empirical studies published from 2001 to 2006, Zinzow et al. (2007) showed that prevalence rates of militaryrelated sexual trauma in women ranged from 30% to 72%, with the higher rates attributed to broader inclusion criteria for defining MST similar to the definition used by VA (e.g., inclusion of sexual harassment and unwanted sexual verbal or physical contact, in addition to the more narrowly defined criteria of attempted or completed oral, vaginal, or anal penetration that occurs through physical force or threat). Zinzow et al. (2007) found that the lower rates of sexual assault were from studies where sexual assault/trauma was defined using the more narrow criteria for MST. However, most prevalence studies have found rates of military sexual assault in the range of 23% to 33% among female veterans accessing VA health care (Skinner et al., 2000; Suris et al., 2004). Prior studies also find that women in the military are more likely to report a history of childhood sexual abuse (CSA) than their civilian counterparts. For example, Zinzow et al. (2007) noted in their review of trauma in female veterans that between 27% and 49% reported a history of CSA, compared to 17% to 32% of civilian women. In their study examining rates of sexual assault and health care utilization in female veterans, Suris et al. (2004) found that 27% endorsed a history of CSA. Similarly, in a random sample of 506 female veterans from the Vietnam era to present, 25% reported a history of CSA (Sadler, Booth, Cook, & Doebbeling, 2003). Furthermore, 28% of these women reported experiencing attempted or completed rape during their military service, and a history of sexual trauma (child or adult) increased the likelihood of rape during military service (Sadler et al., 2003). In addition, follow-up study findings showed that 25% of female veterans reported experiencing CSA and almost 2 out of every 10 women (19%) reported experiencing both CSA and rape prior to their entry into the military (Sadler et al., 2004). Collectively, these results indicate that a history of CSA and/or sexual trauma are common among female veterans and highlight the need for appropriate treatment, particularly as research has demonstrated significant

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short- and long-term consequences of CSA, such as greater levels of fear, hostility, depression, suicide attempts, impaired sexual adjustment, increased promiscuity, and future victimization (Browne & Finkelhor, 1986). Sexual trauma, whether as a child, civilian adult, or while during military service, can lead to the development of PTSD. Furthermore, history of sexual trauma is associated with a greater risk of developing PTSD as compared to other types of traumas (Kessler et al., 1995), and this may be true for female veterans as well (Zinzow et al., 2007). History of any type of sexual assault in female veterans has been shown to significantly increase the odds of meeting diagnostic criteria for PTSD, with one study estimating a fivefold increase in the likelihood of meeting criteria for PTSD for women who experienced sexual assault compared to female veterans without a history of sexual trauma (Suris et al., 2004). Research also suggests that the type of sexual trauma may be associated with differential rates of PTSD. Specifically, MST has been shown to be related to higher PTSD severity than any other type of trauma, regardless of civilian or military context (Yaeger, Himmelfarb, Cammack, & Mintz, 2006). Similarly, among female veterans, those who reported experiencing MST were nine times more likely to be diagnosed with PTSD, and those who experienced CSA were seven times more likely to meet PTSD diagnostic criteria, compared to female veterans without a history of sexual trauma (Suris et al., 2004). Results of the study also demonstrated that MST resulted in increased risk for development of PTSD, even after controlling for CSA and adult nonmilitary sexual assaults. In another study of almost 200 female veterans, results showed that MST was more strongly correlated with PTSD rates than other types of sexual traumas (60% of women reporting MST had PTSD, compared to 47% with pre-military trauma and 55% of those with postmilitary sexual trauma; Himmelfarb, Yaeger, & Mintz, 2006). Of note, CSA was not significantly related to the later development of PTSD or to the later experience of sexual trauma. These findings raise important considerations in that MST may be more strongly associated with PTSD; however, even when statistically addressing prior trauma history, it may not be possible to distinctly separate the potential effects of cumulative trauma. Taken together, the available literature suggests that female veterans report higher rates of trauma exposure and are thus at increased risk for developing PTSD and related mental health problems than civilian women, with childhood abuse an increased risk factor for experiencing MST (Sadler et al., 2003). Although clinicians report differences in the diagnosis and treatment of different types of sexual trauma, there is currently a paucity of literature examining differential impact of CSA, MST, or the combination thereof on treatment outcome. Furthermore, although research indicates that female veterans

