Role of Coping and Family Relationships in Adaptation of Post-Deployment Marines

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Title:
Role of Coping and Family Relationships in Adaptation of Post-Deployment Marines
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1 online resource (73 p.)
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english
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Callahan,Corissa L
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University of Florida
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Gainesville, Fla.
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Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Psychology, Clinical and Health Psychology
Committee Chair:
Eyberg, Sheila M
Committee Members:
Wiens, Brenda A
Rozensky, Ronald H
Smith, Suzanna D

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Subjects / Keywords:
combat -- coping -- deployment -- family -- growth -- marine -- military -- posttraumatic
Clinical and Health Psychology -- Dissertations, Academic -- UF
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Psychology thesis, Ph.D.
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Abstract:
The psychological needs of U.S. military service members and families have been well established; however, the research demonstrating the specific needs is incomplete. Coping strategies, family environments, and mental health were examined in 152 post-deployment Marines. To help promote a comprehensive conceptualization of both the positive and negative impacts of combat-operational deployment stress on mental health, posttraumatic growth was also examined. The factor structure of the Brief COPE suggested three clusters of coping strategies used by Marines: problem-focused coping, support-seeking coping, and avoidant coping. Furthermore, relations between coping and mental health, as measured by Achenbach Adult Self Report, were examined. Avoidant coping was significantly related to mental health problems. In addition, avoidant coping was found to weaken relations between combat-operational deployment stress and mental health problems, suggesting that avoidance may actually serve somewhat as a protective factor for Marines who have experienced high levels of combat-operational deployment stress. Posttraumatic growth was unrelated to degree of combat exposure, perceived threat during deployment, or time since deployment. However, PTG was significantly negatively related to mental health problems, regardless of the amount of combat operational deployment stress reported, suggesting that correlates of PTG in active duty personnel are different than previous studies indicated. Finally, family relationships were negatively related to mental health problems, such that more positive family relationships were associated with fewer mental health problems in Marines. Overall, findings suggest that researchers and clinicians need to carefully consider the extent of avoidant coping and family relationships in understanding and treatment the active duty service member. Furthermore, promotion of posttraumatic growth may be considered a tool to help Marines reintegrate into their families and communities, regardless of extent of combat exposure.
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In the series University of Florida Digital Collections.
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Includes vita.
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Description based on online resource; title from PDF title page.
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This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Corissa L Callahan.
Thesis:
Thesis (Ph.D.)--University of Florida, 2011.
Local:
Adviser: Eyberg, Sheila M.
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RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2013-08-31

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UFE0041939:00001


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1 ROLE OF COPING AND FAMILY RELATIONSHIPS IN ADAPTATION OF POST DEPLOYMENT MARINES By CORISSA L. CALLAHAN A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREM ENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2011

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2 2011 Corissa L. Callahan

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3 To my dear uncle, Wayne M. Haddad whose passion for serving the Marines as a Navy C hap lain not only inspired this work but also made it a reali ty

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4 ACKNOWLEDGMENTS I thank Sheila Eyberg, Ph.D., my chair and research supervisor, for her mentorship, editing hand, and encouragement as I worked on this dissertation I would also like to thank members of my dissertation c ommittee Ronald Rozensky P h.D., Brenda Wiens Ph.D., and Suzanna Smith, Ph.D. for the time and energy they devoted to providing helpful feedback from the early stages of conceptualization, to problem solving methodological challenges, to reconsidering statistical approaches to the data. In addition, a very special thank you goes to all of the members of the Child Study Lab, past and present, for their emotional support throughout this dissertation. Above all, I am grateful for the unfailing support of my family, especially my moth er Doretta Shelley. Without her I would not be where I am today.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .............. 4 LIST OF TABLES ................................ ................................ ................................ ......................... 7 LIST OF FIGURES ................................ ................................ ................................ ....................... 8 LIST OF ABBREVIATIONS ................................ ................................ ................................ ........ 9 ABSTRACT ................................ ................................ ................................ ................................ 10 CHAPTER 1 LITERATURE REVIEW ................................ ................................ ................................ ...... 12 Combat and Mental Health ................................ ................................ ................................ 12 Adaptation to Trauma ................................ ................................ ................................ ......... 17 Coping and Trauma ................................ ................................ ................................ ............ 18 Posttraumatic Growth ................................ ................................ ................................ ......... 20 Research Questions and Hypotheses ................................ ................................ ............. 22 2 METHOD AND PROCEDURES ................................ ................................ ....................... 25 Participants ................................ ................................ ................................ .......................... 25 Design ................................ ................................ ................................ ................................ ... 27 Measures ................................ ................................ ................................ .............................. 28 Demographic and Background Information ................................ ............................. 28 Combat Operational Deploym ent Stress ................................ ................................ 28 Coping ................................ ................................ ................................ ........................... 29 Family Relationships ................................ ................................ ................................ ... 30 Mental Health ................................ ................................ ................................ ............... 30 Posttraumatic Growth ................................ ................................ ................................ .. 31 Procedures ................................ ................................ ................................ ........................... 31 3 RESULTS ................................ ................................ ................................ ............................. 33 Preliminary Analyses ................................ ................................ ................................ .......... 33 Descriptive Statistics ................................ ................................ ................................ .......... 37 Main Analyses ................................ ................................ ................................ ..................... 37 Hypothesis 1 ................................ ................................ ................................ ................. 37 Hypotheses 2.1 2.3 ................................ ................................ ................................ ..... 39 Hypothesis 3 ................................ ................................ ................................ ................. 41 Hypotheses 4.1 4.3 ................................ ................................ ................................ ..... 42 Supplemental Analyses ................................ ................................ ................................ ...... 43

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6 4 DISCUSSION ................................ ................................ ................................ ...................... 50 Summary of Results ................................ ................................ ................................ ........... 50 Limitations ................................ ................................ ................................ ............................ 60 Future Directions ................................ ................................ ................................ ................. 63 APPENDIX A CONFIDENTIAL DEMOGRAPHIC QUESTIONNAIRE ................................ ................ 66 LIST OF REFERENCES ................................ ................................ ................................ ........... 68 BIOGRAPHICAL SK ETCH ................................ ................................ ................................ ....... 73

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7 LIST OF TABLES Table page 2 1 Demographic characteristics (N = 152) ................................ ................................ ........... 27 3 1 M eans and standard deviations for measures used ................................ ...................... 44 3 2 Factor loadings based on exploratory factor analysis with Promax rotation for 11 subscales from the Brief COPE ................................ ................................ ................... 45 3 3 Regression of deployment stress, approach coping, and the interaction of stress and coping onto total mental health problems ................................ ........................... 45 3 4 Regression of de ployment stress, avoidant coping, and the interaction of stress and coping onto total mental health problems ................................ ........................... 46 3 5 Regression of mental health, objective deployment threat, and subjective dep loyment threat onto posttraumatic growth ................................ ........................... 46 3 6 Regression of deployment stress, family relationships, and the interaction of stress and family relationships onto total mental health problems ......................... 47 3 7 Bivariate correlations among study variables. ................................ ................................ 47

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8 LIST OF FIGURES Figure page 3 1 Interaction of avoidant coping and combat operational stress exposure on mental health problems ................................ ................................ ................................ 48 3 2 Percentage of Marines with clinically significant mental health problems (T > 64) by total combat exposure. ................................ ................................ ............................. 49 3 3 Percentage of Marines with borderline clinically significant mental health problems (T > 60 & T < 63) by total combat exposure. ................................ ............ 49

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9 LIST OF ABBREVIATION S ASR Achenbach Adult Self Report COSR Combat operation al stress reaction DRRI Deployment Risk and Resilience Inventory FES Family Environment Scale OIF Operation Iraqi Freedom (i.e., war in Iraq) OEF Operation Enduring Freedom (i. e., war in Afghanistan) PTG Posttraumatic g rowth PTGI Posttraumatic Growth Inventory PTSD Posttraumatic stress d isorder

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10 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the R equirements for the Degree of Doctor of Philosophy ROLE OF COPING AND FAMILY RELATIONSHIPS IN ADAPTATION OF POST DEPLOYMENT MARINES By Corissa L. Callahan August 2011 Chair: Sheila Eyberg Major: Psychology The psychological needs of U.S. military serv ice members and families have been well established; however, the research demonstrating the specific needs is incomplete. Coping strategies, family environments, and mental health were examined in 152 post deployment Marines To help promote a comprehens ive conceptualization of both the positive and negative impacts of combat operational deployment stress on mental health posttraumatic growth was also examined. The factor structure of the Brief COPE suggest ed three clusters of coping strategies used by M arines : problem focused coping, support seeking coping, and avoidant coping. Furthermore, relations between coping and mental health as measured by Achenbach Adult Self Report, were examined. Avoidant coping was significantly related to mental health prob lems. In addition, avoidant coping was found to weaken relations between combat operational deployment stress and mental health problems, suggesting that avoidance may actually serve somewhat as a protective factor for Marines who have experienced high lev els of combat operational deployment stress.

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11 Posttraumatic growth was un related to degree of combat exposure, perceived threat during deployment, or time since deployment H owever, PTG was significantly negatively related to mental health problems, regard less of the amount of combat operatio nal deployment stress reported, suggesting that correlates of PTG in active duty personnel are different than previous studies indicated. Finally, family relationships were negatively related to mental health problems, such that more positive family relationships were associated with fewer mental health problems in Marines. Overall, findings suggest that researchers and clinicians need to carefully consider the extent of avoidant coping and family relationships in unders tanding and treatment the active duty service member. Furthermore, promotion of posttraumatic growth may be considered a tool to help Marines reintegrate into their families and communities, regardless of extent of combat exposure.

