Acceptance and Commitment Therapy for Co-Occurring Posttraumatic Stress Disorder and Alcohol Use Disorders in Veterans: Pilot Treatment Outcomes

Testing the Effectiveness of a Mindfulness- and Acceptance-Based Smartphone App for Nurses Traumatized by the COVID-19 Pandemic: A Pilot Study

A significant proportion of frontline nurses developed post-traumatic stress disorder (PTSD) symptoms as a result of working during the COVID-19 pandemic. This study aimed to determine the efficacy of a mindfulness- and acceptance-based smartphone app intervention among nurses traumatized by the COVID-19 pandemic. This was a two-arm, randomized controlled trial. We randomly assigned 60 frontline nurses working in various clinical settings in the United States during the pandemic to either the intervention group (i.e. participants used the mindfulness app for 6 wk) or the wait-list control group. We assessed the app's efficacy through outcome measures of PTSD symptom severity, experiential avoidance, rumination, mindfulness, and resilience, measured at pre-, mid-, and post-intervention periods and a 1-month follow-up. Intervention satisfaction and perceived usability of the app were assessed within the intervention group. There was strong evidence of within-between interaction for PTSD, experiential avoidance, and rumination, implying significant improvement of these outcomes for the intervention group as compared to the control group. We only found a within-group interaction effect for mindfulness, indicating significant improvement of mindfulness within the intervention group only. Participants in the intervention group reported high satisfaction levels and perceived usability with the app. Findings highlight that mindfulness- and acceptance-based smartphone apps can improve PTSD symptoms of nurses traumatized by the pandemic. Healthcare organizations should provide nurses with accessible interventions (e.g. mindfulness apps) to treat and prevent secondary behavioral consequences of the pandemic, such as PTSD.

The Indirect Influence of Cannabis Use Disorder Symptoms on PTSD Symptom Severity Through Psychological Inflexibility

Background: One in five college students (21%) report using cannabis in the past month, and approximately 10% develop cannabis use disorder (CUD). Further, college students have high rates of trauma exposure, and CUD is prospectively linked to posttraumatic stress disorder (PTSD). Given the high rate of co-occurrence, research is needed to understand transdiagnostic, modifiable factors that could account for the relationship between CUD and PTSD. Psychological inflexibility (PI) is one such factor and refers to difficulty adapting thoughts or behaviors to various situations that reflect of one's personal values. Objectives: PI predicts worse PTSD symptom severity and has been established as a maintaining factor between alcohol use and PTSD, albeit no studies have examined this relationship with CUD. Results: College students (N = 336) completed self-report measures of CUD, PI, and PTSD. A cross-sectional mediation model explained 54% of the variance in PTSD symptom severity, F(5, 330) = 78.86, p < .001. After controlling for age, gender, and probable alcohol use disorder, CUD was not directly associated with PTSD symptom severity, yet was indirectly associated with PTSD through higher PI. Specifically, CUD was associated with higher PI (b = 0.31, p < .05, 95% CI [0.07, 0.54]), and higher PI was associated with greater PTSD symptom severity (b = 1.07, p < .001, 95% CI [0.95, 1.19]). Conclusion: Although CUD has been previously linked with worse PTSD symptoms, results suggest that this occurs through PI. Importantly, PI is malleable, and may be an important treatment target for co-occurring CUD and PTSD in college students.

A brief mindfulness-based intervention for stress, pain, emotion and attention regulation in military service members with mild traumatic brain injury

AIM

The primary aim of this study was to conduct an open pilot clinical trial of a brief mindfulness-based intervention for persistent postconcussion symptoms that occur after mild traumatic brain injury in military service members. For many service members, operational tempo and other time constraints may prevent them from completing a standard mindfulness-based stress reduction course. Thus, this study sought to examine the effectiveness of a five-session intervention called mindfulness-based stress, pain, emotion, and attention regulation (MSPEAR).

METHODS

Participants were active duty service members with a history of mild traumatic brain injury (TBI) and persisting postconcussion symptoms, all of whom were recruited from an outpatient TBI rehabilitation program at a military treatment facility. Of the 38 service members that were initially enrolled, 25 completed the 5-session MSPEAR intervention, and 20 returned for a 5-week follow-up evaluation. Questionnaires assessing perceived stress, positive affect, pain interference and catastrophizing, sleep disturbances, perceived behavioral and attention regulation, self-efficacy and satisfaction with life were administered at preintervention, postintervention, and at 5-week follow-up intervals. Neuropsychological testing at preintervention and 5-week follow-up included performance validity measures, attention, working memory, and executive function measures. T-tests were run to compare for questionnaire measures at preintervention (Time 1) to postintervention (Time 2). Repeated analysis of variances were conducted to compare questionnaire and neuropsychological measures at Time 1, Time 2, and at Time 3 which is the 5-week follow-up.

RESULTS

Improvements in perceived stress, positive affect, behavioral regulation, metacognition, sleep disturbance, self-efficacy, and satisfaction with life were found immediately after the MSPEAR intervention and were maintained at the 5-week follow-up. Magnification and helplessness aspects of pain catastrophizing improved when comparing preintervention to the 5-week follow-up. Pain interference was not significantly different across study assessment times. Neuropsychological testing revealed improvements in sustained attention, working memory, cognitive flexibility, and inhibitory control when comparing preintervention to the 5-week follow-up assessment.

CONCLUSIONS

The MSPEAR intervention appears to show promise as a brief and effective therapy for specific postconcussion symptoms after mild traumatic brain injury in military service members. Each of the components of MSPEAR including stress, pain catastrophizing, emotion and attention regulation showed improvements in this study, and bears further investigation in a larger scale, preferably randomized controlled trial in those active duty military service members who experience persisting symptoms after a mild traumatic brain injury.

Posttraumatic stress and delay discounting: a meta-analytic review

Delay discounting-the extent to which individuals show a preference for smaller immediate rewards over larger delayed rewards-has been proposed as a transdiagnostic neurocognitive process across mental health conditions, but its examination in relation to posttraumatic stress disorder (PTSD) is comparatively recent. To assess the aggregated evidence for elevated delay discounting in relation to posttraumatic stress, we conducted a meta-analysis on existing empirical literature. Bibliographic searches identified 209 candidate articles, of which 13 articles with 14 independent effect sizes were eligible for meta-analysis, reflecting a combined sample size of N = 6897. Individual study designs included case-control (e.g. examination of differences in delay discounting between individuals with and without PTSD) and continuous association studies (e.g. relationship between posttraumatic stress symptom severity and delay discounting). In a combined analysis of all studies, the overall relationship was a small but statistically significant positive association between posttraumatic stress and delay discounting (r = .135, p < .0001). The same relationship was statistically significant for continuous association studies (r = .092, p = .027) and case-control designs (r = .179, p < .001). Evidence of publication bias was minimal. The included studies were limited in that many did not concurrently incorporate other psychiatric conditions in the analyses, leaving the specificity of the relationship to posttraumatic stress less clear. Nonetheless, these findings are broadly consistent with previous meta-analyses of delayed reward discounting in relation to other mental health conditions and provide further evidence for the transdiagnostic utility of this construct.

