Staff Perspective: Social Factors in Military Patients with PTSD
When developing a case conceptualization, we often consider the co-occurring psychological factors at play; however, we may neglect to fully consider the many social factors involved. Maercker and Horn (2013) developed a three level model of socio-interpersonal factors related to the development of PTSD, which can be useful when forming a case conceptualization. The first level considers social affective changes and encompasses factors such as shame, guilt, anger, and revenge. The second level examines close social relationships including social support, and the third level includes distant social contexts such as one’s culture.
Level 1: Individual and Social-affective Factors
The individual level includes shame, guilt, and anger. Notably, these symptoms are central components of moral injury. Although a single definition of moral injury does not exist, it typically refers to exposure through perpetration or witnessing of, failing to prevent, or learning about an act that violates a person’s core beliefs or an act by an authority figure or leader that one considers to be a betrayal. There are two types of moral injury: moral injury by self and moral injury by others. Moral injury by self are those events that violate one's personal moral or ethical code, and moral injury by others is when one witnesses or is the victim of an act in violation of one’s moral or ethical code, such as a sexual assault. Symptoms of moral injury may include those of PTSD, self-harm, and hopelessness. Within patients with PTSD, moral injury by self is more strongly related to intrusion symptoms and moral injury by others more strongly related to anger. A majority of service members with military-related PTSD have symptoms of moral injury, and moral injury may be, in part, responsible for the perpetuation of PTSD after a combat-related trauma. It is believed that guilt, shame, and anxiety may result from the struggle to integrate the morally injurious traumatic event into their view of themselves, others, and the world.
Level 2: Social Support
The second level includes social support. Social support has repeatedly been identified as an important factor in the development, severity, and maintenance of PTSD, and low social support is one of the strongest predictors of PTSD –– even more so in military personnel compared to civilians. Veterans with PTSD typically report less social support from their friends, family, and community as well as worse social functioning, more problems in romantic relationships, and less family cohesion than veterans without PTSD. But it is also possible that one’s perception of available social support is worsened by PTSD, so it can be helpful to assess changes in perceived support.
When discussing social support with military patients, it can be beneficial to discuss both civilian and military support because veterans often differentiate between these sources. For veterans with PTSD, their fellow veterans not only frequently make up the largest portion of their social network, but they also provide more instrumental support compared to relatives and more emotional support than any other source of support, including their spouse, relatives, or nonveteran friends, suggesting veterans seek emotional support more often from other veterans. Importantly, veterans report high levels of support and low interpersonal stress in relationships with fellow veterans but fairly equivalent sources of support and interpersonal stress in their relationship with their spouse. It is possible that veterans are more likely to seek support from their fellow veterans because of the increased interpersonal stress in the relationship with their spouse. However, civilian social support can still help to mitigate posttraumatic stress symptoms.
Unit social support also plays a role in PTSD development, with low unit social support being associated with a probable PTSD diagnosis in veterans. Strong military unit social support can be beneficial both as stressors or traumatic events occur (e.g., during deployment) and with earlier life stressors. However, unit support does seem to be more beneficial for active duty service members than those in the National Guard. If we use studies of firefighters as a proxy, we can consider the role service specific support can play as well. Perceived social support from supervisors, coworkers, and perceived belongingness, which can be increased through social support, are all associated with lower PTSD severity. This suggests that when service members feel supported by their unit and leadership and/or identify themselves as an integral part of the military system, they may be less likely to develop severe PTSD symptoms. Therefore, understanding how a patient perceives themselves within their unit and the broader military community may provide important context during conceptualization.
Level 3: Distant Social Contexts
Distant social contexts includes one’s culture, which for military patients extends beyond their racial and ethnic, religious, or other cultural background to include their military culture. Culture is one’s values, norms and traditions, which may influence how that person thinks, interacts with, and makes judgements about the world around them. In the military culture, this can include objects that identify someone as part of the military (such as their uniform) as well as the ethos, values, beliefs, knowledge, customs, and morals acquired through their membership in the military. In addition to the broader US military culture, there are subcultures that can be relevant to the conceptualization and treatment of these patients, such as distinctions among active duty, National Guard, Reserves, and veterans; differences across service branches; and the special operations community. One’s culture can impact how and when they initiate care, how they perceive their symptoms, and how they perceive their treatment options. If we think about military patients, ideals such as stoicism and an expectation for excellence, though beneficial to their career, can be detrimental to care seeking behaviors. Relatedly, aspects of the military culture may increase stigma regarding mental health symptoms, which is commonly experienced by service members. US service members report being concerned about being treated differently by their unit’s leadership, that they may be seen as weak or that their unit members will have less confidence in them, and about the implications for their career or their ability to obtain a security clearance. Some even report that their commander/supervisor had told them not to seek treatment. These factors can influence how a patient engages in treatment and their perception of symptoms.
Beyond using these factors to enrich your case conceptualization, using the three level socio-interpersonal model may improve the likelihood of treatment success through an awareness of a patient’s social environment. This may include evaluating for possibly morally injurious events or considering incorporating a patient’s social support into their treatment. Care considerate of a patient’s culture can be beneficial in that patients may be more likely to seek and share more information. Additionally, being aware of and considerate of a patient’s culture can increase their satisfaction with their care and the effectiveness of treatment.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Maegan Paxton Willing is a Postdoctoral Fellow at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
When developing a case conceptualization, we often consider the co-occurring psychological factors at play; however, we may neglect to fully consider the many social factors involved. Maercker and Horn (2013) developed a three level model of socio-interpersonal factors related to the development of PTSD, which can be useful when forming a case conceptualization. The first level considers social affective changes and encompasses factors such as shame, guilt, anger, and revenge. The second level examines close social relationships including social support, and the third level includes distant social contexts such as one’s culture.