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12 CHAPTER 1 LITERATURE REV IEW Combat and Mental Health Since the start of the Global War on Terror (GWOT) in 2001, over 1. 8 million service members have been deployed in support of Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF) In the last few years, concern for military personnel and families has extended from the American public to mental health professionals, to the Department of Defense, and to the U.S. Capital The growing concern is underscored by r ecent congressional legislation allocating large sums of m oney for mental health research and treatment of service members and their families The American Psychological Association (APA) has developed several task forces to examine psychological needs of service members and their families, and the Center for Dep loyment Psychology (funded by the Department of Defense) trains both military and civilian psychologists in the deployment related needs of families In just a few years, resources for military families have grown to include a myriad of books, informationa l websites, support blogs, and organizations dedicated to serving those who serve Unfortunately, concern for the psychological needs of military personnel and families seems to have grown faster than the science identifying the specific needs of service m embers and their families, the family dynamics involved with adjustment to combat deployments, and the most effective interventions In addition, research has often been disease focu sed, rather than strength based. Although psychological diagnoses, such as posttraumatic stress disorder (PT SD), assist clinicians and researchers by providing a common language with which to conceptualize and treat mental health problems, diagnoses may or may not be helpful for patients. For example, a diagnosis may help

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13 an ind ividual or his family understand their experiences, but for other s a diagnosis may create a sense of helplessness or shame. Undoubtedly, the needs of the military population would be more fully served by also understanding the strengths or resilience fact ors that buffer the potential impacts of war on service members and their families Maintaining a strength based approach to prevention and intervention programs would be culturally sensitive (i.e., t he independent, problem s olving culture of the military) and likely more accepted by population than an approach that focused on deficits. T he psychological effects of war have been well documented The label for these effects has change d, but the symptoms remained basically the same (Sadock & Sadock, 2003; p.6 28) characterized by fatigue, shortness of breath, heart palpitations, headache, excessive sweating, dizziness, and disturbed sleep dded difficulty concentrating as a symptom World War II saw a rise which included all the above symptoms plus forgetfulness (PTSD) was created and cont inues to be used today Empirical research has demonstrated a connection between combat and a variety of long term mental health, social, and occupational effects (Kulka, et al., 1990) Recently, attempts have been made to investigate the current experien ces of service members during and after wartime deployments in order to aid in early intervention and treatment of problems that may occur following deployments In particular, the Office of the U.S. Army Surgeon General has established the Mental Health Advisory Team (MHAT) to assess the experiences of Army soldiers in theater (combat zone, such as

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14 Iraq or Afghanistan) Even on non combat deployments, service members face physical and environmental stressors, such as extreme temperatures, poor living cond itions, loss of sleep, and insufficient supplies When combat experiences are included, additional stressors are endured: (a) being attacked or ambushed; (b) s eeing/handling dead bodies or human remains ; (c) k nowing/seeing someone seriously injured or kill ed; (d) r eceiving incoming artillery, rocket, or mortar fire, etc. (MHAT V, 2008) Chronic, less dramatic deployment concerns i d entified by over 40% of deploy ed soldiers and Marines include the following: (a) b eing separated from family ; ( b ) l ack of privac y or personal space ; ( c ) Boring and repetitive work, ( d ) Uncertain redeployment date; (e) Lack of personal time off; and ( f) l ong deployment length (MHAT V, 2008). In 2003, the Department of Defense began requiring that service members complete a Post Depl oyment Health Assessment (PDHA) to examine each service related health concerns The PDHA is a three page self report instrument with approximately one half page of mental healt h questions Researchers at Walter Reed Army Institute of Research ( Hoge et al., 2004; Hoge, Auchterlionie, & Milliken, 2006; Milliken, Auchterlonie, & Hoge, 2007) have utilized these post deployment screenings of soldiers and Marines returning from OEF, O IF, and other deployments to determine the relationship between combat deployment and mental health care access during the first year after deployment Findings from PDHA examination posit that 19% of soldiers (n = 1320) and Marines (n = 44 7) screen positi after combat deployment (Hoge et al., 2006) PTSD was assessed with a 4 item screener developed by the Nat ional Center for PTSD (Primary C are PTSD or PC

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15 PTSD ; Prins, Ouimette, Kimerling, et al., 2004 ), and preva lence rates of screening positive (endorsing > 2 items) were 10% for OIF, 5% for OEF, and 2 % for other locations positive, especially for acute stress symptoms In addition, theater of o peration (i.e., Iraq or Afghanistan) was related to a positive screen, such that combat exposed service members returning from Iraq were more likely to experience acute stress symptoms than service members returning from Afghanistan because of the differen ces in the warzone experiences A follow up study e xamined the Post Deployment Health Reassessment (PDHRA a questionnaire mandated by the Assistant Secretary of Defense for Health Affairs 3 4 months post deployment), and found that PTSD positive screen ing rates among National Guard and Active Duty service members doubled from immediate post deployment to 3 4 months after return (Milliken, Auchterlonie, & Hoge, 2007) Likewise, a longitudinal study of physically wounded soldiers at Walter Reed Army Medic al Center showed increased PTSD rates at months 4 and 7, as compared to month 1 (Grieger et al., 2006) This emphasizes both the possible underestimation of PTSD, as well as the likelihood of delayed onset of PTSD during the months of readjustment followin g deployment It is imperative for clinicians to remain cognizant of these suggested trends, although such trends make it difficult to estimate the actual prevalence of PTSD. The best estimates of mental health disorders following exposure to combat come f rom a review detailing studies about the prevalence of PTSD, depression, and traumatic brain injury (TBI) among ret urning service members (Ramchand et al., 2008) The authors estimated from published articles that between 5 and 15 percent of

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16 returning serv ice members have or will develop PTSD However, the authors also discussed several methodological limitations First, most studies reviewed had limited generalizability to the entire military because of exclusion of many of the service members with poorer outcomes who would have been medically evacuate d or discharged. In addition, many studies focused heavily on service members in combat related military occupational specialties (MOS) a focus which would neglect the many individuals who were deployed to c ombat theaters but were not in combat positions. Thus, the ac curacy of estimates of PTSD in the general population of service members is difficult to estimate Furthermore although many studies used a well validated measure of PTSD such as the PTSD Ch eck list ( PCL ; Weathers, Litz, Herman, Huska, & Keane, 1993 ), other studies used screening measures to estimate PTSD, and these screening measures have not been psychometrically evaluat ed Regardless, most studies had strengths and have allowed a base from whi ch to develop further research about the incidence of psychological diagnoses (Ramchand et al., 2008) Although the use of diagnoses helps health care professionals communicate about and treat constellations of symptoms that typically co occur, focusing o n diagnoses may actually limit understanding of the far reaching impacts of combat I t is important to note t hat PTSD is not synonymous with post combat reactions ( combat operational stress reactions ) which are considered typical reactions t o extraordinary stressors Instead, the term Combat Operational Stress Reaction (COSR) is the standard, but not yet official, term across the Services to describe the ran g e of normal and abnormal reactions to the stressors of deployment and war (Moore & Re ger, 2006) Such impacts may span biological, psychological, interpersonal, and spiritual aspects of

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17 COSR pre vention/intervention efforts such as Combat Stress Control multidisciplinary teams are in place and provide m ental health care to service members in theater. Given th e broad impacts of war, and disorders, m ore research is needed using broad standardized, psychometrically valid measure s of mental health In addition, focusing on a range of problems, rather than diagnosable disorders provides a more complete picture of post war experiences of service members This study used a standardized, psychometrically valid measure to examine the mental health of active duty service memb ers Adaptation to T rauma In the early years of psychology, it was assumed that any servicemember with a mental health problem had a personality defect or pre existing weakness However, after DSM III d efined posttraumatic stress disorder, post combat dif ficulties were assumed to occur solely because of exposure to trauma or combat In addition, certain aspects of trauma exposure, such as intensity and duration, have been demonstrated to impact mental health and overall functioning However, research has a lso demonstrated that exposure to trauma is not entirely responsible for subsequent PTSD (King, King, Gudanowski, & Vreven, 1995) Instead, DSM IV TR recognizes the necessary interplay between the objective stressor and the subjective experience or reactio n to the stressor It is well documented that p eople not only differ in the extent to which they experience distress, but also the degree to which they w ill report subjective distress following experience of an objective stressor For example, in a sample of men who h ad experienced combat, only 34% described responding to the combat with intense fear, helplessness, or horror (Breslau & Kessler, 2001) a DSM IV criteria for PTSD.

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18 In addition to characteristics and perceptions of the trauma that are importan t for subsequent adaptation, research has demonstrated the importance of pre trauma and post trauma factors in understanding posttraumatic adaptation A meta analysis of risk factors for PTSD found that female gender low SES, childhood abuse, post trauma stress, and lack of social support contribute to a multicausal view of mental health problems following trauma exposure (Brewin, Andrews, & Valentine, 2000) When considering the post deployment social support, it is obvious that t he family would have a si gnificant and dynamic role in the post deployment environment of returning service members. Despite recognition of the importance of supporting families throughout the cycle of deployment research has not yet evaluated the role of the family environment i The current study examine d the protecti ve role of family relationships in Marines adaptation to combat trauma. Co ping and T rauma Experts on coping strategies have divided coping strategies on various dimensions. One examp le of the categorization of coping strategies is problem focused or emotion focused coping Here, problem focused coping attempts to resolve the stressor and include s behavior s such as making plans, seeking information, and seeking instrumental support (Fo lkman, Lazarus, Gruen, & DeLongis, 1986) On the other hand, emotion focused coping center s on managing emotions resulting from the stressor and include s strategies such as venting, emotional disengagement, and seeking emotional support (Folkman et al., 19 86) O ther coping experts have conceptualized coping on an approach/ avoidance coping continuum (Snyder & Pulvers, 2001) Approach coping is while avoidant coping focus es on avoiding the stressor o

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19 Examples of approach coping include seeking support and planning, while avoidant coping include s withdrawal, denial, and disengagement A recent meta analysis further divided coping strategies by integrating the two conceptualizatio ns (Littleton, Horsley, John, & Nelson, 2007) to examine problem/behavioral approach coping ( i.e., planning, information seeking), emotion/cognitive approach coping ( i.e., seeking emotional support, restructuring cognitions ), problem/behavioral avoidanct c oping ( i.e., disengaging from trying to resolve stressor, withdrawal) and emotion/cognitive avoidant coping ( i.e., denial) In their meta analysis, Littleton and colleagues (2007) evaluate d the relationship between approach and avoidant coping and distr ess following trauma, particularly interperso nal violence and severe injury. The authors also evaluated the moderating effec t of type and duration of trauma on the relationship between coping and distress Overall, results suggested a significant associati on between overall avoidant coping and distress, with no difference betw een problem/behavioral avoidant coping and emotion/cognitive avoidant coping Additionally, no overall association was found between approach coping and distress It is notable, howeve r, that the relationship between approach coping an d less distress was stronger within studies that included trauma of longer duration, a finding that has direct re l evance for the current study, because combat exposure is generally of long duration In a study examining coping patterns among Vietnam combat veteran s findings suggested that some coping strategies ( such as event processing, reflection, religion, and denial) were associated with symptomatology ( Wolfe, Keane, Kaloupek, Mora, & Wine, 1993 ) I n their intervention study, recovery from combat trauma wa s associated

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20 with the process of reconnecting to others (Wolfe et al., 1993), and this conclusion is consistent with other research (Brewin et al., 200 0) emphasizing the importance of social support as protective factor against long term psychopathology following exposure to trauma Another study examining readjustment of Vietnam combat veterans who were not treatment seeking suggested th at nonavoidant (i.e., direct, problem focused) coping was muc h more common in well adjusted veterans. In the same study nonavoidant coping predicted current adjustment better than exposure to combat (Wolfe et al. 1993) In Gulf War veterans, a voidance and passive coping were common a nd were associated with and pre dicted PTSD (Benotsch et al., 2000; Stein et al., 2005). Despite the utility of research on coping and adjustment in Vietnam and Gulf War combat veterans, the vast differences be tween veterans from other conflicts and OIF/ OEF veterans require studies abou t coping and mental health Th is study examined how service members describe their coping and examine d the relations among co mbat operational deployment stress, post deployment coping, and current mental health. Posttraumatic Growth A recent tre nd in the study of adaptation after trauma is the notion that people may experience enhanced functioning following the trauma Tedeshi and Calhoun (2004) define posttraumatic growth (PTG) as a positive psychological change experienced following the struggle with highly challenging circumstances Also known as benefit finding ( Tomich & Helgeson 2004 ), PTG has been studied mainly in response to chronic illness and bereavement (Linley & Joseph, 2004)

