This research examined life events that affect the onset of delayed Post-Traumatic Stress Disorder in aging combat veterans. A common result from experiencing combat trauma is Post-Traumatic Stress Disorder. There is a rapidly growing veteran population experiencing delayed onset Post-Traumatic Stress Disorder. The occurrence of additional life stressors may increase the likelihood that someone will develop Post-Traumatic Stress Disorder in response to a prior traumatic event. Participants of the study were combat veterans over the age of 65. Qualitative data were gathered from interviewing participants on life events they have experienced since combat exposure as well as Post-Traumatic Stress Disorder symptoms. Findings suggested that life events contribute to the delayed onset of Post-Traumatic Stress Disorder in aging combat veterans. Understanding the development and causes of delayed Post-Traumatic Stress Disorder will help social work practice develop and move forward with programs to improve the quality of life for aging veterans.

In this PhD thesis, the lives and experiences of a group of combat veterans who began surfing following their return from war are explored. Having encountered life changing traumatic events and experienced much suffering (with many becoming diagnosed with post-traumatic stress disorder), these veterans joined an ex-services charity called Surf Action where they were introduced to surfing alongside other veterans who shared their suffering. The purpose of this research is to explore the effects of surfing and, more broadly, of participation in the charity Surf Action in the veterans lives and on their well-being. It is the first in-depth qualitative investigation of surfing in the lives of combat veterans. Using a combination of life history interviews and participant observation, I collected and analysed stories from the veterans about their lived experiences. Through rigorously applying the innovative analytical approach of dialogical narrative analysis (Frank, 2010, 2012), also inspired by phenomenology, the effects of the veterans stories both on and for their lives and well-being are examined. The analysis first demonstrates that stories of surfing were focused on the veterans physical and sensory interactions with the ocean environment, and helped to cultivate the notion of embodied respite from suffering. It is then suggested that by telling and enacting a collective story, the veterans at Surf Action (the Combat Surfers ) created a therapeutic community through which they accessed mutual support, recreated positive military identities associated with camaraderie, and legitimised their struggles with PTSD. Next, the masculine performances which shaped the veterans actions and narratives around help-seeking and dealing with PTSD are highlighted. Furthermore, the analysis reveals the meanings associated with moving beyond the chaotic influence of trauma in the veterans lives and suggests ways of keeping well following trauma and PTSD. The thesis also incorporates an ethnographic creative non-fiction as a way of enhancing knowledge translation and facilitating wider impact and dissemination of the findings. Finally, the thesis concludes with empirical, theoretical, methodological, and practical implications of the research, with an emphasis throughout on what to the study adds to knowledge. The potential of surfing to contribute to veterans healthcare is discussed alongside recommendations for the charity Surf Action and future possibilities for expanding this research.

Many combat veterans face difficulties coping with their personal lives, relationships, and families when they leave the service and return to civilian life. Most studies examining the effects of combat on veterans focus on posttraumatic stress disorder (PTSD) as well as a collection of related consequences. Interest in the term moral injury of military veterans as a related mental health construct has grown. Researchers have investigated the effects of spiritual wellness of combat veterans. However, there is a paucity of counseling literature on the relationship between spiritual wellness and moral injury when combat veterans return to civilian life. Investigating the relationship between spiritual wellness and moral injury as based in existential theory could offer insights to improve quality of life of veterans, families, and society. This study examined the connection between spiritual wellness and moral injury among combat veterans using a quantitative survey with a cross-sectional, correlational analysis and incorporating demographic variables. Results showed that the relationship of spiritual wellness on moral injury is statistically significant. Participants with low spiritual well-being were likely to have an elevated level of moral injury. Those with strong levels of life meaning and purpose were less likely to experience moral injury. These findings can be used to help combat veterans heal from the wounds of war. Clinical interventions associated with life meaning and purpose could enable successful reintegration of combat veterans into society. Results could be used to identify and test specific treatment options. Outcomes could also be used to explore the relationship of combat veterans to other professions subject to moral injury and further explore the relationship of moral injury to PTSD.

Some veterans transitioning from military duty to the classroom are not obtaining college degrees. The purpose of this study was to investigate student veterans’ perceptions of the transition services and support systems at their college that might impact the challenges they face while pursuing a college degree. The theoretical framework for this study was Schlossberg’s Theory of Transition. The guiding research question asked how military veterans perceived the transition services and support systems at their university in the context of their decision to obtain their degrees. A purposeful sampling approach was used for selecting student veteran participants who had returned from active duty and were enrolled at the university for 1 year. Moustakas’s transcendental approach was the model used for interviewing 12 veterans. Inductive analysis was used to analyze data, including coding the interview transcripts and identifying themes to capture the collective experience of the veterans. Participants indicated that existing emotional or social support programs, organizations, and personnel to assist them on campus were inadequate. Implications for social change include increasing faculty and staff understanding of veterans’ needs, which may lead to improved transition services, support systems, and communications within the university. Results may be used to improve retention and degree completion rates of student veterans.