Level 1: Individual and Social-affective Factors
The individual level includes shame, guilt, and anger. Notably, these symptoms are central components of moral injury. Although a single definition of moral injury does not exist, it typically refers to exposure through perpetration or witnessing of, failing to prevent, or learning about an act that violates a person’s core beliefs or an act by an authority figure or leader that one considers to be a betrayal. There are two types of moral injury: moral injury by self and moral injury by others. Moral injury by self are those events that violate one's personal moral or ethical code, and moral injury by others is when one witnesses or is the victim of an act in violation of one’s moral or ethical code, such as a sexual assault. Symptoms of moral injury may include those of PTSD, self-harm, and hopelessness. Within patients with PTSD, moral injury by self is more strongly related to intrusion symptoms and moral injury by others more strongly related to anger. A majority of service members with military-related PTSD have symptoms of moral injury, and moral injury may be, in part, responsible for the perpetuation of PTSD after a combat-related trauma. It is believed that guilt, shame, and anxiety may result from the struggle to integrate the morally injurious traumatic event into their view of themselves, others, and the world.
Level 2: Social Support
The second level includes social support. Social support has repeatedly been identified as an important factor in the development, severity, and maintenance of PTSD, and low social support is one of the strongest predictors of PTSD –– even more so in military personnel compared to civilians. Veterans with PTSD typically report less social support from their friends, family, and community as well as worse social functioning, more problems in romantic relationships, and less family cohesion than veterans without PTSD. But it is also possible that one’s perception of available social support is worsened by PTSD, so it can be helpful to assess changes in perceived support.
When discussing social support with military patients, it can be beneficial to discuss both civilian and military support because veterans often differentiate between these sources. For veterans with PTSD, their fellow veterans not only frequently make up the largest portion of their social network, but they also provide more instrumental support compared to relatives and more emotional support than any other source of support, including their spouse, relatives, or nonveteran friends, suggesting veterans seek emotional support more often from other veterans. Importantly, veterans report high levels of support and low interpersonal stress in relationships with fellow veterans but fairly equivalent sources of support and interpersonal stress in their relationship with their spouse. It is possible that veterans are more likely to seek support from their fellow veterans because of the increased interpersonal stress in the relationship with their spouse. However, civilian social support can still help to mitigate posttraumatic stress symptoms.
Unit social support also plays a role in PTSD development, with low unit social support being associated with a probable PTSD diagnosis in veterans. Strong military unit social support can be beneficial both as stressors or traumatic events occur (e.g., during deployment) and with earlier life stressors. However, unit support does seem to be more beneficial for active duty service members than those in the National Guard. If we use studies of firefighters as a proxy, we can consider the role service specific support can play as well. Perceived social support from supervisors, coworkers, and perceived belongingness, which can be increased through social support, are all associated with lower PTSD severity. This suggests that when service members feel supported by their unit and leadership and/or identify themselves as an integral part of the military system, they may be less likely to develop severe PTSD symptoms. Therefore, understanding how a patient perceives themselves within their unit and the broader military community may provide important context during conceptualization.
Level 3: Distant Social Contexts
Distant social contexts includes one’s culture, which for military patients extends beyond their racial and ethnic, religious, or other cultural background to include their military culture. Culture is one’s values, norms and traditions, which may influence how that person thinks, interacts with, and makes judgements about the world around them. In the military culture, this can include objects that identify someone as part of the military (such as their uniform) as well as the ethos, values, beliefs, knowledge, customs, and morals acquired through their membership in the military. In addition to the broader US military culture, there are subcultures that can be relevant to the conceptualization and treatment of these patients, such as distinctions among active duty, National Guard, Reserves, and veterans; differences across service branches; and the special operations community. One’s culture can impact how and when they initiate care, how they perceive their symptoms, and how they perceive their treatment options. If we think about military patients, ideals such as stoicism and an expectation for excellence, though beneficial to their career, can be detrimental to care seeking behaviors. Relatedly, aspects of the military culture may increase stigma regarding mental health symptoms, which is commonly experienced by service members. US service members report being concerned about being treated differently by their unit’s leadership, that they may be seen as weak or that their unit members will have less confidence in them, and about the implications for their career or their ability to obtain a security clearance. Some even report that their commander/supervisor had told them not to seek treatment. These factors can influence how a patient engages in treatment and their perception of symptoms.
Beyond using these factors to enrich your case conceptualization, using the three level socio-interpersonal model may improve the likelihood of treatment success through an awareness of a patient’s social environment. This may include evaluating for possibly morally injurious events or considering incorporating a patient’s social support into their treatment. Care considerate of a patient’s culture can be beneficial in that patients may be more likely to seek and share more information. Additionally, being aware of and considerate of a patient’s culture can increase their satisfaction with their care and the effectiveness of treatment.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Maegan Paxton Willing is a Postdoctoral Fellow at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.