Data Analysis of LGBT Veteran relationship
quality in a study of family-supported PTSD
treatment: Research challenges and
implications for clinical practice
Military Mental Health Initiative – 3rd Annual Spring Conference
133rd Airlift Wing, St. Paul, MN
KIMBERLY STEWART, MA
CENTER FOR CHRONIC DISEASE OUTCOMES
RESEARCH (CCDOR)
MINNEAPOLIS VA HEALTH CARE SYSTEM
LAURA MEIS, PHD
CENTER FOR CHRONIC DISEASE OUTCOMES
RESEARCH (CCDOR)
MINNEAPOLIS VA HEALTH CARE SYSTEM
UNIVERSITY OF MINNESOTA, DEPARTMENT OF
MEDICINE
ACKNOWLEDGEMENTS
MINNEAPOLIS
PHOENIX
Ann Bangerter
Lori Burmeister
Eric Baltutis
Karen Kattar
Emily Hagel Campbell
Rebecca Sanback
Andrea Cutting
Kimberly Henriksen
Christopher Erbes
Emily Erickson
PALO ALTO
Siamak Noorbaloochi
Afsoon Eftekhari
Grace Polusny
Lee Kravetz
Melissa Polusny
Michele Spoont
Craig Rosen
Tina Velasquez
Numerous other volunteers…
CHARLESTON
Peter Tuerk
Martina Radic
US DEPARTMENT OF DEFENSE
W81XWH-12-1-0619_Basic Award
Log# PT110176
DEPARTMENT OF VETERANS
AFFAIRS
RRP12-229
HSR&D CDA 10-035
Work supported with CCDOR
resources and use of facilities at the
Minneapolis VAHCS
Disclaimer: Findings and conclusions in this document are those of the authors and do
not represent the views of the Department of Veterans Affairs or the United States
government. No investigators have affiliations or financial involvement that conflict
with material presented.
WORKSHOP OBJECTIVES
•Provide an overview of Project HomeFront
•Review relevant literature
•Discuss analysis of LGBT sample
•Discuss implications for research & practice
STUDY BACKGROUND
• Trauma-focused psychotherapies have a larger and
stronger evidence base than any other psychological
treatment for PTSD (IOM, 2007)
• Keeping Veterans engaged in these treatments can be
difficult: 1 in 3 will drop out (Chard, 2010; Kehle-Forbes, 2015; Schnurr,
2007; Suris, 2013)
FAMILIES PROVIDE A NATURAL RESOURCE
• Most behavioral change theories consider social environments, yet social
influences are under-investigated adherence predictors (Meis, 2010; Sayer, 2009; Spoont,
2014)
• When family and friends encourage Veterans with PTSD to seek help, the odds
of initiating mental health care increase by 50% (Spoont, 2014)
• DoD, VA, NIMH, APA, IOM, and Congressional legislation have all called for
routine family involvement in Veterans’ PTSD care
• No evidence-based method for formally involving families in PE/CPT
FAMILIES PROVIDE A NATURAL RESOURCE –
CONT’D
• LONG TERM OBJECTIVE:
• Build an adherence intervention that mobilizes Veterans’
families to help Veterans get the most out of treatment
• SHORT TERM OBJECTIVE:
• Identify when and how to formally include family
members in Prolonged Exposure (PE) and Cognitive
Processing Therapy (CPT)
RESEARCH AIMS
1. Determine if family factors
predict adherence
2. Evaluate a family-systems
model of predictors of
treatment adherence
3. Obtain an in-depth
understanding of the
experiences of patients who
adhere less to treatment
Quality of Relationship
1) Relationship Distress
2) Social Support
3) Burden
Greater
Treatment
Adherence
DESIGN AND METHODOLOGY
• Longitudinal, observational study of former service members
naturally receiving PE/CPT across four VA hospitals
• QUANTITATIVE:
• Mailed surveys at treatment initiation (Time 1) and termination (Time 2)
of Veterans and a nominated support person
• QUALITATIVE:
• Semi-structured, open-ended, interviews with
• Veterans with poor adherence
• Their nominated support persons
• Their PE/CPT providers
• To identify unmeasured factors influencing Veterans with poor
adherence and the role of support persons in their treatment
MIXED METHOD EMBEDDED DESIGN
TIME 1 SURVEYS
TIME 2 SURVEYS
Support
Person
Veteran
Veteran
INTERVIEWS
Support
Person
Therapist
Veteran
PE/CPT
Initiation
Support
Person
Termination
VA HOSPITAL RECORDS
Veteran
QUANTITATIVE
QUALITATIVE
CASE VIGNETTE #1 - VERN
CASE VIGNETTE #2 - SHIRLEY
APPROACHING THE ANALYSIS
• Sexual minority Veterans have unique mental health characteristics
(Cochran et al, 2013)
• Life after Don’t Ask, Don’t Tell (DADT) (Goldbach & Castro, 2016)
• Minority stress model (Meyer, 2003)
• Application to gender minorities (Hendricks & Testa, 2012)
• Systemic application at the dyad level (Rostosky & Riggle, 2017)
UNIQUE FACTORS REGARDING LGBT VETERANS
• Don’t Ask, Don’t Tell (DADT) was not repealed until September
20, 2011; this repeal does not include transgender persons
Created a culture of concealment
Mistrust of providers
• Added costs of seeking mental health services outside the VA,
combined with a distrust of providers, are factors for clinicians
to consider when working with LGBT Veterans with PTSD and
their loved ones
THEORETICAL ORIENTATION – MINORITY STRESS MODEL
• New advancements of the minority stress model (Hendricks & Testa,
2012; Rostosky & Riggle, 2017)
• LGBT civilians face societal persecution and chronic
victimization, which leads to significant distress. (Goldbach &
Castro, 2016)
• LGB Veterans are more likely to screen positive for PTSD,
depression, and alcohol use than non-LGB Veterans (Cochran
et al, 2013)
• Concealment of sexual identity has been linked to higher
rates of depression and PTSD (Cochran et al, 2013)
RESEARCH QUESTION
• Research question: Does self-identification as LGBT
negatively influence Veteran family involvement,
relationship quality, and/or adherence to PTSD treatment?