Essential parameters needed for a U-Net-based segmentation of individual bones on planning CT images in the head and neck region using limited datasets for radiotherapy application

Objective.The field of radiotherapy is highly marked by the lack of datasets even with the availability of public datasets. Our study uses a very limited dataset to provide insights on essential parameters needed to automatically and accurately segment individual bones on planning CT images of head and neck cancer patients.Approach.The study was conducted using 30 planning CT images of real patients acquired from 5 different cohorts. 15 cases from 4 cohorts were randomly selected as training and validation datasets while the remaining were used as test datasets. Four experimental sets were formulated to explore parameters such as background patch reduction, class-dependent augmentation and incorporation of a weight map on the loss function.Main results.Our best experimental scenario resulted in a mean Dice score of 0.93 ± 0.06 for other bones (skull, mandible, scapulae, clavicles, humeri and hyoid), 0.93 ± 0.02 for ribs and 0.88 ± 0.03 for vertebrae on 7 test cases from the same cohorts as the training datasets. We compared our proposed solution approach to a retrained nnU-Net and obtained comparable results for vertebral bones while outperforming in the correct identification of the left and right instances of ribs, scapulae, humeri and clavicles. Furthermore, we evaluated the generalization capability of our proposed model on a new cohort and the mean Dice score yielded 0.96 ± 0.10 for other bones, 0.95 ± 0.07 for ribs and 0.81 ± 0.19 for vertebrae on 8 test cases.Significance.With these insights, we are challenging the utilization of an automatic and accurate bone segmentation tool into the clinical routine of radiotherapy despite the limited training datasets.

Acceptance and commitment therapy for co-occurring gambling disorder and posttraumatic stress disorder in veterans: a narrative review

Background: PTSD and gambling disorder (GD) are frequently comorbid. Gambling may provide escape-based coping for the emotions experienced by PTSD sufferers. Military personnel may be at increased risk of PTSD and/or GD. Acceptance and Commitment Therapy (ACT) has been found to improve both PTSD and GD outcomes, yet research into the potential effectiveness of ACT for PTSD and/GD in veterans is scarce.Objective: This review aimed to systematically assess and describe the evidence relating to the use of ACT and acceptance-based therapy for military populations with PTSD and/or GD.Method: Six databases were searched. Selection criteria included studies that featured the armed forces/military, delivered ACT/acceptance-based therapy, and aimed to improve PTSD and/or GD outcomes. A narrative synthesis approach was adopted.Results: From 1,117 results, 39 studies were fully screened and 14 met inclusion criteria. All studies originated from the USA and 9 were associated with United States Department of Veterans Affairs. Therapy use within each study produced an improvement in PTSD and/or GD, yet only one study examined GD and no studies considered comorbid PTSD/GD. The broad range of study designs made it difficult to compare the findings or make generalisations from the collective results. It is unclear which method of ACT delivery is superior (app-based, telehealth, face-to-face, groups, one-to-one, manualised, or unstructured), or what the true effect size is of ACT for PTSD and/or GD.Conclusions: These preliminary findings are promising, yet more research is needed on the delivery format and content of ACT sessions, and whether findings generalise beyond USA-recruited military samples. The cost-effectiveness of remote-based ACT also warrants investigation.HIGHLIGHTS Among veterans, psychological interventions such as Acceptance and Commitment Therapy (ACT) may be effective for Post-Traumatic Stress Disorder (PTSD) and/or Gambling Disorder (GD).There is a paucity of evidence on ACT approaches for treating PTSD and GD in veterans.Further work is needed on context-specific delivery (in-person vs. group), method of ACT intervention (manualised vs unstructured, digital therapeutics) with non-US samples.

Research protocol of the efficacy of probiotics for the treatment of alcohol use disorder among adult males: A comparison with placebo and acceptance and commitment therapy in a randomized controlled trial

BACKGROUND AND AIM

Primarily, this study compares the efficacy of probiotic and acceptance and commitment therapy (ACT) in alleviating the severity of alcohol craving and alcohol use disorder (AUD) among patients who had undergo two weeks of in-patient detoxification. Secondarily, this study compares the efficacy of probiotic and ACT in mitigating the severity of comorbid depression and anxiety symptoms; decreasing serum level of pro-inflammatory cytokines, such as interleukin 1β (IL-1β), interleukin 6 (IL-6), and tumor necrosis factor α (TNF-α); changing the event-related potential in electroencephalogram (EEG) and restoring microbiota flora in the gut of AUD patients.

METHODS AND ANALYSIS

Initially, during Phase I of the study, the serum level of IL-1β, IL-6 and TNF-α; ERP changes in the EEG and fecal microbiota content will be compared between 120 AUD patients and 120 healthy controls. Subsequently in Phase II of the study, 120 AUD patients will be randomized by stratified permuted block randomization into the probiotic, ACT and placebo groups in a 1:1:1 ratio. Participants in the probiotic and placebo groups will be administered one sachet per day of Lactobacillus spp. probiotic and placebo, respectively for 12 weeks. While those in the ACT group will receive one session per week of ACT for 8 weeks. Outcome measures will be administered at four timepoints, such as t0 = baseline assessment prior to intervention, t1 = 8 weeks after intervention began, t2 = 12 weeks after intervention and t3 = 24 weeks after intervention. Primary outcomes are the degrees of alcohol craving, alcohol withdrawal during abstinence and AUD. Secondary outcomes to be assessed are the severity of co-morbid depression and anxiety symptoms; the serum levels of IL-1β, IL-6 and TNF-α; changes in ERP and fecal microbiota content.

TRIAL REGISTRATION NUMBER

NCT05830708 (ClinicalTrials.gov). Registered on April 25, 2023.

Ayahuasca: A review of historical, pharmacological, and therapeutic aspects

Ayahuasca is a psychedelic plant brew originating from the Amazon rainforest. It is formed from two basic components, the Banisteriopsis caapi vine and a plant containing the potent psychedelic dimethyltryptamine (DMT), usually Psychotria viridis. Here we review the history of ayahuasca and describe recent work on its pharmacology, phenomenological responses, and clinical applications. There has been a significant increase in interest in ayahuasca since the turn of the millennium. Anecdotal evidence varies significantly, ranging from evangelical accounts to horror stories involving physical and psychological harm. The effects of the brew on personality and mental health outcomes are discussed in this review. Furthermore, phenomenological analyses of the ayahuasca experience are explored. Ayahuasca is a promising psychedelic agent that warrants greater empirical attention regarding its basic neurochemical mechanisms of action and potential therapeutic application.

