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Peer-Reviewed Journal Articles

Please select from the following research area domains to access our latest published articles.

Moral Injury

Understanding the impact and treatment of moral injury in military service members.

Journal of Traumatic Stress.
https://doi.org/10.1002/jts.22234
Philip Held, Brian J. Klassen, Alyson K. Zalta, Mark H. Polla

This article provides key scientific findings regarding moral injury including: morally injurious war-zone experiences, the prevalence of veterans’ exposure to morally injurious events, core features and the proposed causal model of moral injury, the assessment of moral injury, the role of negative cognitions in moral injury, a review of treatments for moral injury, and challenges providers may experience when providing care for individuals who have been affected by morally injurious experiences.

Using Prolonged Exposure and Cognitive Processing Therapy to treat veterans with moral injury-based PTSD: Two case examples.

Cognitive and Behavioral Practice.
https://doi.org/10.1016/j.cbpra.2017.09.003
Philip Held, Brian J. Klassen, Michael B. Brennan, and Alyson K. Zalta

This study describes two case examples of veterans with moral injury-based PTSD who were successfully treated with Prolonged Exposure Therapy (PE) and Cognitive Processing Therapy (CPT) and experienced significant reductions in PTSD and depression symptoms. It is believed that these improvements were the result of confronting avoidance and adding contextual detail to the traumatic memories, which allowed these patients to reexamine their original interpretations of the events.

Do morally injurious experiences and index events negatively impact intensive PTSD treatment outcomes among combat veterans?

European Journal of Psychotraumatology.
https://doi.org/10.1080/20008198.2021.1877026
Philip Held, Brian J. Klassen, Victoria L. Steigerwald, Dale L. Smith, Karyna Bravo, David C. Rozek, Rebecca Van Horn, Alyson Zalta

Negative posttrauma cognitions mediate the relationship between moral injury and PTSD in a sample of treatment-seeking veterans.

Journal of Traumatic Stress.
https://doi.org/10.1176/appi.focus.20170023
Philip Held, Brian J. Klassen, Denise S. Zou, Blake S. Schroedter, Niranjan S. Karnik, Mark H. Pollack, Alyson K. Zalta

Findings from this study suggest that potentially morally injurious experiences, PTSD, and depression severity appear to be only indirectly related through negative posttrauma cognitions in treatment-seeking veterans with PTSD. Additionally, this study found that individuals who perceive themselves to have engaged in moral wrongdoings are more likely to blame themselves and view themselves more negatively. Similarly, individuals who perceive betrayal may develop more negative views of others and the world, as well as negatively evaluate themselves and their own actions.

“I knew it was wrong the moment I got the order”: A narrative thematic analysis of moral injury in combat veterans.

Psychological Trauma.
https://doi.org/10.1037/tra0000364
Philip Held, Brian J. Klassen, Joanne M. Hall, Tanya R. Friese, Marcel M. Bertsch-Gout, Alyson K. Zalta, and Mark H. Pollack

This article provides key scientific findings regarding moral injury including: morally injurious war-zone experiences, the prevalence of veterans’ exposure to morally injurious events, core features and the proposed causal model of moral injury, the assessment of moral injury, the role of negative cognitions in moral injury, a review of treatments for moral injury, and challenges providers may experience when providing care for individuals who have been affected by morally injurious experiences.

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Substance Use

Impact of hazardous alcohol use on intensive PTSD treatment outcomes among veterans.

European Journal of Psychotraumatology.
https://doi.org/10.1080/20008198.2021.1888541
Philip Held, Victoria L. Steigerwald, Dale L. Smith, Debra Kaysen, Rebecca Van Horn and Niranjan S. Karnik

This study examined how effective a 3-week intensive Cognitive Processing Therapy program would be in reducing PTSD and depressive symptoms for veterans with PTSD and Hazardous Alcohol Use (HAU). It was found that treatment completion rates were high, regardless of having HAU or not. Additionally, veterans with and without HAU were shown to have large reductions in PTSD and depressive symptoms, with little difference in end of treatment symptom reductions between HAU and non-HAU participants.