• Independent variable: Veteran self-identification as a
LGBT (sort of…more on that in a minute!)
• Dependent variables: (1) SP nomination rates of LGBT
Veterans; (2) Responses to measures of relationship
quality; and, (3) LGBT Veteran adherence to PTSD
treatment in our study, relative to non-LGBT Veteran
adherence
LGBT SAMPLE WITHIN HOMEFRONT
• TOTAL (N = 430)
• LGBT (N = 29)
Non-LGBT = 93.7
LGBT = 6.3
SUMMING UP THE DATA
• We ran basic correlations followed by a chi-square
analysis on potentially significant variables to analyze the
relationship between them
• For the LGBT subset, significance was found on only one
item related to relationship quality:
• 69.3% of non-LGBT Veterans named their significant other as the person
with whom they are closest, only 50% of the LGBT sample reported the
same (𝒙2 = 4.5, p < .05)
• While this single finding is not enough to publish, it is
important to consider
POTENTIAL IMPLICATIONS
• Possible reasons for LGBT Vets not reporting their significant other
as the closest person in their lives:
• Internalized homophobia
• Minority stress – external pressures compound negative mental
health outcomes and create distance in relationship
• Queer kinship networks – LGBT people often create strong
social groups born out of rejection from family, community, etc.
CONSIDERATIONS FOR RESEARCH
• Measure items are categorical in nature, whereas the LGBT
population relates more fluidly to some items—identity does not fit
into a category.
• HomeFront’s sample of LGBT individuals changed after controlling
for both gender and sexuality (n=29 to n=28).
• The LGBT acronym itself is notoriously problematic
• Methodology needs to be addressed, so we can better understand
the differences & similarities of minority populations compared to
the majority, and so we can properly address intersecting identities
CONSIDERATIONS FOR CLINICAL PRACTICE
For the LGBT Veteran with PTSD:
EBTs are important, and they work
Don’t assume special accommodations need to be made
Exploration of supportive others
For the family:
Consider burden
EBTs also exist for families (CBCT for PTSD (Monson, 2012) - Consists of three phases, and a total
of 15 sessions)
Help is on the way!
Important dyadic research is ongoing at the VA
CONCLUSIONS
• Veterans are more likely to complete a trauma focused
treatment for PTSD when they:
Are encouraged to face things that make them anxious or
uncomfortable
Believe their closest someone finds the treatment credible
Talk to others about treatment
• LGBT Veterans face unique individual and relational
factors which make all of the above indicators of PTSD
treatment adherence less likely
QUESTIONS
MIXED METHOD EMBEDDED DESIGN
TIME 1 SURVEYS
Veteran
N = 548
(61.0%)
TIME 2 SURVEYS
Support
Person
N = 298
(67.1%
Nominated)
Veteran
N = 352
(65.9%)
INTERVIEWS
Support
Person
N = 230
(79.1%)
Veteran
N = 33
(82.1%)
PE/CPT
Initiation
VA HOSPITAL RECORDS
Veteran
N = 548
Therapist
N = 32
Termination
Support
Person
N = 21
PROJECT HOMEFRONT MEASURES
• Homework Compliance Items
• The Credibility/Expectancy Questionnaire
• The New General Self-Efficacy Scale, adapted to be specific to PTSD treatment adherence.
• University of Rhode Island Change Assessment—Trauma scale
• The Perceived Stigma and Barriers to Care for Psychological Problems
• Stressors and Obstacles that Compete with Treatment scale from the Barriers to Treatment
•
•
•
•
•
•
•
•
•
Participation Scale, adapted for adults
Working Alliance Inventory – Short Form
Subjective Norms scale of the Adherence Determinants Questionnaire
Avoidance-coping strategies of the Coping Response Inventory.
The Hostility Scale from the Buss-Perry Aggression Questionnaire, adapted to refer specifically to
the hostility towards the veteran
Family Attitude Scale
Family Relationship Index from the Family Environment Scale
Tangible Support Scale of the Interpersonal Support Evaluation List
Emotional Support scale from the Multidimensional Scale of Perceived Social Support
PTSD Checklist