Sleep Disturbances in Panic Disorder with Comorbid Complex PTSD: A Possible Relationship and Different Psychopathology?

BACKGROUND

Several studies have shown the possible link between trauma and sleep disturbances, particularly in anxiety disorders. This issue could be because sympathetic hyperarousal is central to both disorders, probably caused by a dysregulation of the noradrenergic system. This study aimed to establish if the comorbidity with complex post-traumatic stress disorder (cPTSD) is associated with sleep disturbances in panic disorder (PD) and if the presence of poor sleep quality is associated with a higher psychopathological burden.

METHODS

Participants (N = 211) with PD completed the International Trauma Questionnaire concerning their most troubling experience, the Hamilton Anxiety Rating Scale (HAM-A), and the Pittsburgh Sleep Quality Index (PSQI) to assess anxiety symptoms and sleep disturbances, respectively.

RESULTS

The sample was divided into two subgroups based on the presence of cPTSD. No significant differences emerged in the bivariate analyses for what concerns sociodemographic features. As for the scores of the psychopathological scales, the analysis highlighted statistically significant differences between the subgroups. Subjects with cPTSD reported significantly higher HAM-A total scores. As for the disturbances in self-organization (DSO) and PSQI scores, these were all significantly higher in the cPTSD subsample. At the logistic regression, the presence of cPTSD was inserted as the dependent variable, while the PSQI scores of the subscales evaluating subjective sleep quality, sleep duration, sleep efficacy, and the use of hypnotics were used as independent variables. The presence of cPTSD was significantly associated with the PSQI subscores for subjective sleep quality and use of hypnotics.

CONCLUSIONS

Patients with PD exhibit more severe sleep disturbances and a higher anxiety burden when experiencing prolonged trauma. Therapeutic advances are needed in this field to target these symptomatologic domains.

Outcomes of Acceptance and Commitment Therapy for depression and predictors of treatment response in Veterans Health Administration patients

BACKGROUND

Acceptance and Commitment Therapy for depression (ACT-D) is a promising depression treatment which has not been evaluated on a large scale within VA. This study aimed to evaluate ACT-D's effectiveness in a national, treatment-seeking sample of Veterans.

METHODS

The sample comprised 831 Veterans who received a primary depression diagnosis and received at least two sessions of ACT-D during fiscal years 2015-2020. We used GLM to measure predictors of symptom change, treatment response (50 % reduction in PHQ-9 and AAQ-II scores), subthreshold depression symptoms (PHQ-9 < 10; AAQ-II < 27), and treatment completion.

RESULTS

Veterans experienced an average reduction of 3.39 points on the PHQ-9 (Cohen's d = 0.56) and 3.76 points on the AAQ-II (Cohen's d = 0.43). On the PHQ-9, 40 % achieved subthreshold depression symptoms. On the AAQ-II, 36 % of Veterans achieved subthreshold psychological inflexibility scores. Service-connected disability rating for depression and higher levels of medical comorbidity were both related to lower levels of overall depression symptom change and treatment response. Substance use disorder and bipolar/psychosis diagnoses were associated with greater reductions in psychological inflexibility.

LIMITATIONS

This is an observational study without a control group, so we were unable to compare the effectiveness of ACT-D to other usual care for depression. We were also unable to assess variables that can influence treatment success, such as therapist fidelity and patient engagement.

CONCLUSIONS

ACT-D achieved similar improvements in depression as reported in controlled trials. Adaptations to ACT-D may be needed to improve outcomes for Veterans with depression and comorbid PTSD.

Acceptance and Commitment Therapy for Destructive Experiential Avoidance (ACT-DEA): A Feasibility Study

This study is a preliminary study on an acceptance and commitment therapy (ACT) program that mitigates destructive experiential avoidance (DEA) behaviors, including self-harm behavior and addiction; Methods: Twenty participants aged 15-25 years who had confirmed DEA behavior within the last month participated in a total of six sessions of ACT. Demographic characteristics, history of psychiatric illness, and TYPES and patterns of DEA behavior were confirmed in the baseline survey. The severity of clinical symptoms, frequency of DEA behavior and impulsivity, characteristics of experiential avoidance (EA) behavior, depression, and quality of life (QOL) were measured before and after the program for comparative statistical tests using the intention-to-treat method. Furthermore, the severity of clinical symptoms was evaluated after each program, along with the frequency of DEA behavior and trends in impulsivity, which were investigated based on the behavior log; Results: After the ACT program, both the frequency of DEA behavior and impulsivity and the severity of clinical symptoms, depression, and anxiety decreased significantly. Furthermore, among the EA characteristics, pain aversion, distraction and inhibition, and delayed behavior significantly improved. Moreover, the overall QOL, psychological and social relationships, and QOL regarding the environment also improved; Conclusions: The results of this feasibility study demonstrate the potential of the ACT program as an effective intervention in DEA behavior. The results of this study may be used as preliminary data for future large-scale randomized studies.

Post-traumatic growth in people experiencing high post-traumatic stress during the COVID-19 pandemic: The protective role of psychological flexibility

The COVID-19 pandemic evokes high levels of post-traumatic stress (PTS) in some people as well as positive personal changes, a phenomenon known as post-traumatic growth (PTG). Experiencing an adverse event as traumatic is crucial for triggering PTG, therefore higher PTS is often associated with higher PTG. This longitudinal study examined the protective role of psychological flexibility in fostering PTG in a group of people reporting high PTS related to COVID-19 as compared to those with low PTS. We hypothesized that higher psychological flexibility will be associated with higher PTG in those with high PTS and that psychological flexibility would be unrelated to PTG in those with low PTS. Secondary data analysis was conducted on data from a larger project investigating the psychological impacts of COVID-19. Adult Italians (N = 382) completed online surveys at Time 1 (three months after the first national lockdown, July 2020) and Time 2 (three months later when the number of COVID-19 cases increased, October 2020). Based on the Impact of Event Scale–Revised cut-off score, two PTS groups were identified at Time 2: low PTS (below cut-off) and high PTS (above cut-off). As predicted, moderation analyses showed that after controlling for Time 1 PTS and PTG and confounding variables, Time 1 psychological flexibility was associated with higher Time 2 PTG in the high PTS group, whereas psychological flexibility was unrelated to PTG in the low PTS group. Four psychological flexibility sub-processes (present moment awareness, defusion, values, committed action) at Time 1 were related to higher Time 2 PTG in only the high PTS group. Findings advance understanding of the role of psychological flexibility in trauma reactions and pandemic mental health adjustment. Evidence-based approaches that target psychological flexibility, like Acceptance and Commitment Therapy, are likely to foster PTG and ultimately adjustment in people with high PTS during and after the pandemic.