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21 PTG has been ass ociated with a numb er of psychosocial variables such as greater perceived threat of the trauma certain aspects of personality, and coping strategies, such as problem focused coping, acceptanc e, and positive religious coping (Linley & Joseph, 2004). In the review, ruminatio n, avoidance, and intrusions were also found to be associated with growth, suggesting the importance of cognitive processing following the post trauma devastated world views (Janoff Bulman, 1992). The review also noted inconsistent findings between time si nce event and PTG, suggesting that further research needs to be done in this area Finally, from inconsistent relations between growth and distress, Linley and Joseph (2004) concluded that they are not merely opposite ends of one continuum, but instead are separate independent experiences. Apart from three combat related studies reviewed by Linley and Joseph (2004), t wo additional studies that examined PTG following combat related experiences were located The first study examined PTG in a sample of Gulf W ar veterans (N = 61) and found that PTG was related to variables such as military status, perceived threat during deployment, and post deployment social support (Maguen, Vogt, King, King, & Litz, 2006) The other study examined PTG in a sample of Vietnam P OWs. PTG was associated with length of captivity, time since capture, and optimism but not psychopathology (Feder et al., 2008) T o advance our understanding of this phenomenon, t he current study examine d PTG in OIF/OEF veterans to e xplore associations be tween PTG and variables such as perceived threat, objective threat of combat exposure, mental health problems, and time since deployment

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22 Research Questions and Hypotheses The first aim of this study wa s to examine a second order factor structure of a mea sure of coping strategies reporte d by active duty Marines Hypothesis 1: Coping strategies, as measured by the Brief COPE, would load on to three hypothesized factors: e motion/ c ognitive approach c oping, p roblem/ behavioral a pproach c oping, and avoidant c o ping. Specifically, Use of Emotional S upport, Positive R eframing, Religion, and Acceptance we re expected to cluster together onto a factor of emotion/cognitive approach coping Subscales of Active C oping, Use of I nstrumental S upport, and Planning would clu ster together as problem/behavioral approach coping Subscales of Self D istraction, Denial, Self B lame, and Behavioral disengagement we re also hypothesized to cluster together on a factor of avoidant coping The second aim of this study wa s to examine re exposure (combat operational deployment stress) and mental health symptoms and to assess the moderating impact of coping on that relationship. Hypothesis a voidant coping would be positively related, whi le use of a pproach coping would be negatively related, to mental health problems, as measured by the Achenbach Adult Self Report (ASR) Total Problems scale Hypothesis 2.2: Avoidant coping would moderate the relationship between combat operational deploym ent stress, as measure d by the Deployment Risk and Resilience Inventory (DRRI) subscales Combat Exposure, Deployment Concerns, and Post Battle Experiences and mental health problems, as measured by the ASR Total Problems scale It wa s hypothesized that h i gher reported avoidant coping would strengthen the association between combat operational deployment stress and mental health problems

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23 Hypothesis 2.3: Approach coping would moderate the relationship between combat operational deployment stress, as measure d by the Deployment Risk and Resilience Inventory (DRRI) subscales Combat Exposure, Deployment Concerns, and Post Battle Experiences and mental health problems, as measured by the ASR Total Problems scale It was hypothesized that higher reported approach coping would weak en the association between combat operational deployment stress and mental health problems The third aim wa s to examine the extent to which trauma exposure i s related to personal growth following deployment. Hypothesis 3: It wa s hypoth esized that reported subjective threat (DRRI Deployment Concerns ) and objective threat during deployment (DRRI Combat Experiences and Post Battle Experiences ) would be positively associated with posttraumatic growth (PTG), as measured by the Posttraumatic Growth Inventory (PTGI) The f ourth aim of this study wa s to assess the relations between family relationships and mental health and to determine the moderating impact of family relationships on the combat operational deployment stress and mental health symptoms Hypothesis 4.1 : It wa s hypoth esized that married Marines would report fewer mental health problems than nonmarried Marines. Hypothesis 4. 2: It wa s hypothesized that the Relationship Dimension of the Family Environment S cale (FES), measured by Cohesion, Expressiveness and Conflict (reverse scored) wil l be negatively associated with total mental health problems Hypothesis 4.3: It wa s hypothesiz ed that family relationships would moderate the relations between combat ope rational deployment stress exposure and mental health

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24 problems In other words, more positive f amily r elationships would weaken the association between combat operational stress and mental health problems, as measured by the ASR Total Problems s cale.

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25 CH APTER 2 METHOD AND PROCEDURE S Participants Participants were volunteers from an active duty Marine battalion located in Parris Island, South Carolina A ll Marines in the battalion both enlisted and officer personnel were invited to participate in a battal ion wide assessment of mental health and resilience The battalion is composed of approximately 335 Marines, ranging in age from 18 to 50 and in rank from Private First Class to Colonel. The battalion is approximately 96% male The study includes 152 enli sted male Marines. Although 1 96 Marines in the battalion wide study completed the informed consent process (59% participation rate) only 1 75 Marines returned their questionnaires. Furthermore, 4 were excluded from the current study because they were fema le and 5 were excluded because they were officers Of the remaining 166 enlisted males, 1 was excluded from all analyses because his response pattern w as invalid. Two Marine s were excluded because their ages and total time served were statistical outliers (i.e. greater than 3 standard deviations above the mean) Eleven participants who had never been deployed were also excluded from subsequent analysis. N o significant differences were found between these 11 never deployed Marines and the Marines retained f or this study on variables of age, mental health problems, and coping strategies. Table 2 1 reports demographic characteristics of participants (N = 1 52 ) Of the participants (N = 1 52 ; age: M = 24. 3 3 SD = 2.2 1 ) retained for analyses, self reported racial /ethnic background was comparable to the general Active Duty population: Caucasian ( 71 %) African American (1 1 %), Hispanic (1 3 %), Asian American (1%) and Other (4%) As expected in a sample of enlisted Marines, 80 % reported high

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26 school as their highest lev el of education, 19 % reported some college, and 1% reported college or beyond In addition, 69 % reported being married, 2 1 % reported being single, and 9 % reported being divorced or separated O f the 9 2 participants who reported having children 6 0 % had 1 child 30 % had 2 children, 9 % had 3 children and 1% had 4 children The majority of the 1 39 children live with the participant (9 1 %) Of th e children who currently live with the study participants 8 7 % are 5 years of age or younger, 1 0 % are 6 12 years of a ge and 2 % are 13 years of age or older. The participants total time in active duty ranged from 1 to 1 3 years ( M = 5. 39 SD = 1. 68 ). Although each Marine includ ed in this study reported at least one deployment during his career (at least 1 deployment ever ) Marines reported being deployed up to 3 times in the 4 years prior to this study (range 0 3, M = 1.83, SD = 0 .78), with total time deployed ranging up to 23 months of the previous 48 months ( M = 12. 09 SD = 5.43) They reported 2 to 58 months ( M = 20.1 2 SD =12. 65 ) since returning from their most recent deployment. Most Marines reported their most recent deployment to be to a combat theater: Afghanistan (8%) and Iraq (78%) Other locations for most recent deployments (10%) included Marine Expeditionary U nit deployments ( MEU: a naval deployme nt that spans multiple areas), K orea, and other middle eastern countries. The Marines who attended the information sessions were generally amenable to participating Several asked if their commanding officers would ha ve access to their answers or if the information obtained would be going into their medical records. Following assurance about confidentiality, most expressed satisfaction and chose to participate As one Marine submitted completed questionnaires, he comme nted that he

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27 interest in their well being and described additional factors that t hey thought impacted In the days following the data collection, the battalion chaplain reported an increase in people requesting some counseling related to matter s of famil y adjustment and spirituality. This increase in support seeking suggests that completing study questionnaires facilitated self assessment or self awareness in some Marines Table 2 1 Dem ographic c haracteristics (N = 152 ) Characteristic % M SD Min Max A ge a 24. 3 3 2.21 20 32 Time Active Duty (in years) 5. 39 1. 68 1 13 Education % High School % Some College % College or Beyond 80 19 1 Ethnicity/Race % Caucasian % African American % Hispanic % Asian % Other 71 11 13 1 4 Marital Status % Single % Married % Divorced/Separated % Unknown 21 69 9 1 a Based on n = 144 Design A correlational cross sectional design was used to examine the impact of coping and family relationships on relations betw een combat operational deployment stress exposure and mental health of M arines The same design was also used to examine

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28 relations between combat operational deployment stress exposure and posttraumatic growth. Measures The m easures were selected with cons ideration both for administration time and psychometric strength, particularly test retest reliability and construct validity. Psychometric support for each measure is described below Demographic and Background Information Demographic Questionnaire. Thi s questionnaire provides descriptive information about the Marine including sex, age, race/ethnicity, education, and factors related to military service, such as total years in active duty, and rank (enlisted or officer) Information about previous deploym ents was also obtained (length and locations of each deployment in the last four years ). The demographic quetionnaire can be found in Appendix A. Combat Operational Deployment Stress Deployment Risk and Resilience Inventory ( DRRI; King, King, & Vogt, 2003 ) This research inventory is a collection of measures of 14 constructs related to deployment stress All measures were derived using a rigorous psychometric approach to scale construction Three scales from the D RRI were used in this study based on theoretical relevance to the study questions and their strong psychometric properties with samples of Gulf War and OIF veterans This study include d Deployment Concerns Combat Experiences (as revised in Vogt, Proctor, King, King, & Vasterling, 2008 ), and Post Battle Experiences (also revised as a Likert scale) Each scale comprises 15 items. Internal consistencies for the scales range from .85 to .89 (King et al., 2003) in a sample of Gulf War veterans and from .78 to .94 in this study. Research supports the validity of

