Relative to most civilian traumas (e.g., sexual assault, car accidents, and disasters), posttraumatic stress disorder (PTSD) from warzone exposure is associated with more chronic and disabling social and occupational functioning problems, as well as poorer response to treatment. Yet, PTSD treatments for war veterans do not target or even systematically assess these functional impairments. Rather, first-line treatments for military- related PTSD focus on symptom change, failing to attend to holistic dimensions of recovery, such as improved work and family functioning and quality of life. The current first-line treatments for PTSD disseminated and mandated in the VA, Prolonged Exposure and Cognitive Processing Therapy, were developed and originally tested on female sexual assault victims. Although strides have been made for these therapies to accommodate veterans traumatized by contexts that are starkly different from most civilian traumas, the therapies still tend to overemphasize victimization from danger-based warzone events as the cause of PTSD and the target for treatment. This is problematic because insufficient attention is paid to the unique phenomenology of warzone experiences within the warrior culture. In particular, existing therapies do not sufficiently address morally compromising war experiences (e.g., killing), termed moral injury (MI), and traumatic loss, neither of which necessarily entail high fear and danger. Yet, these types of experiences are reported by large percentages of veterans as their worst and most currently haunting deployment events. MI and traumatic loss can cause emotional disturbances, such as guilt, shame, low motivation, anhedonia, and anger problems that negatively affect recovery and a variety of functional capacities (e.g., work, self-care, and relationships). The goal of this study is to fill a substantial care-gap in the VA by [testing] an evidence-based treatment for war-related PTSD stemming from MI and traumatic loss focused on improving psychosocial functioning. [We have modified and extended Adaptive Disclosure (AD; Litz et al., 2015), a therapy that was previously tested on deployed Marines, to treat [only] MI and loss (AD-MIL). We have added evidence-based elements to AD designed to foster improvements in functioning and address obstacles to engaging in various functional behaviors in-vivo.] We will conduct a multi-site randomized controlled trial comparing AD-MIL to Present-Centered Therapy (PCT; Frost et al., 2014). We have five hypotheses, grouped into (A) functional change and (B) mental health change. With respect to functional and behavioral change, we hypothesize that post-treatment, 3-, and 6-months post- treatment, Iraq and Afghanistan veterans with PTSD randomized to AD-MIL will have greater: (A.1.) reductions in social, educational, and occupational disability (the primary endpoint); and (A.2.) improvements in quality of life. With respect to change in mental health symptoms, we hypothesize that veterans randomized to AD-MIL will have greater: (B.3.) reductions in PTSD symptom severity and a smaller percentage of PTSD cases; (B.4.) reductions in depressive symptoms; and (B.5.) reductions in shame and guilt. We will also explore the impact of treatment on anger and aggressive behaviors, suicidal ideation, and alcohol abuse. We plan to recruit 93 veterans for each arm of the trial, split equally among the three VA performance sites.

Posttraumatic stress disorder (PTSD) among war veterans is particularly disabling and resistant to treatments that are effective with civilian trauma. Functional rehabilitation and recovery of veterans with PTSD is unlikely to occur with existing frontline therapies because they emphasize fear- and victim-based phenomena and focus solely on PTSD symptom reduction. This study will [test strategies] to target two uniquely damaging warzone traumas, morally transgressive acts and traumatic loss, each of which are associated with social reintegration and employment difficulties, priority areas for VA RR&D. The therapy we [developed] targets social and occupational rehabilitation and emotional and psychological obstacles to engaging in habilitative activities. This research relates to RR&D priority areas to improve functioning in veterans of the Iraq and Afghanistan Wars through innovative treatments that target family and social activities, employment, and quality of life. The focus is to concurrently restore function and reduce symptoms in veterans with PTSD.