A pilot study on the feasibility, acceptability, and preliminary efficacy of a brief text message intervention for co-occurring alcohol misuse and PTSD symptoms in a community sample

Accessible, brief, and self-directed intervention are needed to improve treatment access for individuals with co-occuring PTSD and alcohol misuse. This pilot study tests the feasibility, acceptability, and preliminary efficacy of a brief text message intervention based on cognitive behavioral therapy plus message framing (CBT + Framing) compared to active control providing kind support and attention (KAM), to reduce PTSD symptoms and alcohol use. Two waves of community-based data collection (Wave 1 n = 50; Wave 2 n = 59) were completed. Participants self-reported symptoms at baseline, post-intervention, and 8-week follow-up. Engagement and retention were high, suggesting messages were feasible and acceptable. Across waves and conditions, from baseline to follow-up primary outcomes of PTSD symptoms (medium to large effects), weekly drinks (medium effects), and heavy episodic drinking (small to medium effects) decreased. Consistent with hypotheses, CBT + Framing outperformed KAM for PTSD at post in Wave 2 and for number of heavy drinking episodes at both post and follow-up in Wave 1. Contrary to hypotheses, KAM outperformed CBT + Framing for PTSD at post in Wave 1, and minimal differences were observed between conditions for weekly drinks in both waves. Future studies should continue to develop and test brief, accessible interventions.

Profiling Police Forces against Stress: Risk and Protective Factors for Post-Traumatic Stress Disorder and Burnout in Police Officers

Police officers are frequently exposed to highly stressful situations at work and have an increased risk to develop symptoms of post-traumatic stress disorder (PTSD) and burnout (BO). It is currently not well understood which officers are most at risk to develop these disorders. The aim of this study was to determine which coping strategies and personality traits could act as protective or risk factors in relation to PTSD and BO. The second aim, in the interest of designating preventive and therapeutical measures, was to determine whether certain profiles of police officers could be identified as high risk for developing mental disorders. Herein, 1073 French-speaking police officers in Switzerland reported in an online survey about their PTSD and BO symptoms, anxiety, depression, suicide ideation, coping strategies, occupational stress, and personality factors. The cluster analysis highlighted three principal profiles of police officers: those who are not at risk of developing pathologies because they are not exposed or insensitive to these stressors, and those who are, among which personality and coping strategies oriented the risk of developing PTSD or BO. These same protective and risk factors were also corroborated in the linear and logistic regression analyses. These results may suggest that a crucial opportunity for mitigating mental health issues in the force could consist of screening recruits for risk-related personality traits and orienting them towards psychological training programs for the development of functional coping strategies.

A Randomized Pilot Study of Acceptance and Commitment Therapy to Improve Social Support for Veterans with PTSD

Veterans with PTSD often have substantial interpersonal difficulties and low levels of social support, which puts them at increased risk of mortality, but few treatments address global social impairment for veterans with PTSD. This study is a pilot randomized trial of Acceptance and Commitment Therapy to Improve Social Support for Veterans with PTSD (ACT-SS), a psychotherapy that targets social avoidance and eroded social relationships, compared to Person-Centered Therapy (PCT), a non-directive psychotherapy. Participants were randomized to twelve sessions of either ACT-SS (n = 21) or PCT (n = 19). The results showed that veterans with PTSD had high ratings of satisfaction for both treatments. Contrary to the PCT group, participants in the ACT-SS group showed a significant improvement in the quality of social relationships, engagement in social and leisure activities, and PTSD symptoms from the baseline assessment to the end of treatment and a three-month follow-up. Veterans in the ACT-SS group, but not the PCT group, also showed significant improvements in mindfulness and valued living and a reduction in experiential avoidance from baseline to the end of treatment, with sustained improvements in valued living at the three-month follow-up. Overall, the present study demonstrated the feasibility, acceptability, and positive preliminary outcomes of ACT-SS for veterans with PTSD.

Exploring the relationships between resilience, mindfulness, and experiential avoidance after the use of a mindfulness- and acceptance-based mobile app for posttraumatic stress disorder

PURPOSE

This study used a mindfulness- and acceptance-based mobile app to examine the relationships between resilience, mindfulness, experiential avoidance, and posttraumatic stress disorder (PTSD) symptoms.

DESIGN AND METHODS

A quasi-experimental pre-posttest, single-group study design was used. A total of 23 college student veterans used the app for 4 weeks. Outcomes of resilience, mindfulness, experiential avoidance, and PTSD were measured at three time-points (baseline, end of Week 2, and end of Week 4).

FINDINGS

All outcomes significantly improved at postintervention. Improvements in resilience and PTSD significantly correlated with improvement in mindfulness.

PRACTICE IMPLICATIONS

Mindfulness- and acceptance-based mobile apps can be safely used by individuals with PTSD as a complementary approach to enhance resilient coping with PTSD.

Development of a Telephone-Delivered Acceptance and Commitment Therapy Intervention for People Living with HIV who are Hazardous Drinkers

Alcohol use among people living with HIV (PWH) has been increasingly recognized as an important component of HIV care. Transdiagnostic treatments, such as Acceptance and Commitment Therapy (ACT), that target core processes common to multiple mental health and substance-related problems, may be ideal in HIV treatment settings where psychological and behavioral health comorbidities are high. In advance of a randomized clinical trial (RCT), the overall objective of this study was to systematically adapt an ACT-based intervention originally developed for smoking cessation, into an ACT intervention for PWH who drink at hazardous levels. Consistent with the ADAPT-ITT model, the adaptation progressed systematically in several phases, which included structured team meetings, three focus group discussions with PWH (N = 13), and in-depth interviews with HIV providers (N = 10), and development of standardized operating procedures for interventionist training, supervision, and eventual RCT implementation. The procedures described here offer a template for transparent reporting on early phase behavioral RCTs.

Building a More Diverse and Inclusive Science: Mindfulness-Based Approaches for Latinx Individuals

Objectives

This article represents a call to action for the mindfulness field to be more diverse and inclusive of Latinx individuals. Building a diverse and inclusive science around mindfulness-based approaches (MBAs) that considers important group-level cultural and contextual information is an important public health challenge in need of innovative solutions.

Methods

We describe ways that the Latinx population is poised to benefit from MBAs. We further elucidate challenges, describe potential solutions, and outline a research agenda that may hold promise for building a more inclusive mindfulness movement.

Results

Our recommendations center around developing nuanced cultural adaptations to MBAs, engaging Latinx individuals in research, increasing the rigor of scientific studies pertaining to Latinx individuals, relying on implementation science to develop innovative methods for disseminating MBAs to Latinx individuals, developing training and certification mechanisms to increase diversity and representation of Latinx mindfulness teachers, and creating mechanisms for the oversight of MBAs within this group.