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29 ability to discriminate between combat and noncombat veteran subgroups (Vogt et al., 2008) Evidence of criterion related validity with a population of OIF veterans is strong (Vogt et al., 2008) Two participants (#6 4 and #76) were excluded from analyses involving DRRI due to complete missing DRRI data Furthermore, because of multiple missing items, two participants (#29 and #182) Deployment Concerns scores were excluded and two participants (#10 and #82) Combat Expe riences scores were excluded. Coping Brief COPE (Carver, 1997) The Brief COPE is a 28 item self report scale that measures multiple domains of coping in response to general stress or a specific stressor Items are rated on a 4 point Likert scale (Not at all, A little bit, A medium amount, A lot). Because of possible risk to participants, q uestions regarding drug/alcohol use were replaced with questions about exercise and relaxation, but these items were not used in this study. Dimensions of coping used in this study include d Use of Emotional S upport, Positive R eframing, Acceptance, Religion, Active C oping, Use of Instrumental S upport, Planning, Denial, Self B lame, Self Distraction, and Behavioral D isengagement Each scale is creating by summing its two ite ms Psychometric data suggest ed good internal consistency for t h e above from .60 .8 3 in this study ), with the exception of Acceptance and Self Distraction ) However, the items from these subscales were still included in composites because they were highly correlated with the other items. R esearch has also shown the Brief COPE to demonstrate a factor structure similar to the full length COPE ( Carver, Scheier, & Weintraub, 1989; Carver,

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30 1997) with evidence of validity. Two participants (#201 and #83) Brief COPE responses were excluded from analyses because they were fully or partiall y incomplete. Family Relationships Family Environment Scale Short Form (FES; Moos & Moos, 1994) The FES is a self report measure of the social climate of families that has been widely used for clinical and research purposes. It consists of 90 true false items, resulting in 10 subscales within three domains. This study used the Relationship domain ( Cohesion, Expressiveness, Conflict), measured with 27 items. Approximately half of the items were reverse coded to indicate positive family functioning. The FES has normative data 7 in this study. The FES has demonstrated evidence of test retest reliability, construct validity, and discriminant validity (Moos & Moos, 1994). It has also demonstrated negative relations to life stress in a sample of Navy families (Eastman, Archer, & Ba ll, 1990). One half complete. Mental Health Adult Self Report for Ages 18 59 (ASR; Achenbach & Rescorla, 2003). The ASR is a 123 item self report measure of adult emotional a nd behavioral problems. Each item is rated on a three point scale from (0) not true to (2) very true or often true Item scores are summed into empirically derived narrow and broad band scale scores. To eliminate possible risk associated with participati on, five questions were excluded: #6 I use drugs; #92 Does things that may cause trouble with the law; #124 126 regarding tobacco, alcohol, and drug use Th is study used the Total Problems Scale which is the sum of all it ems, with the exception of 11 item s measuring socially desirable behaviors

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31 (#2, 4, 15, 49, 73, 80, 88, 98, 106, 109, 123). Item rating s may also be used to derive scores corresponding to DSM IV diagnoses In this study, internal consistency for the Total Problems Scale was 0.95 Posttraum atic Growth Posttraumatic Growth Inventory ( PTGI; Tedeschi & Calhoun, 1996). The PTGI is a 21 item self report measure that measures positive changes following a difficult event (adversarial growth) using a 6 point scale. The PTGI has been reported to show overall alpha reliability of .90 and 2 month test retest reliability of .71 (Tedeschi & Calhoun, 1996). It has been used to examine change following a variety of traumas, but showed excellent alpha consistency (.96) in a sample veterans previously deploye d to the Persian Gulf (Maguen, Vogt, King, King, & Litz, 2006). In this study, the PTGI Total Score was used and demonstrate Procedures Approval to recruit participants was obtained from the Commanding Officer (CO) of Weapons and Field Training Battalion. Following approval by the University of Florida IRB 01 and the Office of Naval Research, t he study was advertised to Marines via the family newsletter and posted bulletins on base In addition, the PI attended a battalion meeting described the study, and informed the Marines of the specific location and times that she would be available to further describe the study and consent interested individuals. When Marines came to the designated study location, the voluntary nature of par ticipation was emphasized To further reduce the possibility of group pressure and to increase anonymity, all Marines who came to the study informatio n sessions received an Informed Consent F orm ( ICF) and an envelope with questionnaires After the ICF was

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32 on the ICF if they did not want to participate They were told to sign and date the ICF if they agree to participate The ICFs were collected separately from the questionnair es The PI was available after the meeting or by phone/email to answer questions privately Marines were given the option to complete the questionnaires in person or to return the envelope to a locked box regardless of their participation, thus increasing anonymity All Marines who received a packet of questionnaires was given a list of local no/low cost mental health providers

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33 CHAPTER 3 RESULTS D ata analysis w as conducted using the Statistical Package for the Social Sciences 17.0 (SPSS). Preliminary sta tistical analyses descriptive statistics, and specific analyses for each hypothesis are detailed below. Preliminary Analyses Demographic data including age, total time active duty, and total # of dep loyments in the last four years were examined for outl iers using boxplots and z scores of variables It was expected that no more than 5% of the z scores (absolute value) would be greater than 1.96, no more than 1% of z scores greater than 2.58, and no z scores greater than 3.29 (Field, 2005) As described in the Participants section, two participants were removed from further analysis because their age and total time in active duty were statistical outliers ( greater than 3.29 standard deviations above the mean ) To manage missing data, r andomly missing item v alues were replaced with the % of the total number of items. On the DRRI, seven items were replaced with mean Combat Experiences score, and six items were replaced with Post Battle Experiences s core. On the Brief COPE, data replacement was not conducted because each subscale ha s only two items. As described ab scores were excluded from analyses because of missing data. One additional participant had a single missing item, which resulted in a missing score for Behavioral Disengagement subscale On the Family Environment Scale, missing items were also replaced when no more than one item of the subscale was missing Five items were replaced with the

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34 Cohe sion s core and two were replaced with the Expressiveness score. On the Posttraumatic Growth Inventory, a total of four item scores were replaced with the T o ensure univariate normal distribution descriptive statistics were examined for the DRRI subscales and composites Brief COPE subscales and composites FES Relationship Index ASR Total Problems and PTGI Total The DRRI Total score was made by summing z scores of Combat Experiences, Deployment Concerns, and Post Battle Experiences Z scores were necessary because the subscales are measured on different scales. DRRI Total appeared normally distributed based on visual inspection of histogram and boxplots, as well as non significant Kolmogorov Smi rnov and Shapiro Wilk normality tests On the subscales of the Deployment Risk and Resilience Inventory, Deployment Concerns and Combat Experiences appeared normally distributed by visual inspection of histograms and boxplots Values of skewness and kurto sis did not indicate non normality, and the Kolmogorov Smirnov(a) and Shapiro Wilk tests indicated nonsignificant deviances from normality Post Battle Experiences appeared slightly positively skewed, with three outliers However, once Post Battle Experien ces and Combat Experiences were combined into a composite of Objective Deployment Threat, the distribution did not have outliers. Because visual inspection suggested that the distribution was positively skewed, square root transformation was made to Object ive Deployment Threat On the transformed data, values of skewness and kurtosis did not indicate non normality, and the Kolmogorov Smirnov(a) and Shapiro Wilk tests likewise indicated nonsignificant deviances from normality Finally the Subjective Deploym ent

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35 Threat score was equivalent to the Deployment Concerns subscale The histogram and boxplot suggested normal distribution, and v alues of skewness (z skewness = 1.86) and kurtosis (z kurtosis = 0.28) did not indicate non normality. Descriptive statistic s histograms, and boxplots of Brief COPE subscales were examined for normality. For subscales of Active Coping, Planning Self Blame and Positive Reframing values of skewness and kurtosis were consistent with visual inspection of normality and did not in dicate significant deviance from normality However, for subscales of Emotional Support Religion Denial and Behavioral Disengagement absolute values of skewness z scores were greater than 2.58, s uggesting significant skewness at p < .01. In addition, I nstrumental Support had a skewness z score greater than 1.96, suggesting significant skewness at p < .05 Although Kolmogorov Smirnov and Shapiro Wilk normality tests were significant for all Brief COPE subscales used such results were interpreted with ca ution because of the large sample size (Field, 2005) Because of the restricted range of these non normal ly distributed subscales, it was not possible to transform these variables to sufficiently meet assumptions of univariate normality, which is necessary for Confirm atory Factor Analysis (CFA) Hence, hypothesized factor s of emotion/cognitive a pproach c oping, a voidant c oping and p roblem/ b ehavioral a pproach c oping could not be tested statistically with CFA. Although unable to be confirmed statistically, th e a priori constructs were used for Aim 2 because of the theoretical basis on which they were combined For the construct of avoidant c oping, Self Distraction, Denial, Self Blame and Behavioral Disengagement for the subscale of Self Distraction

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36 both items were moderately corre lated (r > 0.5) with the total avoidant c oping sc ore In addition, Cronba e included the two items originally considered to be part of t he Self Distraction scale than when those same items were ex c luded Avoidant c oping was examined for normality. The histogram, boxplot, and values of skewness and kurtosis indica ted nonsignificant deviances fro m normality. Approach c oping was also created on a theoretical basis: Use of emotional support, Positive reframing, Religion, Active coping, Acceptance, Use of instrumental support, and Planning were summed. Acceptance was moderate ( = 0.5 3), items were included in approach coping because of their theoretical relation to the construct Acceptance Approach c oping was examined for normality. The histogram, boxplot, and values of skewne ss and kurtosis indicated non significant deviances f r o m normality The Relationship Dimension of the Family Environment Scale (FES) was made by summing the Cohesion, Expressiveness and Conflict and subscales of the married Marines. Some items of each sub scale were reverse coded so that the score was consistent with more positive family relationships Conflict was scored so that higher scores were indicative of lower conflict Visual inspection of histograms and boxplots demonstrated that the Relationship Index was significantly negatively skewed. To normalize the distribution, a square root transformation was conducted on the reverse coded data. To help with interpretability, the data was reverse coded again, so that higher numbers meant more positive fam ily relationships

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37 Visual inspection of the ASR Total Problems demonstrated positively skewed distribution. To normalize the distribution, a square root transformation was conducted on the ASR Total Problems On the transformed data, v alues of skewness an d kurtosis did not indicate non normality, and the Kolmogorov Smirnov(a) and Shapiro Wilk tests likewise indicated nonsignificant deviances from normality Visual inspection of histograms and boxplots of PTGI Total demonstrated slight negatively skewed dis tribution. The z score value of s kewness (1.98) was at the upper threshold for acceptability, but the values of kurtosis (0.42) did not indicate non normality. Transformations of PTGI Total score resulted in significant deviances from normality so nontran sformed data was used for analyses. Descriptive Statistics Means, standard deviations, ranges for each scale used in this study are detailed in Table 3 1 Presented are the three subscales of the DRRI, including the original dichotom ous score and revised frequency score for Combat Experiences and Post Battle Experiences two hypothetical constructs derived from the Brief COPE, the Total Problems score of the ASR, and the PTGI Total score M ain Analyses Hypothesis 1 For Hypothesis 1, that responses on the Brief COPE will load onto 3 a prior i factor s, a confirmatory factor analysis (CFA) was unable to be conducted b ecause the distributions of Brief COPE subscales deviated significantly from normality Because CFA uses s tatistical infere nce to test a hypothesized factor structure univariate normality is a necessary assum ption for CFA