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Intensive Treatment

Evaluating changes in negative posttrauma cognition as a mechanism of PTSD severity changes in two separate intensive treatment programs for veterans.

BMC Psychiatry.
https://doi.org/10.1186/s12888-022-04296-1
Held, P., Kaysen, D. L., & Smith, D. L.

This study examined veterans completing a cognitive processing therapy (CPT)-based intensive treatment program (ITP) to better understand the relationship between negative posttrauma cognitions (NPCs) and PTSD symptoms. Overall, treatment decreased NPCs and PTSD symptoms, but changes in NPCs were not found to occur before changes in PTSD symptoms. So, NPCs can serve as a sign of if PTSD treatments are working well, but future studies are needed to understand how ITPs result in changes to PTSD symptoms.

The Role of Time Since Trauma on Treatment Outcomes of Veterans in Two Intensive Posttraumatic Stress Disorder Treatment Programs.

Journal of Traumatic Stress.
Manuscript accepted for publication.
Splaine, C., Smith, D.L., Held, P.

A qualitative investigation of barriers to initiating a three-week intensive PTSD treatment program for veterans.

Traumatology.
Manuscript accepted for publication
Steigerwald, V. L., Bagley, J. M., Parrish, M. S., Van Horn, R., & Held, P.

Phone interviews were completed with veterans to identify barriers to completing intensive treatment programs (ITPs) for PTSD. These veterans were accepted into an ITP but did not end up participating in the program. Timing and travel, work and school, and problems with the program intake process were the most common barriers to starting the ITP. These results emphasize the need to examine parts of ITP intake processes that may cause participants to not join these programs.

Building strong therapeutic relationships quickly: The effect of the perceived working alliance on veterans’ intensive PTSD treatment outcomes.

Psychotherapy.
https://doi.org/10.1037/pst0000447
Held, P., Meade, E. A., Kovacevic, M., Smith, D. L., Pridgen, S., Coleman, J. A., & Klassen, B. J.

Feasibility of a 3-Week Intensive Treatment Program for Service Members and Veterans with PTSD.

Psychological Trauma.
https://doi.org/10.1037/tra0000485
Philip Held, Brian J. Klassen, Randy A. Boley, Shannon Wiltsey Stirman, Dale L. Smith, Michael B. Brennan, Rebecca Van Horn, Mark H. Pollack, Niranjan S. Karnik, and Alyson K. Zalta

The goal of this study was to examine the effectiveness and feasibility of a 3-week intensive inpatient treatment program. In this program, patients participated in multiple daily sessions alongside supplemental activities such as yoga and mindfulness. Results show that this condensed version of a treatment program generates high rates of veteran interest and satisfaction, making PTSD treatment more accessible and effective.

Treatment response trajectories in a three-week CPT-Based intensive treatment for veterans with PTSD.

Journal of Psychiatric Research.
https://doi.org/10.1016/j.jpsychires.2021.07.004
Philip Held, Dale L. Smith, Jenna M. Bagley, Merdijana Kovacevic, Victoria L. Steigerwald, Rebecca Van Horn, Niranjan S. Karnik

The aim of this study was to identify the different rates at which individuals typically respond to a condensed and intensive version of PTSD treatment and how to better predict how quickly someone may respond. Results indicated that PTSD patients engaging in intensive treatment can be grouped into four typical rates of response. Further, the characteristics of an individual’s PTSD symptoms before and at early stages of treatment may serve as a way to predict how quickly they will respond to treatment.

Improving Mental, Physical, and Social Functioning Through Participation in a 3-Week Cognitive Processing Therapy-Based Intensive PTSD Treatment.

Journal of Anxiety Disorders.
https://www.sciencedirect.com/science/article/pii/S0887618522000330
Dale L. Smith, Merdijana Kovacevic, Mauricio Montes, Sarah Pridgen, Philip Held

While ITPs for PTSD have been shown to produce large and long-term reductions in PTSD severity, the potential effects of ITPs on mental, physical, and social functioning following treatment completion has been largely unexplored. Results indicated that reductions in PTSD severity during treatment significantly predicted improved mental, physical, and social functioning at follow-up. This study supports the ability of ITPs to enact meaningful improvement in functioning among veterans with PTSD in a short timeframe.