Conclusions

There has been a lack of inclusivity of Latinx individuals in the field of MBAs with regards to research studies, barriers to access for economically disadvantaged groups, and lack of diversity in its workforce. Considering the recognition of adverse social drivers of health that generate chronic stress and health disparities, the Latinx population is especially poised to benefit greatly from MBAs. A diverse and inclusive mindfulness science holds promise to enhance the effectiveness, acceptability, feasibility, and wide-scale dissemination and implementation of MBAs.

Psychedelic treatment for co-occurring alcohol misuse and post-traumatic stress symptoms among United States Special Operations Forces Veterans

Background & aims

Special Operations Forces Veterans (SOFV) have unique treatment needs stemming from multiple repeated forms of combat exposure resulting in a complex sequela of problems including alcohol misuse and post-traumatic stress symptoms. Current approved pharmacologic treatments for alcohol misuse and PTSD are lacking in adherence and efficacy, warranting novel treatment development. The current study examined the correlations between psychedelic treatment and changes in alcohol misuse among trauma exposed United States SOFV.

Method

An anonymous internet-based survey was conducted among SOFV who completed a specific psychedelic clinical program in Mexico. Retrospective questions probed alcohol use and post-traumatic stress symptoms during the 30-days before and 30-days after the psychedelic treatment. A total of 65 SOFV completed treatment and were eligible for contact. Of these, 51 (78%) completed the survey, and 27 (42%) reported alcohol misuse (≥4 on the AUDIT-C) in the 30 days prior to treatment and were included in analyses (Mean Age = 40; male = 96%; Caucasian/White = 96%).

Results

There were significant and very large reductions in retrospective reports of alcohol use (P < 0.001; d = –2.4) and post-traumatic stress symptoms (P < 0.001; d = –2.8) and a significant and large increase in psychological flexibility (P < 0.001; d = –1.8), from before-to-after the psychedelic treatment. In the 30 days after treatment, 85% reduced their alcohol consumption to non-risky levels (33% abstinent; 52% non-risky drinking). Increases in psychological flexibility were strongly associated with reductions in alcohol use and post-traumatic stress symptoms (rs range 0.38–0.90; ps < 0.05).

Conclusion

Rigorous longitudinal studies should be conducted to determine whether psychedelic-assisted therapy holds promise as an intervention in this population.

Indirect Associations Between Posttraumatic Stress Symptoms and Other Psychiatric Symptoms, Alcohol Use, and Well-being via Psychological Flexibility Among Police Officers

Police officers experience a high number of potentially traumatic events (PTEs) often associated with elevated posttraumatic stress symptoms (PTSS). In addition, PTSS are related to co-occurring psychiatric symptoms (e.g., anxiety, depression), alcohol misuse, and low perceived well-being. Yet, behavioral processes that may account for the associations between PTSS and unfavorable outcomes remain unspecified. Psychological flexibility, or one's response to private experiences (e.g., PTE-related memories) with an open, aware, and active approach, may be one such process. The present study aimed to evaluate psychological flexibility as both a mediator and moderator of PTSS and commonly co-occurring psychiatric symptoms, alcohol use, and general well-being, using cross-sectional data provided by a sample of police officers (N = 459) recruited from three regionally distributed U.S. police agencies. Structural equation modeling indicated a well-fitting model wherein psychological flexibility indirectly accounted for associations among PTSS and endogenous outcomes, χ² (107, N = 457) = 225.33, p < .001, CFI = .99, TLI = .98, RMSEA = .05, 90% CI [.04, .06], SRMR = .03. Psychological flexibility also moderated associations between PTSS and psychiatric symptoms, B = 1.58 (SE = 0.22), p < .001; and well-being, B = -3.84 (SE = 0.46), p < .001. Although additional research is needed, these preliminary results suggest psychological flexibility may be a behavioral process that accounts for negative outcomes associated with PTSS and a productive intervention target in the context of PTSS and generalized distress. Further research regarding the role of psychological flexibility in PTSS-related outcomes for police officers appears warranted.

A network analysis of two conceptual approaches to the etiology of PTSD

Two prominent conceptual models of posttraumatic stress disorder (PTSD) are the cognitive model, associated with cognitive processing therapy (CPT; Resick & Schnicke, 1992), and the functional contextualist model, underlying acceptance and commitment therapy (ACT; Hayes et al., 1999). Network analysis was used to examine dynamic interactions among cognitive (relating to CPT) and functional contextualistic (relating to ACT) variables and PTSD symptoms in a sample of 722 trauma-exposed adults. Results from the cognitive networks highlighted the importance of maladaptive beliefs about threat in maintaining the co-occurrence of PTSD symptoms and cognitive variables. Additionally, PTSD symptoms were more likely to lead to cognitive variables, rather than the reverse direction. Results from the functional contextualist networks identified numerous associations amongst variables that contribute to the co-occurrence of PTSD symptoms and psychological inflexibility. Findings from this study may help generate causal hypotheses that can be tested further using a longitudinal study design.

The Choice Point Model of Acceptance and Commitment Therapy With Inpatient Substance Use and Co-occurring Populations: A Pilot Study

Objectives: Acceptance and Commitment Therapy (ACT) is an empirically supported treatment which aims to enhance self-acceptance and a commitment to core values. The present study examined the effectiveness of the Choice Point model of ACT in a residential substance use disorder (SUD) setting. Choice Point is a contemporary approach to ACT and targets transdiagnostic processes.

Methods: This uncontrolled quasi-experimental design assessed 47 participants taking part in Choice Point for Substances (CHOPS) in order to investigate its influence on psychological inflexibility, values-based action, and self-compassion over time. The study additionally assessed for sleeper effects and associations between transdiagnostic processes and warning signs of relapse.

Results: Findings demonstrated a decrease in psychological inflexibility and increases in values-based action and self-compassion over time. Gains were maintained at follow-up, and sleeper effects were observed for psychological inflexibility and mindfulness. Correlational analysis suggested that all transdiagnostic processes were related to warning signs of relapse at follow-up.

Conclusion: These results provide preliminary evidence for the feasibility, acceptability, and effectiveness of CHOPS for SUD. Observed sleeper effects in psychological inflexibility and mindfulness indicate that CHOPS may provide longer-term benefits critical to a population where relapse is common. While encouraging, these findings should be interpreted with caution. Future research should utilize comparison groups when investigating CHOPS.