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38 Exploratory Factor Analysis (EFA) is often used to descriptively summarize relationships in a large set of variables; therefore, assumptions regarding uni variate normality are not in force (Tabachni c k & Fidell, 200 7 ). Its purpose is to find the dimensionality of reliable, common, shared variance (in contrast to PCA which tries to find dimensions that account for all the variance in a dataset) An initial EF A of the 11 Brief COPE subscales (2 items each) was conducted to identify a probable factor structure. List wise deletion was used to manage data of the 5 participants who did not have complete responses to the Brief COPE Based on the initial hypothesis, c ombining theoretical continua of avoidance approach coping and emotion problem focused coping, a three factor solution was anticipated: Emotion/Cognitive Approach, Problem/Behavioral Approach, and Avoidance Promax rotation was used to allow for correlat ed factors which posits that only components with eigenvalues greater than or equal to 1 should be interpreted, a n interpretation of a 3 factor solution was suppor ted. The first factor efficacy in mana ging the problem through both problem solving and cognitive reframing support from others, including instrumental support, emotional support, and religion (i.e., support from faith and beliefs) The third factor measures the degree to which the individual avoids managing the stressor or the associated emotions The pattern of standardized regression coefficients for the three factor solution is detailed in Table 3 2 Despite use of Promax rotation to allo w for correlations among factors, the factors were minimally related: problem focused coping was positively correlated with support

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39 seeking coping (r = .36). Avoidant coping was negatively related to problem focused coping (r = .12) and was negligibly rel ated to support seeking coping (r = .04). factor. The subscale with a split loading was included in the factor with the highest loading. Problem focused coping demonstrated internal consistency of .74, support seeking coping avoidant coping = .61. Although EFA was not conducted on the individual items of the Brief COPE, ginal item responses were used to calculate it: Problem focused coping ( = .80), support seeking coping ( = .79) avoidant coping ( = .69). Because of the exploratory nature of this factor anal ysis, two and four factor solutions were also extracted and examined for interpretability. In the two factor solution, active coping planning, positive reframing, instrumental support, emotional support, acceptance, loaded onto the first factor with coefficients greater than .40. Religion also loaded onto the first factor with a loading of .38 Denial, behavioral disengagement, self b lame, and self distraction loaded onto the second factor. Although interpreted components should be greater than 1, the fourth factor had an eigenvalue of .954 and was therefor e examined. Interestingly, the four factor solution was very similar to the three factor solution, with the exception of Self Blame which loaded by itself onto the fourth factor. Hypotheses 2.1 2.3 For the second aim of the study examining relations betw trauma exposure and mental health symptoms and the moderating impact of coping,

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40 two hierarchical multiple regressions were conducted. In the first regression, total combat operational deployment stress and time since deployment were ent ered in Block 1, Approach Coping was entered in Block 2 and the interaction between combat operational deployment stress and a pproach coping was entered in Block 3 To protect the analysis from multicollinearity, which makes interpretation of b weights di fficult, the residualized interaction term was entered into Block 3. T o obtain the residualized interaction term, t he product of total combat operational deployment stress and approach coping was computed, then orthogonalized by regressing total combat ope rational deployment stress and approach coping onto the product and saving the unstandardized residuals The residual was then entered in Block 3 to test for the interaction. For t he first multiple regression, the model did not predict Total Problems R 2 = 0.07 (F[4,12 8 ]= 2. 28 p = .064 ) Contrary to the hypothesis that Approach coping and the inte raction of Approach Coping and d eployment stress would be negatively related to mental health, Blocks 2 and 3 did not explain significantly more variance in Tota l Problems than the first Block (S ee Table 3.3 ) In the second regression predicting mental health problems, total combat operational deployment stress and time since deployment were entered in Block 1, Avoidant Coping was entered in Block 2 and the inter action between combat operational deployment stress and a voidance coping was entered in Block 3 Again, the product term was orthogonalized by regressing total combat operational deployment stress and avoidant coping onto their product and saving the unsta ndardized residuals which were entered in Block 3 Overall the model significantly predicted Total Problems, R 2 = 0.319 (F[4,127] = 14.90, p < .001 In this

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41 regression, the addition of Avoidant Coping explained significantly more variance in Total Proble R 2 between Avoidant Coping and Deployment stress explained significantly more variance in Total Problems R 2 As hypothesized, Avoidant Coping was signifi cantly positively related to total problems; however, the interaction was significantly negatively related to total mental health problems. Thus, contrary to the hypothesis, the relationship between combat operational deployment stress and total mental hea lth problems was stronger for individuals with lower, not higher, avoidant coping. In other words, the relationship between combat operational deployment stress and mental health problems was negative for individuals who reported more avoidant coping. Figu re 3 1 demonstrates the somewhat protective nature of avoidant coping on mental health problems. Thus, overall, avoidant coping was positively related to total problems, but when combined with high levels of combat operational deployment stress, the intera ction was related to fewer total problems. Hypothesis 3 For Hypothesi s 3 examining relations among combat operational deployment stress and posttraumatic growth, a hierarchical multiple regression w as conducted predicting posttraumatic growth To control for background variables that may be related Pearson product moment and point biserial correlations (for continuous and dichotomous variables, respectively) w ere calculated between PTG and background/demographic variables of age, marital status, ethnicity time since last deployment, total deployments in last 4 years, and recent theatre of deployment (i.e. Iraq, Afghanistan, or other) and Total Mental Health Problems PTG was significantly related to Total Problems (r = .22, p < .01). Thus, Total Problem s was entered in Block

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42 1. Block 2 included Objective Deployment Threat made by summing DRRI subscales Combat Experiences and Post Battle Experiences and Subjective Deployment Threat measured by DRRI Deployment Concerns Overall, the model explained sign ificant variance in PTG, R 2 = 0.11 (F[3,130] = 5.80, p < .01. However, only the main effect of Total Problems was significant; neither Objective Threat nor Subjective Threat predicted significant variance in PTG. Hypotheses 4.1 4.3 For Hypothesis 4. 1, tha t married Marines would repor t fewer mental health problems than nonmarried Marines a t test was performed to compare the means of the ASR Total Problems The analysis indicated nonsignificant differences [t(135) = 0.38] in reported mental health of marr ied Marine s ( M = 7.23, SD = 1.89) and single Marines ( M = 7.37, SD = 1.74) For Hypothesis 4. 2, that family relationships will moderate the relations between combat operational deployment stress and mental health, a hierarchical multiple regression w as co nducted predicting mental health (ASR Total Problems) of married Marines The Family Relationship construct was made by scores for each of the three subscales, Cohesion, Expressiveness, and Conflict, with higher scores indicating more positive relationship s and lower scores indicating worse functioning As such, a higher Conflict score meant less family conflict Total combat operational deployment stress and time since deployment were entered in Block 1, family relationships was entered in Block 2 and th e interaction between combat operational deployment stress and family relationships was entered in Block 3 Again, the product term was orthogonalized by regressing total combat operational deployment stress and family relationships onto their product and saving the

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43 unstandardized residuals which were entered in Block 3 Overall the model significantly predicted Total Problems, R 2 = 0.225 (F[4,85] = 6 18 p < .001 ) In this regression, the addition of Family Relationships explained significantly more vari ance in R 2 = .151 16.24 p < .001. The addition of the residualized interaction between Family relationships and combat operational deployment stress did not explain significantly more variance. Supplemental Analyses To better un derstand relations between combat exposure and mental health problems, Marines were divided into tertiles by their total reported combat operationa l deployment stress Figure 3 2 shows the percentage of Marines in the study who endorsed clinically signific ant elevations of mental health problems. Clinically significant elevations were determined by T scores of 64 or higher, as recommended by the ASR manual (Achenbach & Rescorla, yr). Based on the distribution of mental health problems in the general populat ion, one would expect approximately 8% of the population to endorse such elevations It is interesting that there seems to be a dose response of combat operational deployment stress for Total Problems reported, but the relations between stress and symptoms are not linear for internalizaing or externalizing problems. Figure 3 3 shows the percentage of Marines in the study who endorsed borderline risk elevations were determined by T scores between 60 and 63, as recommended by the ASR manual (Achenbach & Rescorla, yr). Based on the distribution of mental health problems in the general population, one would expect approximately 6% of the population to endorse such

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44 elevations When compared to the Figure 3 1, a different dose response pattern is observed. Because of the ways that internalizing and externalizing symptoms may differentially relate to study variable s examined, exploratory bivariate correlations were conducted. Table 3 7 lists the correlations. O f note, avoidant coping was significantly related to both externalizing and internalizing problems, while approach coping was significantly related to posttraumatic growth only. In addition, family relationships were related positively to posttraumatic gro wth. Family relationships were also significantly negatively related to externalizing and internalizing problems, and avoidant coping. Table 3 1 Me ans and standard deviations for measures used Variable M SD Range Alpha DRRI a Deployment Concerns 45.34 9.64 19.0 66.0 0.78 Combat Experiences Frequency Based 41.27 13.46 15.0 75.0 0.9 3 Original Scale (Yes No) 10.7 3.56 0.0 15.0 0.88 Post Battle Experiences Frequency Ba sed 38.61 13.25 15.0 75.0 0.9 4 Original Scale (Yes No) 11.4 4.14 0.0 15.0 0.9 2 Brief COPE Avoidant Coping 15.98 3.80 8 .0 27 .0 0. 69 Approach Coping 34.28 6.70 19 .0 52 .0 0. 8 3 FES Relationship Index 18.56 4.60 3.0 26.0 0.77 ASR Total Problems 57.98 27.78 8.0 154.0 0.95 PTGI Total 59.6 19.55 0.0 102.0 0.92 a The original scale used for Combat Experiences and Post Battle Experiences was dichotomous. Revisions were made to allow for a greater variability in scores. Both scores are reported for comparison to previous populations.