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experience higher rates of CSA than their civilian counterparts, there are no known published data examining whether a history of CSA and MST affects successful treatment outcome as compared to female veterans with MST who do not report a history of CSA. Thus, the present study aimed to examine pretreatment PTSD and depression severity, as well as treatment outcome, between female veterans who report experiencing MST, with and without a history of CSA. Since all patients in the sample reported an index trauma of MST and findings by Himmelfarb et al. (2006) and Yaeger et al. (2006) showed that MST was more strongly linked to PTSD than pre-military, post-military, or other types of trauma, we hypothesized that the two groups would neither differ on pre- or posttreatment measures of posttraumatic stress symptoms nor on a measure of depression. Similarly, we hypothesized that the level of improvement from pre- to posttreatment would be similar for both groups.

Method Participants Participants included in this study were 110 female veterans who were admitted to a PTSD residential program in a mid-Western Veterans Affairs Medical Center. All patients met diagnostic criteria for PTSD based on an index trauma of MST. The mean age for the sample was 46.7 years (SD = 7.74), and the mean education level was 13.96 years (SD = 1.88). Patients’ self-reported racial identification was 48% African American/Black, 48% Caucasian/ White, 2% Hispanic/Latino, and 1% each of Native American and Multicultural. Forty-six percent of the sample was disabled, 11% were employed full- or part-time, 37% were unemployed, and 6% were retired. Forty-eight percent were divorced, 24% single, 11% married, 10% separated, 4% remarried, and 3% widowed. A majority of patients (55%) served in the military during the post-Vietnam era, 27% Persian Gulf, 9% Vietnam, 6% Iraq/Afghanistan, 2% Korea, and 1% in other eras.

Procedure For patients to be admitted to the 7-week residential PTSD treatment program, they had to be a female veteran who met current diagnostic criteria for PTSD or subthreshold PTSD related to any traumatic event. Patients could be referred from a provider within the VA system, provider in the community, or self-referred. Exclusionary criteria included conditions or circumstances that required a higher level of care. Specifically, exclusion criteria consisted of suicidal or homicidal intention (those with ideation but without intention

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were included), untreated or active psychosis, current substance dependence requiring detoxification, or any current legal or medical problems (e.g., uncontrolled seizure disorder) that would interfere with participation in the program. Female veterans were admitted in cohorts of approximately 10 patients per cohort. Research was approved by the IRB and waivers were granted by the respective institutional review board for use of archival data.

Measures Upon admission to the residential treatment program, patients’ symptoms and functioning were assessed with both clinician-administered and self-report measures. The same measures were utilized for post-treatment assessments, which were completed by a mental health clinician who was not the patient’s treating clinician. As data were obtained through chart review, only summary scores were documented, and therefore, item-level data were not available. Blake et al.’s (1990) the Clinician-Administered PTSD Scale (CAPS) is used to determine both the frequency and the intensity of the 17 symptoms outlined in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) for a PTSD diagnosis. The items were asked in response to an index trauma (e.g., the worst or most distressing trauma as identified by the patient). A total severity score was determined by summing the frequency and intensity ratings. The Life Events Checklist (LEC) was also administered as part of the CAPS assessment and was used to operationalize the definitions of MST and CSA. MST was defined as “sexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm) occurring to you or witnessing this happen to someone else” that occurred during military service. A history of CSA was endorsed when the patient responded affirmatively to “when you were a child, did an adult ever approach you in a sexual manner which made you feel uncomfortable?” First, Spitzer, Gibbon, & Williams’s (1996) the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-IV) is a structured interview designed to assess the current and lifetime Axis I disorders, such as mood disorders, substance use disorders, and anxiety disorders other than PTSD, and to screen for psychotic symptoms. Based on patients’ responses for each symptom, clinicians rate reported symptoms on a scale of 1 (absent) to 3 (present). The ratings for the symptoms endorsed for each Axis I disorder are then compared to the DSM-IV-TR diagnostic criteria to determine if a diagnosis is warranted. Research on the reliability and validity of the SCID-IV supports its use with clinical samples (Shear et al., 2000). For the current study, pretreatment SCID-IV diagnoses were used for descriptive purposes.