Delivering Intensive PTSD Treatment Virtually: The Development of a 2-Week Intensive Cognitive Processing Therapy-Based Program in Response to Covid-19.

Cognitive and Behavioral Practice.
https://doi.org/10.1016/j.cbpra.2020.09.002
Philip Held, Brian J. Klassen, Jennifer A. Coleman, Kaitlin Thompson, Thad S. Rydberg, Rebecca Van Horn

In our 2-week virtual intensive treatment program, veterans attended two 50-minute treatment sessions per day, with the option to attend supplemental services such as yoga or art therapy. During treatment, veterans were able to engage in effective and adaptive PTSD treatment in a format that was not disruptive to their home life outside of sessions. Therapists were similarly pleased with the ease of delivering treatment in an online format. Results of this study provide preliminary evidence of the opportunity to provide effective and widely accessible PTSD treatment in a condensed and virtual format.

Treating posttraumatic stress disorder at home in a single week using 1-week virtual massed cognitive processing therapy.

Journal of Traumatic Stress
https://doi.org/10.1002/jts.22831
Philip Held, Merdijana Kovacevic, Kelsey Petrey, Enya A. Meade, Sarah Pridgen, Mauricio Montes, Michelle L. Miller, Dale L. Smith, Niranjan S. Karnik

This study evaluated 1-week massed Cognitive Processing Therapy (CPT) delivered virtually (i.e., via telehealth) to a community sample of trauma-exposed individuals. Overall, 1-week massed CPT delivered virtually was shown to be feasible and to result in rapid symptom reductions that were sustained over time. Virtual massed CPT has the potential to increase access to effective treatments and help trauma survivors restore aspects of their lives in short amounts of time.

Intensely Delivered Cognitive-Behavioral Therapies: An Overview of a Promising Treatment Delivery Format for PTSD and Other Mental Health Disorders.

Psychiatric Annals.
https://doi.org/10.3928/00485713-20190711-01
Philip Held, PhD; Jenna M. Bagley, BS, BA; Brian J. Klassen, PhD; and Mark H. Pollack, MD

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Sexual Trauma

Changes in guilt cognitions in intensive PTSD treatment among veterans who experienced military sexual trauma or combat trauma.

Journal of Anxiety Disorders.
Manuscript accepted for publication.
Meade, E.A., Smith, D.L., Montes, M. Norman, S.B., & Held, P.

Data collected from veterans in an intensive treatment program for PTSD was analyzed to see how trauma-related guilt cognition changes resulted in changes in PTSD and depression symptoms, and if these changes were different between combat trauma and military sexual trauma populations. In both groups, changes in wrongdoing predicted PTSD symptom reduction, and changes in hindsight bias predicted PTSD and depression symptom reduction. Changes in insufficient justification were significantly different between trauma populations.

“You're going to look at me differently”: A qualitative study of disclosure experiences among survivors of military sexual assault.

Journal of Traumatic Stress.
https://doi.org/10.1002/jts.22797
Rufa, A. K., Carroll, K. K., Lofgreen, A., Klassen, B., Held, P., & Zalta, A. K.

A qualitative study was carried out with treatment-seeking survivors of military sexual assault (MSA) to learn more about their experience disclosing MSA to family, friends, romantic partners, and other people in their support network. Some findings from the interview were that the reasoning for disclosing MSA was similar between participants and differences in their disclosure experiences were influenced by the context in which these conversations took place.

An Overview of Sexual Trauma in the U.S. Military.

Focus (American Psychiatric Publishing).
https://doi.org/10.1176/appi.focus.20170024
Ashton M Lofgreen, PhD; Kathryn K Carroll, PhD; Sheila A Dugan MD; and Niranjan S Karnik MD, PhD

This study examined the structural and environmental constraints that may make it difficult for military sexual trauma (MST) survivors to both report and recover from their trauma. Individuals who are apart of the LGBTQ+ community as well as men may also face unique set of clinical issues as related to their MST experience. Comprehensive clinical care (physical, mental, sexual health) for MST survivors is necessary to help treat their trauma.