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45 Table 3 2. Factor lo adings based on exploratory factor analysis with Promax rotation for 11 subscales from the Brief COPE Subscale Problem focused Factor Support seeking Avoidance Plann ing Active Coping Acceptance Positive Reframing Emotional Support Instrumental Support Religion Denial Behavioral Disengagement Self Distraction Self Blame .73 .69 .62 .46 .45 .83 .77 .35 .65 .66 .50 .45 Note: Factor loadings < .3 are supp ressed T able 3 3. Regression of deployment stress, approach coping, and the interaction of stress and coping onto total mental health problems B SE B Block 1 Constant 7.13 0.30 Months since deployment 0.01 0.01 .09 Total Deployment Stress 0.17 0.07 .23** Block 2 Constant 7.51 .92 Months since deployment 0.01 0.01 .09 Total Deployment Stress 0.17 0.07 .22* Approach Coping 0.01 0.03 .04 Block 3 Constant 7.61 0.93 Months since deployment 0.01 0.01 .08 Total Deployment Stress 0.17 0.07 .22* Approach Coping 0.01 0.03 .04 Deployment Stress X Approach Coping 0.01 0.01 .08 Note R 2 = .06 for Block 1; *p < .05, **p < .01. ***p < .001

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46 Table 3 4. Regression of deployment stress, avoidant coping, and the interaction of stress and coping onto total mental health problems B SE B Block 1 Constant 7 .09 0.30 Months since deployment 0.01 0.01 .09 Total Deployment Stress 0.17 0.07 .22* Block 2 Constant 3.40 0.64 Months since deployment 0.00 0.01 .01 Total Deployment Stress 0.11 0.06 .15 Avoidance Coping 0.24 0. 04 .49*** Block 3 Constant 3.18 0.63 Months since deployment 0.00 0.01 .02 Total Deployment Stress 0.10 0.06 .13 Avoidance Coping 0.26 0.04 .51*** Deployment Stress X Avoidance Coping 0.04 0.01 .19* Note R 2 = .06 for B *p < .05, **p < .01. ***p < .001 Table 3 5. Regression of mental health, objective deployment threat, and subjective deployment threat onto posttraumatic growth B SE B Block 1 Constant 81 .06 6.23 Total Problems 2.79 0.81 .28* Block 2 Constant 64.43 11.10 Total Problems 3.14 0.82 .31* ** Objective Threat 0.90 1.17 .07 Subjective Threat 0.29 0.17 .15 Note: R 2 *p < .05, **p < .01. ***p < .001

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47 Table 3 6. Regression of deployment stress, family relationships, and the interaction of stress and family relationships onto total mental health problems B SE B Block 1 Constant 6.96 0.36 Months sin ce deployment 0.01 0.02 .06 Total Deployment Stress 0.17 0.08 .22* Block 2 Constant 13.02 1.54 Months since deployment 0.01 0.01 .06 Total Deployment Stress 0.15 0.07 .19* Family Relationships 1.08 0.27 .41*** Block 3 Constant 13.08 1.53 Months since deployment 0.01 0.01 .06 Total Deployment Stress 0.14 0.07 .19 Family Relationships 1.10 0.27 .41*** Deployment Stress X Family Rel. 0.17 0.11 .15 Note R 2 = .05 for Block 1; for Block 3. *p < .05, **p < .01. ***p < .001 Table 3 7. Bivariate correlations among study variables. Externalizing Problems Internalizing Problems Months Since Deployment Approach Coping Avoidant Coping Combat operat ional Deployment Stress PTGI Total Externalizing Problems 1 Internalizing Problems .545 ** 1 Months Since Deployment .168 .035 1 Approach Coping .127 .021 .060 1 Avoidant Coping .361 * .500 * .185 .117 1 Combat O perational Deplyoment Stress .220 ** .127 .025 .022 .103 1 PTGI Total .184 .183 .135 .245 ** .097 .119 1 Family Relationships .321 * .295 * .186 .040 .286 * .043 .381 * * p < .05, ** p < .01, *** p < .001

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48 Figure 3 1. Interacti on of avoidant coping and combat operational stress exposure on mental health problems Note: Low combat operational deployment stress was determined by scores greater than 1 standard deviation below the mean (N=22) while high combat operational deploymen t stress was determined by scores greater than 1 standard deviation above the mean (N=21)

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49 Figure 3 2. Percentage of Marines with clinically significant mental health problems (T > 64) by total combat exposure. Figure 3 3 Percentage of Marines with b orderline clinically significant mental health problems (T > 60 & T < 63) by total combat exposure.

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50 CHAPTER 4 DISCUSSION Summary of Results relationships relate to mental health and influence the relations between combat operational deployment stress and mental health problems. This study also assessed the posttraumatic growth (or positive outcomes) resulting from deployment of Marines, to examine relation s among PTG, combat exposure and mental health. The first aim of the study was to explore the factor structure of a measure of into three overarching coping approaches, reflecting a combination o f approach and avoidance coping with problem and emo tion focused coping (Littleton et al. 2007): emotion/ cognitive approach coping, problem/ behavioral approach coping, and avoidant coping. An exploratory factor analysis of the 11 subscales of the Brief COPE suggested three clusters of coping s trategies fairly similar to th e hypothesized factors The first factor clustered together four subscales of the Brief COPE -Planning, Active Coping, Acceptance, and Positive Reframing -that seemed to measure a self efficacy in reducing the impact of the stressor through problem solving such as planning and cognitive restructuring. This first factor was labeled problem focused coping The second factor clustered together three subscales -Religion, Use of Emotional Support, and Use of Instrumental Support that appeared to represent support seeking coping The third factor clustered together the four remaining maladaptive subscales of the Brief COPE Denial, Behavioral Disengagement, Self Distraction, and Self Blame, which had been hypothesized to cluster together as

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51 avoidant coping Although three clusters of coping were obtained from the factor analysis, caution is warranted in their interpretation because of the small sample size, which may result i n the obtained factors being unstable. The coping subscales did not clu ster precisely as hypothesized; however, the pattern appears conceptually sound. Similar to previous research, Active C oping, P lanning, and P ositive R eframing clustered together (Carver 1997). A study of military recruits found that the Acceptance subscale also loaded onto this first factor, although Positive Reframing did not (Cohn & Pakenham, 2008). Consistent with the current study, Use of Emotional Support and Use of Instrumental Su pport formed a factor in the original COPE and the Brief COPE validation s tudies (Carver, Scheier, & Weintraub, 1989; Carver, 1997 ) In the current study, though, these two subscales combined with Religion to form the second factor Although Religion was l ess related to support seeking coping than the other two subscales, it is understandable that it would be or emotional support. Considering the low endorsement of spirituality/ religiosity of Marines in this study, a significant relation between Religion and support seeking coping was unexpected and suggests a needs for additional research in this area. If ad ditional research finds religion benefit the military to continue to provide access to faith or spirituality based supports, such as chaplains. Although t he Brief COPE s ubscales of Denial, Behavioral Disengagement, Self Distraction, and Self Blame grouped together as hypothesized based on theory

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52 categorizing coping strategies as approach o r avoidance coping (Littleton et al. 2007), these subscales did not cluster togethe r similarly in other factor analytic studies of the Brief COPE. For example, i n a sample of military recruits (i.e. people in early stages of training to be in the military) Denial and Self Blame loaded onto separate factors without Behavioral Disengageme nt or Self Distraction (Cohn & Pakenham, 2008). The divergence of this previous factor analytic findings of the Brief COPE may have resulted from examination of a different population, measurement of a slightly different construct, o r from statistical procedures. The sample used to validate the Brief COPE (Carver, 1997) was a sample of hurricane survivors ( N = 168, 66% female), arguably a population likely to use different coping strategies than Marines. Cohn and Pakenham (2008) studi ed a population of military recruits, who are demographically more similar to the sample in the current study than the general population. However, the recruits differed in one very important way from the current study population they had not yet been ex posed to combat deployments. Given that the spectrum of posttraumatic symptoms includes dissociative and avoidant behaviors, people who have endured combat may demonstrate a different pattern of coping from people who have not endured combat. In addition Given the importance of dispositional versus situational coping in the adaptation to military trauma (Punam ki et al., 2008), th i s may be an important diffe rentia t ion. The current study asked the participants to report how they generally deal with stress, leaving the interpretation of

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53 considered different stressors while answering the items. It has been suggested that adaptive coping strategies will depend on the control lability of the stress (Folkman et al., 198 6 ). Thus, the factor structure of the Brief COPE could be dependent upon whether the p articipant were considering a controllable stressor (such as a family disagreement), a noncontrollable stressor (such as work duties), or an inconsistent combination of the two. Finally, the factor structure of the Brief COPE may be different depending on the statistical methods used. The study used to validate the Brief COPE (Carver, 1997) conducted an exploratory factor analysis with all items on the measure (first order factor analysis), but the sample was small for such an analysis. Cohn and Pakenham ( 2008) conducted a second order factor analysis of the 14 subscales of the Brief COPE, whereas the current study used only 11 subscales because of their theoretical relevance to constructs of interest. In addition, the Cohn and Pakenham study (2008) used bo th principal components analysis and confirmatory factor analysis on the same dataset warranting caution in interpretation. Although the factor structure in the current study diverged from factor structures found in earlier studies, definitive conclusio ns or interpretations cannot be made because of the exploratory nature of the studies. Thus, future research is needed to standardize and validate the COPE and Brief COPE on a large population of adults, as well as a large military population. Such standar dization will be necessary to be able to fully interpret the observed patterns of responses. Any major differences between implications for researchers interested in examining coping in service members.

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54 strategies and post deployment adaptation, unit leaders and clinicians can promote interventions that include positive coping strategies that are sensiti ve to the military culture. operational deployment stress and mental health symptoms. Further, coping was examined to determine its relation to with mental health and to see if i t changed the relations between combat operational deploym ent stress and mental health. Based on previous studies of coping i n war veterans (Mikulincer & Solomon, 1989) it was hypothesized that Marines who reported using more approach coping would be less impacted (i.e., have better mental health) by combat operational deployment stress. On the other hand, it was hypothesized that Marines who reported more avoidant coping would be more impacted by combat operational deployment stress, and therefore show w orse mental health if they reported high combat exposure Regardless of their self reported coping strategies, Marines who reported higher combat operational deployment stress also repor ted more mental health symptoms, when time since the most recent deplo yment was taken into consideration. Contrary to the hypothesis, however, approach coping was not significantly related to mental health symptoms, nor did it change the relationship between combat operational deployment stress and mental health. This was un exp ected because the meta analysis of coping and trauma demonstrated a stronger association between approach coping and distress for people who experienced traumas of longer duration compared to peopl e who had experienced

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55 trauma of shorter duration and de ployment could be easily considered as such a trauma of longer duration (Littleton et al., 2007). On the other hand Marines who reported using more avoidant coping strategies also reported more mental health problems, as hypothesized. In addition, avoid ant coping was found to weaken relations between combat operational deployment stress and mental health problems. In other words, when Marines reported high levels of avoidant coping and combat operational deployment stress, they reported fewer mental heal th problem when compared to Marines with low levels of avoidant coping and high levels of combat operational deployment stress. This correlation, although small in magnitude, suggests that avoidance may actually serve as a protective f actor for Marines who have experienced high levels of combat operational deployment stress Although this second aim was to determine how coping and combat operational deployment stress were related to mental health, many additional factors likely contribute to this relations hip. It is possible that the observed relations differ in Marines reporting clinically significant mental health problems, and that by using all Marines for the analyses, some of the effects in Futher, as the significant interaction effect between avoidant coping and combat operation deployment stress suggests, relations may be different for Marines who have experience high versus low combat stress. Although the obtained findings can help us understand patterns of coping and mental he alth, an epidemiological approach (i.e., use of risk ratios) may help us understand the impact of a given risk factor for post deployment adaptation The examination of general mental health problems on a continuum, rather than categorically by DSM IV dia gnosis, was a strength of this study. However, coping may

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56 be differentially related to internalizing and externalizing problems or even subgroups of symptoms. Thus, it may be important for future research to examine relations between coping and specific sy mptom groupings. The significant association between avoidant coping and mental health has implications for clinicians and unit leadership. The promotion of healthy coping strategies is important following deployment, but it is also very important to rec ognize the potential utility of avoidant coping strategies in Marines who have experienced higher levels of combat operational deployment stress than their peers. For clinicians working with service members with PTSD, this finding suggests that some cognit ive behavioral therapy or prolonged exposure therapy could be useful and healthy, but elimination of all avoidant coping strategies may result in increased problems. is n ot equally related to externalizing and internalizing problems, suggesting that additional research needs to empirically examine the amount of avoidant coping to promote or allow within the context of mental health treatment, depending on the presenting pr oblem. The third aim of this study was to examine posttraumatic growth (PTG). Contrary to the hypotheses, PTG was un related to degree of combat exposure, perceived threat during deployment, or time since deployment In contrast, Marines who reported fewer mental health problems also reported greater positive change resulting from deployment, regardless of the amount of combat operational deployment stress they reported.