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Beck et al.’s (1996) the Beck Depression Inventory–Second edition (BDI-II) is a widely used instrument for assessing depressive symptoms in adults. The BDI-II consists of 21 items that are rated on a 4-point Likert-type scale ranging from 0 to 1 (higher scores refer to greater depression severity), for a maximum score of 63. The BDI-II has been shown to have high internal consistency (coefficient alpha ranging from .92 to .93) and good test-retest reliability (r = .93). Weathers et al.’s (1991) the PTSD Checklist Stressor Specific Version (PCL-S) is an extensively used self-report measure of PTSD symptoms. The PCL-S asks patients to rate PTSD symptoms in relation to the identified index trauma in terms of how distressing each symptom has been in the past week. Items on the PCL-S directly correspond with the 17 diagnostic criteria for PTSD, and each item is rated on a 5-point Likert-type scale ranging from 1 (not at all) to 5 (extremely). The PCL has demonstrated strong psychometric properties, including good test-retest reliability (.96) and validity (kappa = .64; Weathers, Litz, Herman, Huska, & Keane, 1993).

Treatment Following the completion of pre-treatment assessments and determination of appropriateness for care, patients engaged in the treatment program. Specifically, according to Resick, Monson, and Chard (2007), patients received two individual and two group Cognitive Processing Therapy sessions (CPT) per week. Individual sessions could be added as needed (e.g., processing a second trauma account, providing assistance with an assignment). CPT was chosen as the trauma-focused treatment for the residential program due to the established efficacy of CPT with civilians who had a history of rape, child sexual abuse, or combinations of trauma types, including multiple experiences of interpersonal trauma (Chard, 2005; Resick, Nishith, Weaver, Astin, & Feuer, 2002). In addition, patients attended approximately 25 hr per week of group therapy, which focused on psychoeducation and skill-building. Examples of group topics included anger management, communication, relapse prevention, and introduction to modules of Dialectical Behavior Therapy (DBT; Linehan, 1993) such as distress tolerance, mindfulness, and interpersonal effectiveness. CPT remained the overarching framework for the program, with CPT principles incorporated into the group content (e.g., identifying “stuck points” or disruptive thoughts to address through practice assignments). The majority of programming took place 5 days per week (MondayFriday), with some recreation therapy on weekends. Patients were expected to attend all individual and group programming.

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Data Analytic Plan Several data analytic techniques were utilized to evaluate the influence of CSA on treatment outcome among women who met diagnostic criteria for PTSD based on MST. First, two groups were created from the sample of female veterans with an index trauma of MST: (1) Female veterans who also reported a history of childhood sexual abuse (MST/CSA) and (2) Female veterans who did not endorse a history of CSA (MST).1 These groups were used for all subsequent analyses, including t tests and chi-square analyses to assess pre-treatment and study variables for significant differences. The primary study analyses involved the use of repeated measures analysis of variance (RM ANOVA) to determine the effect of CSA history on residential treatment outcome (i.e., clinician-assessed PTSD severity, self-reported PTSD symptom severity, and self-reported depression severity). Treatment outcome was also assessed with chi-square analyses for PTSD diagnostic status and treatment completion. It should be noted that although 10 patients did not complete residential treatment, they were included in the analyses with use of missing data techniques. Specifically, the expectation maximization (EM) algorithm was used to impute expected values based on the other variables included in the analyses.

Results Sample Characteristics Of the 110 female veterans included in the sample who met diagnostic criteria for PTSD based on an index trauma of MST, 55.5% (n=61) reported a history of CSA and 44.5% (n=49) did not endorse a history of CSA. Of the 110 patients, 10 did not complete the program due to substance, behavioral problems, or emergency demands at home but were included in the analyses. The most frequent comorbid psychological disorders were major depression (64.5%), history of alcohol abuse/dependence (53.7%), history of cocaine abuse/dependence (29.9%), and panic disorder (20%). Patients received an average of 12 sessions (SD=1.86) of individual CPT during the residential program.