Elucidating factors associated with adherence to treatment for physical and mental health conditions is important, given well-documented associations between non-adherence and poor treatment outcomes. Researchers have worked to identify such factors; however, most studies focus on adherence to medical, rather than, psychological treatments. Clarifying variables that predict adherence to psychotherapy is particularly important for individuals with post-traumatic stress disorder (PTSD), for whom treatment, which typically involves exposure to trauma-related stimuli and imagery, can be aversive. It may consequently be associated with high nonadherence rates, even though studies indicate that greater adherence to PTSD treatment relates to better treatment outcomes. Research needs to identify factors that increase or decrease the likelihood that affected individuals will enter and complete therapy. Although several studies to date have examined adherence to treatment for PTSD, this literature is limited on several fronts. First, studies on psychotherapy adherence have identified few consistent predictors of treatment adherence. Second, adherence to psychotherapy is rarely a central focus of treatment-related research; more typically, researchers treat adherence as secondary in importance to treatment outcomes. Third, little research on psychotherapy adherence has been theoretically driven. Fourth, little adherence research has focused on combat veterans with PTSD, who tend to have particularly poor treatment outcomes. Especially lacking is knowledge about predictors of adherence in veterans who have recently returned from combat; most research focuses on veterans of the Vietnam War, many of whom were initially traumatized decades earlier. The study tested the hypothesis that elevated reports of a specific type of PTSD symptom--avoidance/emotional numbing-- predicted poorer adherence to treatment in 160 veterans who received psychotherapy. No significant associations between avoidance and emotional numbing symptoms and adherence were found. However, emotional numbing was negatively related to psychotherapy adherence. Other variables typically related to PTSD and treatment outcomes were found to be important predictors of psychotherapy adherence and completion/noncompletion of therapy.

Albert Bandura’s construct of moral disengagement has been recognized as theoretically useful for the study of self-destructive behaviors and moral disengagement, and to provide a unique criterion for empirical investigation of United States combat veterans returning from the wars in Iraq and Afghanistan. The purpose of this project is to better understand predictors related to the disengagement of moral self-sanctions in order that self-destructive behaviors related to Post Traumatic Stress Disorder, such as drug and alcohol abuse, and the ultimate self-destructive behavior of suicide, might be mitigated. Charles Snyder’s hope construct, Harold Koenig and Arndt Büssing’s concept of intrinsic religiosity and Corey Keyes’ notion of psychological flourishing are chosen as viable predictor variables. Hope and intrinsic religiosity are found to be significant and to be correlated with moral disengagement. Inferences regarding the results are postulated and suggestions are made for research regarding other possible predictors of moral disengagement. Agentive moral reinforcement is discussed and proposals offered related to increasing psychological resilience and decreasing the agent’s risk associated with moral disengagement.

Background. The current study was conducted to increase understanding of factors that promote or deter post-combat adaptation. In total, five research questions were posed and tested, leading to examination of how difficulties with emotion regulation, post-deployment coping self-efficacy (PDCSE), and disrupted worldview work in-concert to influence post-combat adaptation (as measured by PTSD severity, depression severity, and quality of life perceptions). Methods. The final sample included cross-sectional data for 123 OEF/OIF veterans who were referred for assessment and/or treatment in an outpatient clinic in a Veterans Affairs Medical Center. Path analysis, employing bootstrapping re-sampling, was used to test hypotheses, yielding metrics for model fit, direct effects, and hypothesized indirect effects. Results. Overall findings demonstrated that each of the models tested were a good fit for explaining post-combat adaptation outcomes, with the final integrated model (including combat exposure, difficulties with emotion regulation, PDCSE, and negative worldview) explaining 49% of the variance in PTSD, 60% of the variance in depression severity, and 42% of the variance in quality of life, respectively. Findings across all models demonstrated that emotion dysregulation played a significant role in promoting worse post-combat adaptation, and that this effect primarily worked through alterations in PDCSE and negative worldview. Conclusions. This study concludes with interpretation of findings via theory and the extant literature. Future research and intervention implications are discussed, including the need to focus post-combat therapies on altering PDCSE and negative worldview, and more broadly, on factors that diminish meaningful life for combat veterans. / Ph. D.