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57 Findings from this study contradict previously published results concerning PTG in veter ans. Research with personnel returning from conflicts in Iraq or Afghanistan is quite limited, however, and no previous study of PTG included OIF/OEF veterans In a study of Gulf War veterans, PTG was related to perceived threat during deployment (Mague n et al. 2006) However, the experiences of service personnel in the Gulf War vary greatly when compared to personnel who served in OIF/OEF. Gulf War veterans reported significantly lower scores on Combat Experiences ( M = 3.99, SD = 3.24; King, King, Vogt Knight, & Samp er 2006) than the Marines in this study ( M = 10.7, SD = 3.56) They also reported lower scores on Post Battle Experiences ( M = 5.99, SD = 4.11; King et al., 2006) than Marines in this study ( M = 11.4, SD = 4.14) Interestingly, Deployme nt Concerns reported by Gulf War veterans ( M = 47.37, SD = 11.13) were similar to reports in this study ( M = 45.34, SD = 9.64). Thus, it is plausible that in Gulf War veterans, PTG was related to perceived threat in the absence of high levels of objective threat. Because Marines in the current study reported high levels of objective threat, it is l ikely that PTG will demonstr a te a different course than it did following the Gulf War. Another finding in this study that diverged from an earlier study of PTG w as one conducted with Vietnam POWs in which PTG w as related to length of captivity, time since capture, and optimism, but not psychopathology ( Feder et al., 2008). The current study found a significant relation between PTG and mental health problems, but n ot with time since deployment. It is unknown if the divergent findings are due to me asurement differences, population differences or both For example, the Vietnam POW study examined the relations between PTG and a diagnosis of PTSD, while the current stu dy

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58 assessed mental health problems on a continuum. By assessing a broader range of psychopathology, the current study may have been better able to examine the relation between psychopathology and PTG than studies that only examine d one type of symptomotolo gy. Furthermore, the amount of time that had elapsed for PTG to occur was much longer for the Vietnam veterans than for the Marines i n the current study, possibly providing a chance for more positive reframing or necessary cognitive processing Given that the relation between time and PTG is inconsistent in the literature (Linley &. Joseph, 200 4), the current study furthers the understanding of the temporal course of PTG. Thus far, issues related to the temporal course of PTG remain unclear. PTG is recogn ized as an important part of a comprehensive understanding of the sequalae of trauma, yet much of the literature focuses on adaptation to chronic illness, single trauma, or bereavement (Linley & Joseph, 2004) rather than the adaptation to the multiple comb at related deployments of current conflicts In a review of empirical studies examining positive changes following trauma and adversity (Linley & Joseph, 2004), only three studies examined growth after combat, and none of those three used a standardized me asure of PTG (Schnurr, Rosenberg, & Friedman, 1993; Waysman, Schwarzwald, & Solomon, 2001; Fontant & Rosenheck, 1998). In addition to studies of PTG in combat veterans located by the meta analysis, we identified two additional studies that examined PTG in veterans -the Feder et al.( 2008) study and the Maguen et al. (2006) study discussed earlier The importance of the findings on PTG in this study is that it advances our understanding of PTG in present day Marines, which has

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59 implications for clinicians who work with OIF/OEF veterans who have endured combat related traumas. The fourth aim of this study was to examine associations between combat operational deployment stress, family relationships, and mental health problems. Although marriage has been cons istently linked with better mental health in individuals, as compared to single counterparts, findings in the current study did not suggest significantly different mental health in married versus non married Marines. Two possible explanations for this diff erence from the general population should be examined in future research. First, comparable mental health problems may be the result of additional stressors or worries that married Marines must contend with throughout the cycle of deployment. However, on t he other hand, it may be that the cohesion and brotherhood of the military create for the single Marines a social support system unlike what a male civilian might experience. As hypothesized, Marines who reported better family relationships (greater cohesi on, greater expressiveness, and less conflict) also reported fewer mental health problems. However, more positive family relationships did not moderate the way that operational deployment stress and mental health were related. Thus, conclus ions cannot yet be made regarding the importance of social support in recovery from combat operational deployment stress Future research should more fully examine this because of importance of social support found in r ecovery from other sources of tr auma (Brewin et al., 2000). Few studies have addressed the influence of the family among active duty personnel, and evidence supporting the positive effects of family cohesion, expressiveness, and low conflict on the mental health of returning

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60 Marines This finding emphasizes the importance clinical assessment and promotion of Future longitudinal research needs to be conducted to determine causality in other words, the cu rrent study does not provide information as to whether poor family relationships lead to worse mental health after deployment or if poor mental health leads to worse family relationships or even if both mental health and family environment result from a th ird variable Limitations This study has several limitations that are important to note. First, because the study design was correlational, causation cannot be inferred Conclusions about any variable causing mental health problems cannot be made. Instead we can only make conclusions about the strong relations among the variables Considering the complex nature of traumatic sequelae, it is likely that causation is reciprocal (or circular) in that changes in one variable lead to changes in the other. Copi ng strategies may impact mental health problems following combat exposure, but mental health problems may also impact coping strategies. Further, t his study was also unable to control for every possible risk factor for poor adaptation following deploymen t For example, early childhood trauma, caregiver attachment, and pre trauma coping have been demonstrated to relate significantly to an individu trauma adaptation ( Brewin et al., 2000; Yehuda, 2004). Similarly, this study could not account for ev ery resilience factor that has been associated with posstrauma recovery Future research will be needed to integrate associated risk and resilience factors into a cumulative risk index to help identify people who are at greatest

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61 risk for developing mental health problems following deployments and to provide treatment. Another study limitation is the time span of information obtained about deployments To reduce participant burden and error in recall, the demographic questionnaire asked about deployments tha t occurred only in the last four years. However, given the conflicts in Afghanistan have been ongoing since 2001, more detailed information about the lengths and specific locations of deployments could have provided a measure of total time in combat theate rs, which has been found to relate to post deployment adaptation (Castro & McGurk, 2007). Although the battalion was demographically representative of the U.S. Marine Corps, the findings of this study may not generalize to other branches of the military It is especially important to keep in mind the vastly different duties of sailors and airmen, as compared to Marines A lthough experiences of soldiers in Iraq and Afghanistan may es exist in their deployment For example, soldiers tend to have 18 month deployment, whereas a typical Marine deployment is approximately 7 months. In addition, a study of Marines and soldiers experiencing combat found that the soldiers were slightly olde r, more likely to have children, more educated, and had longer deployments (Castro & McGurk, 2007) Such differences may impact how service members adjust. Thus, the study results are only generalizable to other Marines and service members with combat expe riences and demographic background similar to Marines. For this study, self report measures were carefully selected on the basis of their solid psychometric properties. Although a strength of this study was that it was

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62 unrelated to the Department of Defe nse, which may increase honesty in responses, self report measures remain subject to social desirability bias Furthermore, only one measure had been specifically validated for use with a population of veterans ( i.e., the Deployment Risk and Resilience Inv entory) Although we expect that the measures are psychometrically sound based on their previous psychometric studies, it is possible that the measures perform differently within a population of Marines when compared to the populations on which they were s tandardized. Such differences would have implications for conclusions that could be inferred from results Although a lack of psychometric data with Marines is less than ideal, this study provides an important first step for researchers interested in how t hese measures perform in a sample of Marines. Another study limitation related to measurement is the measurement of coping. Littleton and colleagues (2007) suggested that self report measures of coping strategies may confound coping behavior with distress (i.e., I give up trying to deal with it) and coping outcome Such a confound is related to circular causality stress impacts coping strategies, which also impact stress. Observational data such as physiological reactivity to a stressor or performance on a learned helplessness task, may provide additional helpful information in the measurement of Marines coping. Third party report, such as may also provide additional insight about Finally, asking about a specific stressor, rather than general coping, may help clarify the differences in situational versus dispositional coping. Finally, statistical limitations existed in this study. As noted, a confirmatory factor analysis could not be used because the da ta deviated significantly from normality. In addition, the sample was somewhat small to conduct a factor analysis. Hence, definitive

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63 conclusions about the factor structure of the Brief COPE cannot be made. Instead, the findings can be viewed as a beginni ng point for future research on the Brief COPE Other statistical limitations involve its cross sectional design, which prevents the ability to infer causality. Future Directions Although this study advances our understanding of the broad impact of combat operational deployment stress on service members, much more research is needed before we fully understand the intricacies of long term exposure to combat Because of the potential confound of retrospective self report of combat experiences with psychopath ology, future research should measure the amount of exposure while the service member is in theater a feat which may not be logistically simple Competing models of combat stress injuries implicate learning theory, cognitive theories, and biological mod els of stress (Nash & Baker, 2007) in understanding the impacts of combat stress on service members Research that integrates these three approaches may help elucidate the complementary nature of the models For example, by continuing to understand conditi oned fear responses, clinicians can better treat service members presenting with PTSD. Similarly, more standardized research on the shattered world views and cognitive distortions (Janoff Bulman, 1992) implicated in post combat psychological disorders wou ld aid in prevention and intervention efforts. Future research must also int e grate the biological effects of combat Recent years have seen an explosion of research in the biological impacts of stress, and a thorough review of the literature is beyond the scope of this study. However, b iological consequences of cumulative stress have been associated with both physical and psychological disorders (De Klout, Vreugdenhil, Oitzl, & Jols, 1998; H eim, Ehlert, &