Pre-Treatment Comparisons To evaluate pre-treatment group differences, independent samples t tests were performed between the MST (n = 49) and MST/CSA (n = 61) groups on the continuous measures and chi-square analyses were employed on categorical variables. Independent samples t tests indicated that no significant

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differences emerged between the groups pertaining to age, t(108) = −1.61, p = .11, d = .30, 1 − β = .46, or years of education, t(108) = .79, p = .43, d = .15, 1 − β = .19. The groups also did not significantly differ on pre-treatment symptom severity scores on the CAPS, t(108) = −.91, p = .36, d = .17, 1 − β = .23; PCL, t(105) =−.77, p = .45, d = .15, 1 − β = .19; or BDI-II, t(108) = .48, p = .64, d = .09, 1 − β = .12. Results of the chi-square analyses demonstrated that the MST and MST/ CSA groups did not significantly differ in terms of ethnicity (White/Other), χ2(1) = .02, p = .88, ϕ = .01, 1 − β = .05; marital status (married/other), χ2(1) = .05, p = .83, ϕ = .02, 1 − β = .06; or service era (post-Vietnam/other), χ2(1) = .44, p = .51, ϕ = .06, 1 − β = .10. The groups did significantly differ on employment status (employed/other), χ2(1) = 8.20, p < .01, ϕ = .27, 1 − β = .81, with a greater number of patients without CSA employed either full- or part-time. However, it should be noted that only 11% of the sample reported full- or parttime employment.

Effects of Treatment Clinician-assessed PTSD symptoms.  A RM ANOVA was conducted to determine the influence of CSA history on treatment outcome, as measured by the CAPS, among female veterans with an index trauma of MST. The mean scores and standard deviations for both groups on all outcome measures at pre- and posttreatment are displayed in Table 1. The RM ANOVA results demonstrated a significant within-subjects effect for time, F(1, 108) = 304.10, p < .000, partial η2 = .74, d = 1.0, 1 − β = 1.0. These findings indicate that the MST and MST/CSA groups significantly decreased their scores on the CAPS following treatment. A significant between-subjects group effect was not detected, F(1, 108) = .13, p =.18, partial η2 = .00, d = .07, 1 − β = .31. Furthermore, the group × time interaction, F(1, 108) = .71, p =.40, partial η2 = .01, d = .13, 1 − β = .77, did not yield significant results suggesting that the groups did not differ on their symptom reduction on the CAPS over the course of treatment. Self-reported PTSD symptoms.  A second RM ANOVA was utilized to assess the impact of CSA history on treatment outcome, as measured by the PCL. The RM ANOVA results showed a significant effect for time, F(1, 108) = 98.15, p < .000, partial η2 = .48, d = 1.00, 1 − β = 1.0. These findings again demonstrated that the MST and MST/CSA groups significantly decreased their scores on the PCL following treatment. A significant group effect was not detected, F(1, 108) = .33, p = .57, partial η2 = .00, d = .09, 1 − β = .46. Similarly, no significant group × time interactions emerged from

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Table 1.  Means and Standard Deviations for the Groups at Pre- and Posttreatment. Pretreatment  

Posttreatment

MST

MST/CSA

MST

MST/CSA

Measure

(n = 49)

(n = 61)

(n = 49)

(n = 61)

CAPS   PCL   BDI-II  

74.24 (14.60) 64.28 (9.88) 36.18 (9.74)

76.79 (14.41) 66.02 (12.89) 35.30 (9.75)

43.04 (19.86) 50.38 (16.94) 24.05 (11.98)

42.41 (18.36) 46.30 (17.22) 21.53 (14.79)

Note. MST = military sexual trauma; CSA = childhood sexual abuse; MST = MST index trauma, no CSA history; MST/CSA = MST index trauma, CSA history; CAPS = Clinician-Administered PTSD Scale; PCL = PTSD Checklist; BDI-II = Beck Depression Inventory–Second Edition.

the analyses, F(1, 108) = 2.61, p = .11, partial η2 = .02, d = .36, 1 − β = 1.0, indicating that the groups did not significantly vary on their symptom reduction on the PCL following treatment. Self-reported depression symptoms. A final RM ANOVA was conducted to analyze the influence of CSA history on treatment outcome, as measured by the BDI-II. Findings from the RM ANOVA analyses demonstrated a significant effect for time, F(1, 108) = 106.12, p < .000, partial η2 = .50, d = 1.0, 1 − β = 1.0. These results again indicated that the MST and MST/CSA groups significantly decreased their self-reported depression scores following treatment. A significant group effect was not found, F(1, 108) = .81, p = .37, partial η2 = .01, d = .15, 1 − β = .88. Again, no significant group × time interactions resulted from the analyses, F(1, 108) = .43, p = .51, partial η2 = .00, d = .10, 1 − β = .55, indicating that the groups were not divergent in their symptom reduction on the BDI-II after treatment.