Negative posttraumatic cognitions among military sexual trauma survivors.

Journal of Affective Disorders
https://doi.org/10.1016/j.jad.2018.05.024
Kathryn K. Carroll, PhD; Ashton M Lofgreen, PhD; Darian C Weaver, BS; Philip Held, PhD; Brian J. Klassen, PhD; Dale L. Smith, PhD; Niranjan S Karnick MD, PhD; Mark H Pollack, MD; Alyson K Zalta, PhD

Improving Treatment Outcomes for a 3-week Intensive Outpatient Program for Posttraumatic Stress Disorder in Survivors of Military Sexual Trauma.

Journal of Affective Disorders.
https://doi.org/10.1016/j.jad.2020.03.036
Ashton M. Lofgreen, PhD; Vanessa Tirone, PhD; Kathryn K. Caroll, PhD; Anne K. Rufa, PhD; Dale L. Smith, PhD; Jenna M. Bagley, B.S., B.A.; Alyson K. Zalta, PhD; Michael B. Brennan, PsyD; Rebecca Van Horn, MD; Mark H. Pollack, MD; Philip Held, PhD

In this study, the authors examined the effectiveness of a modified intensive outpatient program (IOP) to specifically include things that would be helpful to MST survivors like skills groups that worked on emotional regulation and interpersonal interactions as well as trainings for both clinical and non-clinical staff to increase understanding of the unique difficulties faced by MST survivors. They found that the program changes were helpful and the excellent treatment outcomes were comparable to those in the combat trauma cohorts.

Examining the Impact of Sexual Revictimization in a Sample of Veterans Undergoing Intensive PTSD Treatment.

Journal of Interpersonal Violence.
https://doi.org/10.1177/0886260519897333
Vanessa Tirone, Dale Smith, Victoria L Steigerwald, Jenna M Bagley, Michael Brennan, Rebecca Van Horn, Mark Pollack, Philip Held

Findings from this study suggest that potentially morally injurious experiences, PTSD, and depression severity appear to be only indirectly related through negative posttrauma cognitions in treatment-seeking veterans with PTSD. Additionally, this study found that individuals who perceive themselves to have engaged in moral wrongdoings are more likely to blame themselves and view themselves more negatively. Similarly, individuals who perceive betrayal may develop more negative views of others and the world, as well as negatively evaluate themselves and their own actions.

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Machine Learning

Moving toward precision PTSD treatment: predicting veterans' intensive PTSD treatment response using continuously updating machine learning models.

Psychological Medicine.
https://doi.org/10.1017/S0033291722002689
Smith, D. L., & Held, P.

The purpose of this study was to evaluate how well machine learning models can predict the timing of when treatment responses become apparent during cognitive processing therapy (CPT)-based intensive treatment programs (ITPs). Three machine learning model performances were examined using data from a 3-week CPT-based ITP and a 2-week CPT-based ITP. When looking at both ITPs, results from different models were similar, having modest prediction accuracy of PTSD symptom severity at the end of the ITPs using baseline data and increasing prediction accuracy using data from later treatment visits.

Who will respond to intensive PTSD treatment? A machine learning approach to predicting response prior to starting treatment.

Journal of Psychiatric Research.
https://doi.org/10.1016/j.jpsychires.2022.03.066
Held, P., Schubert, R. A., Pridgen, S., Kovacevic, M., Montes, M., Christ, N. M., Banerjee, U., & Smith, D. L.

This study assessed if machine learning models could be used to predict veterans’ treatment responses to a 3-week cognitive processing therapy (CPT)-based intensive treatment program (ITP). The performance of six machine learning models and statistical methods were evaluated using demographic information and clinical measures collected before participants started the ITP. Elastic net and gradient boosted models were able to predict participants who would respond minimally to treatment and participants who would respond quickly to treatment.

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Our Work

MORAL INJURY

SUBSTANCE USE

INTENSIVE TREATMENT

SEXUAL TRAUMA

MACHINE LEARNING

MORAL
INJURY

SUBSTANCE
USE

INTENSIVE
TREATMENT

SEXUAL
TRAUMA

MACHINE
LEARNING