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64 Hellhammer, 2000 ) Animal studies suggest that cort isol (stress hormone) induces damage to the hippocampus (Sapolsky, 2000), a brain structure implicated in memory and belief systems in humans and better understanding is needed to aid in treatment planning Furthermore, long term exposure to significant s tresso rs, and therefore cortisol, damage s the HPA (hypothalamic pituitary adrenal) axis, contributing to an (Nash & Baker, 2007) Intervention studies provide evidence that normalization of hypothalamic pituitary ad renal ( HPA) axis function co occurs with improved behavioral functioning (i.e., Felmingham, et al., 2007; Martin, Martin, Rai, Richardson, & Royall, 2001). Hence, additional research on physiological reactivity would help us further understand rel ations between cumulative biological effects of stress, coping behaviors, and problem behaviors, such as dysregulated affect, poor impulse control, and aggression. Because of the way that learning theories, cognitive theories, and biological responses to stress interact with each other future research should measure pre and post deployment coping to help disentangle coping as a risk factor for post deployment psychopathology from coping as an outcome of deployment. In other words, it is possible that the biological impacts of stress mediate the experience of combat and subsequent maladaptive coping behaviors. For example, denial and avoidance may be an adaptive response to extreme stress, yet such coping becomes maladaptive when individuals respond to rou tine stressors in the same way. Another very important research direction is the family environment as a function of repeated parental deployments. Again, longitudinal research would clarify the causal processes between family environment as a pre deploy ment risk factor and as a post

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65 deployment outcome. Furthermore, the use of a trauma informed developmental perspective would be ideal for examining the adaptation of military children to repeated, dangerous deployments and for investigating the presence of any post deployment mental health difficulties of the children and the non deployed spouse. Because many service members and families seek mental health services, it is important for clinicians to make decisions based on the best available research, consi stent with the principles of Evidence based Practice in Psychology (American Psychological Association, 2006). It is also important for clinicians to continue to incorporate their clinical expertise with literature when working with a military population especially because of the limited research with OIF/ OEF veterans Essentially, it is the iterative process between clinicians and researchers that would result in delivery of the highest quality services for military service members and their families.

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66 APPENDIX A CONFIDENTIAL DEMOGRA PHIC QUESTIONNAIRE Please complete all items Leave no blank spaces. Sex : _________ M ___________ F Age : ___________ Race : _____ Caucasian _____ Asian _____ African American _____ Native American _____ Hispanic _____ O ther (Specify _____________) What is your current marital status ? _____ married _____ separated _____ divorced _____ widowed _____ single How many years of education did you complete? __ _______ How many children do you have : _____________ Ages : _______________ Do they live at home with you? Y N MILITARY SERVICE INFORMATION Total Time Active Duty : ____________ years Rank (check one): ___ Enlisted ____ Officer Please list deployments in the last 4 years below. Use back of paper if more space is needed. Start date (mm/yy) Return date (mm/yy) Location(s) 1. 2. 3. 4. 5.

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67 Please specify monthly income in the household Include spouse/partner if applicable. Service Membe r Spouse/Partner $____________ Wages from Employment (before taxes) $_________________ $____________ Special Pay (e.g. jump, dive, demo, etc.) $_________________ $____________ Public Assistance $_________________ $____________ Social Security $____________ _____ $____________ Disability Compensation $_________________ $________ ____ Unemployment Compensation $__________ _______ $____________ Alimony $_________________ $____________ Child Support $_________________ $____________ Monies from Relatives $_________________ $____________ Interest from Investments $_________________ $____________ $____________ _____ Does any other adult in the household have an income? Y / N If yes, amount monthly: $______________

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70 King, L. A., King, D. W., Vogt, D. S., Knight, J., Samper, R. E. (2006). Deplo yment Risk and Resilience Inventory: A Collection of Measures for Studying Deployment Related Experiences of Military Personnel and Veterans. Military Psychology, 18, 89 120. Kulka, R. A., Schlenger, W. E., Fairbank, J. A. Hough, R. L., Jordan, B. K., Mar mar, C. R., and Weiss, D. S. (1990). Trauma and the Vietnam Generation: Report of Findings from the National Vietnam Veterans Readjustment Study Brunner/Mazel, New York. Linley, P.A., & Joseph, S. (2004). Postive change following trauma and adversity: A r eview. Journal of Traumatic Stress, 17, 11 21. Littleton, H. L., Horsley, S., John, S., & Nelson, D. V. (2007). Trauma coping strategies and psychological distress: A meta analysis. Journal of Traumatic Stress, 20, 977 988. Maguen, S., Vogt, D.S., King, L.A., King, D.W., & Litz, B.T. (2006). Posttraumatic growth among Gulf War I veterans: The predictive role of predeployment, deployment and postdeployment factors. Journal of Loss and Trauma, 11 373 388. Martin, S. D., Martin, E., Rai, S. S., Richardson, M. A., & Royall, R. (2001). Brain blood flow changes in depressed patients treated with interpersonal psychotherapy or venlafaxine hydrochloride: preliminary findings. Archives of General Psychiatry, 58 641 648. Mental Health Advisory Team (MHAT) V ( 20 08). Operation Iraqi Freedom 06 08: Iraq; Operation Enduring Freedom 8: Afghanistan Accessed April 10, 2008 http://www.armymedicine.army.mil/news/mhat/mhat_v/mhat v.cfm. Milliken, C. S., Auchterlonie, J.L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among Active and Reserve Component soldiers returning from the Iraq war. Journal of the American Medical Association 298 2141 2148. Mikulincer, M., & Solomon, Z. (1989). Causal attribution, coping strategies, and combat relat ed post traumatic stress disorder. European Journal of Personality, 3 269 284. Moore, B.A., & Reger, G. (2006) Historical and Contemporary Perspectives of Combat Stress and the Army Combat Stress Control Team In Figley & Nash (Eds.) Combat Stress Injur y Theory, Research, and Management. New York: Routledge.

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71 Moos, R. H., & Moos, B. S. (1994). Family environment scale (3rd ed.). Palo Alto, CA: Consulting Psychologists Press, Inc. Nash, W.P. & Baker, D.G. (2007). Competing and Complementary Models of Co mbat Stress Injury. In C. R. Figley & W. P. Nash (Eds.) Combat Stress Injury Theory, Research, and Management, pp 65 96. New York: Routledge Psychosocial stress Book Series. Punamki R., Salo, J., Komproe, I., Quota, S., El Masri, M., De Jong, J.T. V.M. ( 2 008 ). Dispositional and situational coping and mental health among Palestinian political ex prisoners Anxiety, Stress, & Coping, 21, 337 358. Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D. S., Shaw Hegwer, J., Thrailkill, A., Gu sman, F.D., Sheikh, J. I. (2004). The primary care PTSD screen (PC PTSD): development and operating characteristics. Primary Care Psychiatry, 9, 9 14. Ramchand, R., Karney, B.R., Osilla, K.C., Burns, R.M., & Calderone, L.B. (2008). Prevalence of PTSD, Dep ression and TBI Among Returning Service members In Tanielian, T., & Jaycox, L.H. (Eds.). Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Rand Corporation. Accessed April, 17, 2008. http:/ /rand.org/pubs/monographs/2008/RAND_MG720.pdf. Sadock, B.J., & Sadock, V.A. (2003). Lippincott Williams & Wilkins: Philadelphia, PA. Sapolsky, R.M. (2000). Glucocorticoids and hippocampal atrophy in neuropsychiat ric disorders. Archives of General Psychiatry, 57, 925 935. Schnurr, P. P., Rosenberg, S. D., & Friedman, M. J. (1993). Change in MMPI scores from college to adulthood as a function of military service. Journal of Abnormal Psychology, 102 288 296. Snyd processes (pp. 3 29). Oxford: Oxford University Press. Stein, A. L., Tarn, G. Q., Lund, L. M., Haji, U., Dashevsky, B. A., & Baker, D. G. (2005). Correlates for posttraumatic stress disorder in GulfWar veterans: A retrospective study of main and moderating effects. Journa l of Anxi ety Disorders, 19, 861 876. Tabachnick, B. G., and Fidell, L. S. (2007). Using Multivariate Statistics 5th ed. Boston: Allyn and Bacon.

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72 Te deschi, R., & Calhoun, L. (1996) The posttraumatic growth inventory: Measuring the positive legacy of trauma. Journal of Traumatic Stress, 9 (3), 455 472. Tedeschi, R.G., & Calho un, L.G. (2004). Target article: "Posttraumatic growth: Conceptual foundations and empirical evidence." Psychological Inquiry, 15 1 18. Tomich, P. L., & Helgeson, V. S (2004) Is finding something good in the bad always good? Benefit finding among women with breast cancer Health Psychology, 23, 16 23. Vogt, D. S., Proctor, S. P., King, D. W., King, L. A., & Vasterling, J.,J. (2008). Validation of scales from the deployment risk and resilience inventory in a sample of operation iraqi freedom veterans. A ssessment, 15 391 403. Waysman, M., Schwarzwald, J., & Solomon, Z. (2001). Hardiness: An examination of its relationship with positive and negative long term changes following trauma. Journal of Traumatic Stress, 14 531 548. Weathers, F., Litz, B., He rman, D., Huska, J., & Keane, T. (October 1993). The PTSD Checklist (PCL): Reliability, Validity, and Diagnostic Utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX. Wolfe, J., Keane T.M., Kaloupek, D.G., Mora, C.A., & Wine, P. (1993). Patterns of positive readjustment in Vietnam combat veterans, Journal of Traumatic Stress, 6 179 193. Yehuda, R. (2004). Risk and resilience in posttraumatic stess disorder. Journal of Clinical Psych iatry, 65 29 36.

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73 BIOGRAPHICAL SKETCH Corissa Callahan entered the doctoral training program in the Department of Clinical and Health Psychology at the University of Florida in August 2006. In the clinical child psychology track she was a graduate researc h assistant for Sheila Eyberg, Ph.D., on an NIMH funded study examining group versus individual parent child interaction therapy for preschoolers with attention deficit hyperactivity disorder In 2004, Corissa obtained a Bachelor of Science degree in human development from Cornell University, where she completed an honors thesis under the mentorship of Gary Evans, Ph.D After graduation from Cornell, Corissa worked at the University of California Los Angeles as a research assistant for Michelle Craske, Ph. D., in the Anxiety Disorders Behavioral Research Program There, she coordinated an NIMH funded study of risk factors for developing mood and anxiety disorders in late adolescence. Corissa plans to focus her research and clinical work on the psychological needs of United States (U.S.) military personnel and their families, a passion she has already begun to pursue She has given multiple un iversity presentations and four conference presentations on this topic, and in October 2008, she was funded by Division 19 of the American Psychological Association to attend the APA Presidential Task Force o n the Psychological Needs of U.S. Service Members and their Families as a student monitor She is completing her predoctoral psychology residency at the Medical Colleg e of Georgia / Charlie Norwood Veterans Administration Consortium, where she has begun integrating her clinical inte rests by working with children a nd families and a veteran population.