Post-Treatment Comparisons The groups did not significantly differ on post-treatment symptom scores on the CAPS, t(108) = .17, p = .86, d = .01, 1 − β = .05; PCL, t(108) = 1.24, p = .22, d = .23, 1 − β = .22; or BDI-II, t(108) = .96, p = .34, d = .19, 1 − β = .16. Furthermore, a statistically significant difference was not observed between the MST and MST/CSA groups on the number of patients who met

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diagnostic criteria for PTSD at post-treatment, χ2(1) = .91, p = .34, ϕ = .09, 1 − β = .16. Specifically, results showed that 69.4% of the 49 MST and 60.7% of the 61 MST/CSA patients no longer met diagnostic criteria for PTSD after treatment. This finding further suggests that the groups were comparable in their rates of meeting diagnostic criteria for PTSD following treatment. Last, the MST and MST/CSA groups did not differ in the number of sessions attended, t(93) = −.99, p = .33, d = .20, 1 − β = .17, or treatment completion, χ2(1) = 1.32, p = .72, ϕ = .04, 1 − β = .07, with 89.8% of the MST group and 91.8% of the MST/CSA group completing residential treatment.

Discussion Study results showed that the MST and MST/CSA groups did not significantly differ on pre-treatment symptom severity, including clinician-assessed PTSD, self-reported PTSD, and self-reported depression. Furthermore, the MST and MST/CSA groups generally did not differ in pre-treatment demographic variables, aside from those without a history of CSA more likely to be full- or part-time employed. These findings suggest that female veterans with MST and a history of CSA present similarly with regard to PTSD and depression severity, as well as demographic factors, as compared to female veterans with MST without a history of CSA. The study also demonstrated significant effects for time on treatment outcome variables (i.e., CAPS, PCL, and BDI-II), which indicates that female veterans generally experienced clinically significant reductions in PTSD and depression symptom severity over the course of residential treatment. Another consistent result demonstrated in the study was the lack of group differences. In other words, PTSD and depression symptom severity did not vary significantly between the MST and MST/CSA groups at pre- and post-treatment. Related, the MST and MST/CSA groups were comparable in their rates of meeting diagnostic criteria for PTSD following treatment. Similarly, a group × time effect was consistently not shown, suggesting that the MST and MST/ CSA did not significantly differ in their rate of change in PTSD and depression symptom severity. With regard to treatment completion, the groups completed treatment at similar rates and attended a comparable number of individual CPT sessions. Overall, these findings suggest that residential PTSD treatment (i.e., CPT with adjunctive treatment, including skill-building) effectively reduces PTSD and depression symptoms among women with an index trauma of MST, with and without a history of CSA. Furthermore, results indicate that female veterans with MST and CSA did not significantly differ in their reduction in PTSD and depression symptom severity over the course of residential PTSD treatment.