Identifying Mental Disorders in Primary Care: Diagnostic Accuracy of the Connected Mind Fast Check (CMFC) Electronic Screen

Primary care physicians (PCPs) often daily address diagnoses and treatment of mental disorders in their practices. The current study examined the Connected Mind Fast Check (CMFC), a two-tiered electronic screen, assessing six common mental disorders. The eight-item Initial Screen assesses possible symptoms, whereas SAM modules establish provisional diagnoses and areas of clinical concern. With 234 patients from five independent PCP offices, diagnostic accuracy was tested with the SCID-5-RV as the external criterion. Concerningly, many patients were unaware of their current mental disorders and comorbidities. The CMFC Initial Screen evidenced strong sensitivity, identifying with very few missing diagnoses. About two-thirds of provisional SAM diagnoses were confirmed with high specificities. Bipolar Disorder posed the most challenges at both tiers. Importantly, the suicide screen identified all patients with suicide plans and three-fourths with ideation. In general, the CMFC effectively identified provisional diagnoses, impairment, and potential suicidality.

Experiential avoidance is associated with medical and mental health diagnoses in a national sample of deployed Gulf War veterans

A substantial minority of deployed Gulf War veterans developed posttraumatic stress disorder (PTSD), depression, and several chronic illnesses. Although military combat and exposure to certain nuclear, biological, and chemical agents (NBCs) increase risk for post-deployment health problems, they do not fully explain many Gulf War veteran health diagnoses and are not viable treatment targets. Experiential avoidance (EA; one's unwillingness to remain in contact with unpleasant internal experiences) is a modifiable psychosocial risk factor associated with PTSD and depression in veterans as well as pain and gastrointestinal diseases in the general population. In this study, we recruited a national sample of deployed Gulf War veterans (N = 454) to test the hypothesis that greater EA would be significantly associated with higher lifetime odds of PTSD, depression, "Gulf War Illness" (GWI/CMI), and other chronic illnesses common in this veteran cohort. Participants completed a self-report battery assessing demographic, military-related, and health-related information. Multivariate analyses showed that after adjusting for age, sex, race, combat exposure, and NBC exposure, worse EA was associated with higher lifetime odds of PTSD, depression GWI/CMI, gastrointestinal problems, irritable bowel syndrome, arthritis, fibromyalgia, and chronic fatigue syndrome (ORs ranged 1.25 to 2.89; effect sizes ranged small to large), but not asthma or chronic obstructive pulmonary disease. Our findings suggest medical and mental health providers alike should assess for EA and potentially target EA as part of a comprehensive, biopsychosocial approach to improving Gulf War veterans' health and wellbeing. Study limitations and future research directions are also discussed.

Effect of alcohol interventions on suicidal ideation and behaviour: A systematic review and meta-analysis

BACKGROUND

Alcohol consumption is related to both suicidal ideation and behaviour, but evidence regarding the effect of psychological interventions to reduce alcohol use on self-harm, suicidal behaviour and ideation is limited. Therefore, the aim of the current study was to conduct a systematic literature review and meta-analysis of the effect of alcohol-related psychological interventions on these outcomes at the individual level.

METHODS

We searched the Cochrane CENTRAL, Cochrane DARE, EMBASE, Medline, ProQuest, PsycINFO, PubMed, SCOPUS, and Web of Science electronic databases to 5 January 2021. We included all English-language papers worldwide utilising psychological interventions with a focus on harmful alcohol use and suicidal ideation, self-harm, and/or suicidal behaviour.

RESULTS

We identified 11 studies, nine provided sufficient numerical data for meta-analysis. Although the methods and effect sizes varied substantially in the studies, reducing alcohol may led to a reduction in self-harm and suicide attempt by the final follow-up assessment (Odds ratio [OR] 0.57, 95% confidence interval [CI] 0.33 to 0.97, 6 studies, 491 participants, I² = 0%). However, there was no apparent effect for these interventions on suicidal ideation or suicide deaths. There was no significant difference in effect by therapeutic approach. Neither intervention dose (in hours) nor duration (in months) significantly explained differences in treatment effectiveness.

CONCLUSIONS

Interventions targeting harmful alcohol consumption may contribute towards a reduction in self-harm at the individual level. However, there was no apparent effect of these interventions on suicidal ideation (measured either continuously or dichotomously) or suicide deaths.

Emotion regulation and experiential avoidance moderate the association between posttraumatic symptoms and alcohol use disorder among Israeli combat veterans

INTRODUCTION

the association between Posttraumatic Stress symptoms (PTSS) and Alcohol Use Disorder (AUD) among combat veterans is well established. However, little is known concerning the intertwining effect of distress oriented coping mechanisms on this association. In this study, we sought to explore the moderating role of experiential avoidance (EA), cognitive reappraisal (CR) and expressive suppression (ES) on the association between PTSS and AUD among Israeli combat veterans.

METHOD

Participants were 189 Israel Defense Forces (IDF) male combat veterans (mean age = 30.03) who completed a set of validated self-report questionnaires assessing PTSS, AUD, EA, CR and ES. Moderation analyses were conducted using a four-step hierarchical regression analysis and an ordinary least squares regression analysis.

RESULTS

Analyses indicated that individuals with average or high levels of EA or ES exhibited significant positive association between PTSS and AUD, yet those with low levels of EA or ES exhibited no significant association between PTSS and AUD (b = 0.14,Confidence Interval (CI)[0.06, 0.22, SE = 0.04, t = 3.65, p = .000, 95%] for EA and b = 0.17, CI[0.07, 0.25, SE = 0.04, t = 3.69, p = .000, 95%] for ES). In addition, CR moderated the association between PTSS and AUD (b = 0.18, CI[0.07, 0.29, SE = 0.06, t = 3.24, p = .001, 95%]), so that the association between PTSS and AUD is positive and stronger for higher levels of CR.

CONCLUSIONS

Our findings imply that EA, ES and CR and emotion regulation may be major facilitators of the association between PTSS and AUD among combat veterans. These findings are discussed in the Israeli context as well as in light of a general psychological perspective.

Prevention of suicidal behavior in bipolar disorder

BACKGROUND

Excess mortality is a critical hallmark of bipolar disorder (BD) due to co-occurring general medical disorders and especially from suicide. It is timely to review of the status of suicide in BD and to consider the possibility of limiting suicidal risk.

METHODS

We carried out a semi-systematic review of recent research reports pertaining to suicide in BD.

FINDINGS

Suicide risk in BD is greater than with most other psychiatric disorders. Suicide rates (per 100,000/year) are approximately 11 and 4 in the adult and juvenile general populations, but over 200 in adults, and 100 among juveniles diagnosed with BD. Suicide attempt rates with BD are at least 20 times higher than in the adult general population, and over 50 times higher among juveniles. Notable suicidal risk factors in BD include: previous suicidal acts, depression, mixed-agitated-dysphoric moods, rapid mood-shifts, impulsivity, and co-occurring substance abuse. Suicide-preventing therapeutics for BD remain severely underdeveloped. Evidence favoring lithium treatment is stronger than for other measures, although encouraging findings are emerging for other treatments.