Veterans suffering from posttraumatic stress (PTSD), compared to relative trauma-exposed veterans without PTSD, have more serious relationship problems. Research in the area of combat trauma-related symptoms and intimate partner relationships have to-date, mostly focused on identifying the negative outcomes of trauma but have not elaborated on how the symptoms themselves act as agents in negative relationship functioning. The purpose of this study was to identify a relationship between combat-related PTSD symptoms of insomnia/sleep dysfunction, avoidance/emotional numbing, and intimate partner distress - specifically the mechanisms by which symptoms and distress are maintained or exacerbated. A review of combat trauma and relationship theories indicated that a newly applied theory, Conservation of Resources (COR) could account for specific combat trauma symptomology, the effects of non-PTSD intimate partners’ distress, and the course of these aspects. This study predominately utilized quantitative data for exploratory correlational research. One hundred and fifteen Canadian combat veterans completed self-administered questionnaires that included demographic characteristics, supplementary questions and the study variables: PTSD assessment, dyadic adjustment, and sleep issues. Results indicated that PTSD overall is negatively related to dyadic adjustment, and that avoidance symptoms represent the most detrimental cluster of PTSD in terms of relationship functioning. Although insomnia/sleep dysfunction was not correlated to dyadic adjustment for those with PTSD, it was identified as a contributor to negative relationship functioning through supplementary responses. The study suggests a revised Canadian PTSD prevalence rate of 29%, which is noteworthy when compared to the previous PTSD prevalence rate estimation of 10%. The application of COR theory to combat veterans and relationship functioning is supported by the results of this study. Findings of this study can aid clinicians in the enhancement of couple therapies, draw attention to the need for improved deployment screening and care provisions for military members, and contribute to the breadth of empirical literature.

Indiana University-Purdue University Indianapolis (IUPUI) / Traumatic brain injury (TBI) has emerged as a major cause of morbidity among U.S. soldiers who have served in Iraq and Afghanistan. Even mild TBI (mTBI) can result in cognitive impairments that can impact how veterans experience such things as physical symptoms, emotions and behaviors, instrumental activities of daily living, interpersonal interactions, and community reintegration. The purpose of this study was to develop a comprehensive self-management intervention for veterans with mTBI to facilitate their community reintegration upon returning from deployment to combat zones. This study was conducted in two Phases. Phase I entailed collecting qualitative data regarding needs, concerns, strategies used, and advice given by eight veterans with mTBI, guided by a conceptual model derived from Ferrans’ and colleagues’ health-related quality of life model and the TBI literature. Six key categories and predominant themes emerged providing further support for the model (cognitive impairments, physical symptoms, emotions and behaviors, instrumental activities of daily living, interpersonal interactions, and community reintegration). Guided by the conceptual model, a mTBI Veteran Needs and Concerns Checklist and 14 algorithms making up the VETeranS Compensate, Adapt, REintegrate (VETSCARE) intervention were developed. Phase II entailed obtaining review of the mTBI Veteran Needs and Concerns Checklist and the 14 VETSCARE algorithms from six TBI experts. On a scale of 1 to 5, with 5 being strongly agree, expert ratings provided moderate evidence of content validity for the checklist (3.33), and for the 14 algorithms (problem relevance 3.92, accuracy 3.73, feasibility 3.80, acceptability 3.84). The average overall expert rating for the VETSCARE intervention was 3.82. The checklist and the 14 algorithms are being revised based on specific comments provided by the experts. Once revised, the mTBI Veteran Needs and Concerns Checklist and the VETSCARE intervention will be tested for feasibility in a future pilot study with veterans with mTBI who have recently returned from combat zones in Iraq and Afghanistan.

Doctor of Philosophy / Department of Educational Leadership / Sarah Jane Fishback / A new group of learners is emerging in the adult learning environment as a result of the United States being at war for more than 10 years. More than two million warriors served in the Global War on Terrorism (GWOT). Educational institutions across the United States are experiencing growing numbers of students who are military combat veterans of the GWOT. These numbers will continue to grow as more of them transition back into life after combat. These students are arriving in class with varying levels of combat trauma experience and possibly Post Traumatic Stress Disorder (PTSD), major depression, Traumatic Brain Injury (TBI) or a combination of these and other difficulties. The purpose of this research was to learn from military veteran students how their combat experience affects them in the classroom. Specifically it looked at the types of combat experiences they have and the types of physical and mental effects they report experiencing while attending and participating in educational learning activities. This research h sought to gain insight into how combat experience influences the learning experience for GWOT military combat veterans who participate in an educational learning environment. It explored the types of experiences these students bring into that learning environment and how their participation in learning activities is affected.