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Taken together, these results are important for several reasons. First, they provide initial evidence to challenge possible assumptions that individuals with a CSA and MST history are more symptomatic than those with an MST history alone and that those with CSA/MST cannot reduce symptoms following trauma-focused therapy. In addition, these findings suggest that individuals who have experienced MST and CSA show similar rates of symptom improvement, and did not need more sessions, than those without a history of CSA when treated in a residential program. Finally, the results provide additional support for the effectiveness of CPT for the treatment of PTSD in women with complex trauma histories, including CSA (Chard, 2005; Resick et al., 2002). As with any research study, limitations should be noted. First, the comprehensive treatment provided and the patient population seeking residential treatment program may limit the generalizability of the results. Furthermore, given the intensive nature of the treatment program, including the inclusion of several adjunct skill-based interventions, it is not possible to tease apart the effects of the separate components (e.g., CPT, other psychoeducation groups) of the treatment program on symptom reduction. Related, psychotherapy groups were provided (such as modules of DBT), which may have facilitated broader symptom relief above and beyond symptoms of PTSD and depression. As a result, investigating differences between these populations in an outpatient treatment setting would provide important data. Second, although the analyses were generally adequately powered for the main effects of time and the interactions in the analyses, they were not consistently powered for the group main effects. As a result, the lack of significant findings for the group main effects should be replicated with larger samples. The study also offers several strengths and contributes to the larger body of MST literature. The current study appears to utilize the largest sample to date investigating female veterans with MST, with and without a history of CSA, over the course of residential treatment for PTSD. As a result, findings provide an initial description of the influence of CSA on residential PTSD treatment outcome among women with an MST history. The use of wellvalidated, clinician-assessed and self-report instruments at pre- and posttreatment offers a methodological strength. Regarding data analysis, missing data techniques were utilized to increase power and generalizability of the results to the sample examined. As veterans continue to seek VA care, treatments that are effective in reducing symptom complaints need to be identified, including treatments to reduce PTSD and other symptoms related to MST. Future studies should attempt to replicate these findings with male and female veterans in both residential and

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outpatient settings. In addition, examining the unique effects of traumafocused treatment and adjunctive interventions (e.g., skill-building, psychoeducation) is warranted. Furthermore, assessing additional outcome variables such as self-harm behaviors, health conditions, medical care utilization, quality of life, and measures of functioning would provide important clinical information. It is imperative that research and clinical efforts continue to identify the best treatment options for veterans with symptoms resulting from MST and the factors that influence their outcome in treatment. Acknowledgments We would like to thank the staff at the Trauma Recovery Center at the Cincinnati VA Medical Center, particularly the data efforts of Lindsey Davidson, B.A.

Authors’ Note Content of this manuscript does not reflect the views of the United States Government or Department of Veterans Affairs.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

Note 1.

We attempted to create a childhood sexual abuse (CSA) group of female veterans who endorsed a history of CSA, but not military sexual trauma, for further comparison. However, the sample size was too small for analysis.

References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck depression inventory-II. San Antonio, TX: Psychological Corporation. Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Charney, D. S., & Keane, T. M. (1990). The clinician administered PTSD scale-IV. Boston, MA: Behavioral Sciences Division, National Center for PTSD. Browne, A., & Finkelhor, D. (1986). Impact of child sexual abuse: A review of the research. Psychological Bulletin, 99, 66-77. doi:10.1037//0033-2909.99.1.66

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Author Biographies Kristen H. Walter, PhD, is a staff psychologist and researcher at the Trauma Recovery Center at the Cincinnati VA Medical Center (VAMC). Her primary research interests include examining predictors and outcome of PTSD treatment as well as the influence of a history of traumatic brain injury on PTSD treatment outcome. She has authored peer-reviewed publications on the treatment of PTSD. Amy Buckley, PhD, is a clinical psychologist with extensive training and experience in the diagnosis and treatment of anxiety disorders. She currently serves as a staff

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psychologist in the Trauma Recovery Center at the Cincinnati VAMC, working predominantly in the women’s residential PTSD program as a lead clinician. Her primary interests include the etiology and treatment of anxiety disorders and mechanisms of change involved in treatment outcome. Jennifer M. Simpson, LISW, is a clinician at the Trauma Recovery Center at the Cincinnati VAMC. She has worked as lead clinician in the Women’s Residential PTSD program. She is a certified provider of evidence-based treatment protocols for PTSD including Cognitive Processing Therapy and Prolonged Exposure Therapy, and she has an extensive training in Dialectical Behavior Training skills. Kathleen M. Chard, PhD, is the Director of the Trauma Recovery Center at the Cincinnati VAMC and the VA Cognitive Processing Therapy (CPT) Implementation Director. She is also the author of the CPT for Sexual Abuse treatment manual and coauthor of the Cognitive Processing Therapy: Military Version manual. She has also published numerous peer-reviewed articles on treatment for PTSD.

Downloaded from jiv.sagepub.com at UNIV OF WESTERN ONTARIO on March 8, 2015

Residential PTSD treatment for female veterans with military sexual trauma: does a history of childhood sexual abuse influence outcome?

This study examined whether a history of childhood sexual abuse (CSA) influenced treatment outcome among female veterans with an index trauma of milit...
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