CONCLUSIONS

Suicide is a leading clinical challenge for those caring for BD patients. Improved understanding of risk and protective factors combined with knowledge and close follow-up of BD patients should limit suicidal risk. Ethically appropriate and scientifically sound studies of plausible medicinal, physical, and psychosocial treatments aimed at suicide prevention specifically for BD patients are urgently needed.

Examining the Role of Craving, Mindfulness, and Psychological Flexibility in a Sample of Individuals with Substance Use Disorder

Substance Use Disorder (SUD) continues to represent a significant public health crisis in the United States. Purpose: Novel and effective treatments are needed, and third wave behavioral approaches focused on increasing mindfulness and psychological flexibility appear promising. However, the unique and shared impact of mindfulness and psychological flexibility on substance craving is not well understood. Methods: The current study explores how mindfulness and psychological flexibility predict substance craving while controlling for severity of substance dependence in a sample (N = 284) of treatment-seeking adults with SUD. Results and Discussion: Results suggest that mindfulness and psychological flexibility each account for unique variance in substance craving over and above the other. Implications and limitations are discussed.

Autotraumatic Stress Disorders: Posttraumatic Stress Disorder Variants When the Victim Bears Responsibility for the Trauma

Autotraumatic stress disorders (ATSD), variants of posttraumatic stress disorder PTSD, may develop in individuals after traumatic stressors for which they carry some responsibility, for example, serious self-injury and injury or death to others after murderous rages or careless vehicular driving. In ATSD, the individual is both the causative actor and casualty. As a result, in ATSD, distinctive negative psychological sequelae are grafted onto the usual distressing symptoms of PTSD, differentiating them from both PTSD and complex-PTSD. Whether the actions were intentional or unintentional and regardless of complications by comorbid psychiatric disorders, individuals with ATSD additionally experience some or all of the following symptoms stemming from actions for which they were responsible, wholly or in part: severe and unrelenting reality-based guilt, shame, remorse, regret, bitterness, self-betrayal, inability to trust oneself, and moral injury. Empirical studies investigating trauma-associated guilt and moral injury provide evidence to support these formulations. Clinical vignettes illustrate a range of circumstances leading to ATSD, in each instance adding significantly to the individual's distress, impeding recovery, and often requiring specific psychotherapeutic attention over and above that required for PTSD or complex-PTSD. These psychotherapeutic strategies have included intense, prolonged, noninterruptive, open-minded listening; avoiding premature whitewashing of responsibility and guilt; facilitating grief over lost innocence; helping create personal narratives that permit self-acceptance despite permanently altered damaged self-image; and, for some individuals, guiding repentance and restorative actions. Systematic case series and additional studies are necessary to ascertain how intentionality, self-harm versus harming others, and various comorbidities shape ATSD presentations, and to better delineate effective treatment strategies.

College student veterans' experience with a mindfulness- and acceptance-based mobile app intervention for PTSD: A qualitative study

This study aimed to explore college student military veterans' experience with a mindfulness- and acceptance-based smartphone app intervention. Upon the 4-week participation in the intervention, 23 student veterans took part in semi-structured interviews. In the thematic analysis of the interview transcripts, three main themes emerged: (1) generating momentum of app use; (2) optimizing the functions and benefits of the app; and (3) resolving to deepen the practice of mindfulness and acceptance. Considering the low engagement rates of several previous app-based studies, our results provide a useful framework for incorporating human feedback and support in enhancing users' engagement with the app.

The Use of Acceptance and Commitment Therapy in Substance Use Disorders: A Review of Literature

Background

Acceptance and commitment therapy (ACT) is a form of behavioral therapy that teaches people to learn to accept rather than avoid challenging situations in their lives. ACT has shown to be an intervention with great success in the reduction of various mental disorders and substance use disorders (SUDs). The core of ACT when used in SUD treatment is guiding people to accept the urges and symptoms associated with substance misuse (acceptance) and use psychological flexibility and value-based interventions to reduce those urges and the symptoms (commitment). The purpose of this study is to review the existing literature to examine the evidence on the use of ACT in the management of SUD.

Methods

A thorough search of four databases (CINAHL, PubMed.gov, PsycINFO and PsycNET) from 2011 to 2020 was conducted using search terms like ACT, ACT and SUD, ACT, and substance misuse. The articles retrieved were critically appraised using the Critically Appraised Topic (CAT) Checklist.

Results

Most of the studies showed that ACT was effective in the management of SUD showing significant evidence of a reduction in substance use or total discontinuation with subsequent abstinence.

Conclusions

The literature review concluded that success has been achieved using ACT either as monotherapy or in combination with other therapy in the treatment of individuals with SUD.

Acceptance and Commitment Therapy Delivered via Telehealth for the Treatment of Co-Occurring Depression, PTSD, and Nicotine Use in a Male Veteran

Symptoms of depression, posttraumatic stress, and substance use disorders commonly co-occur and are a tremendous health burden among the U.S. military veteran population. Acceptance and Commitment Therapy (ACT) is an evidence-based, transdiagnostic, integrated approach that has been used to treat these problems. Delivering psychotherapy via telehealth helps to break down barriers to care. This case study describes the application of ACT via telehealth with a male veteran with co-occurring symptoms of depression, PTSD and nicotine addiction. His depressive symptoms, PTSD symptoms, and nicotine use decreased substantially over the course of therapy. He demonstrated increased willingness to experience negatively evaluated internal experiences such as emotions and urges to use nicotine, defusion from self-critical and other unhelpful thoughts, more consistent engagement in values-consistent behaviors, and increased behavioral engagement in his social life. Treatment implications and unique aspects of the telehealth modality are discussed. Recommendations are made for training clinicians who may be considering providing services via telehealth or using ACT.

Promoting Resilience Among College Student Veterans Through an Acceptance-and-Commitment-Therapy App: An Intervention Refinement Study

Military veterans' stigmatized views on mental disorders and traditional mental health care considerably reduce veterans' access to mental health services. The present study aimed to refine a previously developed non-stigmatizing smartphone-app intervention based on the principles of acceptance and commitment therapy for college student veterans with posttraumatic stress disorder (PTSD). To this end, we tested the acceptability of the developed prototype using a mixed-method study design. A total of nine student veterans participated in the study by using the app intervention and completing pre-post study measures and a post-intervention qualitative interview. The results showed that the intervention was highly acceptable. The results of the qualitative data analysis highlighted relevant themes related to strategies for improving the content, delivery, and structure of the intervention. The results also showed that, despite a decrease in the participants' adherence as the intervention progressed, there was a consistent improvement in the participants' resilience, PTSD, and rumination. Based on the results, the intervention was revised for prospective feasibility and efficacy testing. Our results highlight the need to use a collaborative approach in the early stage of the development of self-management PTSD interventions.

Process-based functional analysis can help behavioral science step up to novel challenges: COVID - 19 as an example

Historically speaking, the behavioral tradition advanced functional analysis as a method of applying existing principles to novel situations. In the more than half a century since that idea was advanced, functional analysis has either fallen into disuse, as in most of applied psychology, or has been used but modified to a point that is virtually inapplicable elsewhere, as in applied behavior analysis work with severe developmental disabilities. In this paper we argue that the current challenges with COVID-19 present an ideal time to reinvigorate functional analysis by combining it with the growing body of evidence on processes of change, organized under an extended evolutionary meta-model. This new form of process-based functional analysis takes advantage of the strengths of contextual behavioral science, while opening avenues of fruitful interaction with other wings of intervention and evolutionary science more generally. Using the psychological flexibility model as an example, we show how this approach solves the key problems of classical functional analysis and helps professionals deal with novel challenges such as those posed by COVID-19. Humanity is now facing an extraordinary and unexpected situation. Behavioral science needs to rise to that challenge in a way that provides both immediate practical value and greater assurance of long-term benefits for our understanding of human complexity more generally. Process-based functional analysis can be a vehicle to do just that.

Identifying Change Targets for Posttraumatic Stress Disorder Among Suicidal and Self-Injuring Women With Borderline Personality Disorder

Research on psychotherapies for posttraumatic stress disorder (PTSD) is increasingly focused on understanding not only which treatments work but why and for whom they work. The present pilot study evaluated the temporal relations between five hypothesized change targets-posttraumatic cognitions, guilt, shame, general emotion dysregulation, and experiential avoidance-and PTSD severity among women with PTSD, borderline personality disorder, and recent suicidal and/or self-injurious behaviors. Participants (N = 26) were randomized to receive 1 year of dialectical behavior therapy (DBT) with or without the DBT prolonged exposure (DBT PE) protocol for PTSD. Potential change targets and PTSD were assessed at 4-month intervals during treatment and at 3-month posttreatment follow-up. Time-lagged mixed-effects models indicated that between-person differences in all change targets except guilt were associated with more severe PTSD, η² s = .32-.55, and, except for general emotion dysregulation, slowed the rate of change in PTSD severity over time, η² s = .20-.39. In DBT but not in DBT + DBT PE, individuals with higher levels of guilt and experiential avoidance relative to their own average had more severe PTSD at the next assessment point, η² s = .12-.25. The associations between the proposed change targets and PTSD severity were not bidirectional, except for general emotion dysregulation, η² = .50; and posttraumatic cognitions, η² = .06. These preliminary findings suggest that trauma-related cognitions, shame, and guilt, as well as problems regulating them, may be important change targets for improving PTSD in this patient population.

The Role of Affect in Psychosocial Treatments for Substance Use Disorders

PURPOSE OF REVIEW

This paper provides a narrative review of studies published over the past five years that have examined the role of affect, including both affective symptoms and affective disorders, in psychosocial treatments for substance use disorder.

RECENT FINDINGS

A growing body of literature suggests that affective symptoms and affective disorders may moderate substance use disorder treatment efficacy, mediate the effects of treatment on substance use outcomes, and may be directly changed by substance use disorder treatment.

SUMMARY

Substance use disorders and affective disorders commonly co-occur, and both affect and affective disorders are associated with substance use disorder treatment outcomes. Future research should continue to examine affect as a moderator, mediator, and outcome of substance use disorder treatments. In particular, new studies that are designed to test precision medicine hypotheses would greatly expand our understanding of the role of affective symptoms and disorders in substance use disorder treatment.

Student Veterans' Coping with Posttraumatic Stress Symptoms: A Glaserian Grounded Theory Study

The present study investigated the ways in which student military veterans cope with their posttraumatic stress symptoms. The participants were a total of 21 military veterans attending a U.S. university. The results of the grounded theory data analysis reveal the core category of modulating intrusions, a process indicating how student veterans cope with recurrent and unwanted posttraumatic stress experiences. Our findings also demonstrate that veterans cope by either avoiding or allowing themselves to experience the pain associated from their traumatic experiences. The proposed framework can be meaningfully used to facilitate the development of adaptive coping among veterans with posttraumatic stress.

Moving Moral Injury Into the Future With Functional Contextualism: A Response to Nash's "Unpacking Two Models for Understanding Moral Injury" (2019)

In his commentary on the Journal of Traumatic Stress special issue on moral injury (Vol. 32, Issue 3), Nash (2019) critiques both Farnsworth's (2019) descriptive-prescriptive framework for differentiating posttraumatic stress disorder (PTSD) from moral injury and Farnsworth, Drescher, Evans, and Walser's (2017) functional contextual definition of moral injury and related concepts. To make his arguments, Nash contrasts these two frameworks with the Navy and Marine Corps Combat Operational Stress Control (COSC) model wherein moral stressors are presumed to cause literal damage to intrapsychic structures. Unfortunately, in drawing his comparisons, Nash makes several misstatements that we feel are important to clarify. We respond to Nash's commentary by first identifying the proper sources for the critiqued frameworks and correctly locate Farnsworth et al.'s functional contextual definition of moral injury within the domain of third-wave cognitive behavioral therapies. We go on to compare and contrast the respective origins of the COSC and functional contextual models, noting important differences in their intended purposes. Next, we defend our model against Nash's critiques by highlighting how a functional contextual approach to moral injury (a) links with evolutionary science, (b) captures multiple levels of analysis, (c) is parsimonious, (d) serves diverse populations, (e) directly informs interventions, (f) promotes moral humility, and (g) decreases stigma while preserving client autonomy. In our conclusion, we recognize the value of the COSC model for its intended purposes while also encouraging deep and respectful dialogue among researchers and clinicians regarding the proposed benefits of the functional contextual model of moral injury.

Integrating Treatment for Co-Occurring Mental Health Conditions

Given the high co-occurrence between alcohol use disorder (AUD) and mental health conditions (MHCs), and the increased morbidity associated with the presence of co-occurring disorders, it is important that co-occurring disorders be identified and both disorders addressed in integrated treatment. Tremendous heterogeneity exists among individuals with co-occurring conditions, and factors related to both AUD and MHCs, including symptom type and acuity, illness severity, the chronicity of symptoms, and recovery capital, should be considered when recommending treatment interventions. This article reviews the prevalence of co-occurring AUD and MHCs, screening tools to identify individuals with symptoms of AUD and MHCs, and subsequent assessment of co-occurring disorders. Types of integrated treatment and current challenges to integrate treatment for co-occurring disorders effectively are reviewed. Innovative uses of technology to improve education on co-occurring disorders and treatment delivery are also discussed. Systemic challenges exist to providing integrated treatment in all treatment settings, and continued research is needed to determine ways to improve access to treatment.