Psychological intervention program
In this studies, the primary psychological intervention programs comprised Cognitive Behavioral Therapy (CBT), Exposure Therapy (ET), and Mindfulness intervention. Additionally, there is a notable presence of treatments that leverage the internet, computer technology, and virtual reality, complemented by a range of innovative psychological therapies that are emerging in the field.
Cognitive Behavioral Therapy (Table 2) includes Cognitive Processing Therapy (CPT) [25–30], such as Group-CPT [26,27] and CPT combined with Transcranial Magnetic Stimulation (TMS) intervention [29]. Furthermore, there are also the Cognitive Therapy [17,31,32], Trauma Management Therapy (TMT) [33], Self-management Therapy (SMT) [34,35], and Angry Management Therapy (AMT) [36,37].
Exposure Therapies (Table 3) involve Prolonged Exposure Therapy (PET) [18,38–46], Written Exposure Therapy (WET) [12], Imagery Exposure Therapy (IET) [47], and Trauma-Focused group Therapy (TEGT) [48]. Notably, two studies were 3-arm RCTs [44,46], that not only compare the effectiveness of exposure therapy with that of the control group but also further explore its comparative effectiveness with mindfulness and virtual reality exposure interventions. Another 4-arm RCT [45] explored the contrasting effects between massively prolonged and spaced prolonged exposures.
Mindfulness intervention (Table 4) includes Mindfulness-Based Stress Reduction (MBSR) and Telehealth MBSR [49–51] Mindfulness-Based Cognitive Therapy (MBCT) [19,52], Transcendental meditation (TM) [46], Mantram Repetition Program (MRP) [53,54], and Acceptance and commitment therapy (ACT) [55]. Two of these 3-arm RCTs [46,56] compared Mindfulness intervention with web-based Mindfulness and PET, respectively.
New technology-based treatments (Table 5) encompass Internet and Computer-based Treatment (ICT) modalities [56–59] and Virtual-Reality Exposure therapy (VRET) utilizing real-time computer graphics and head-mounted visual displays for intervention [44,60–62]. And the other psychotherapy (Table 6) included Emotional Freedom Techniques (EFT) [63], which combines Eastern meridian acupressure and Western psychology’s energy therapy, Imagery Rescripting (IR) [64], Telephone Care Management (TCM) [65], among others.
The control groups in the literature included Waitlist, Treatment as Usual, Present Centered Therapy (PCT), Relaxation, Psychoeducational, Supportive Counseling, and other comparative studies between different psychotherapies.
Efficacy of psychotherapy
Efficacy of CBT
This paper includes six studies on Cognitive Processing Therapy interventions for PTSD in military personnel [25–30], encompassing 416 veterans and active-duty military personnel. CPT focuses on the interconnectedness of thoughts, feelings, behavior, and physical sensations, highlighting the significance and impact of traumatic experiences on individuals. Actively reviewing and processing traumatic events to address hindering mindsets is a crucial aspect of treatment. Widely used in the United States Departments of Defense and Veterans Affairs [66], CPT has proven beneficial in treating PTSD in military personnel when compared to control groups (waitlist/TAU/PCT) [25–28,30]. However, high dropout rates and a proportion of patients not benefiting significantly have prompted scholars to analyze CPT further.
Two studies [26,27] explored the efficacy of group-CPT interventions, revealing significant reductions in PTSD symptoms that persisted a year later. However, concerns arose as half of the patients still experienced distress. While group therapy may be beneficial, individual therapy was provided for those not showing improvement in group settings. Another study [29] examined the effectiveness of a comprehensive intervention (TMS + CPT) and found a more significant effect than CPT alone, with efficacy lasting up to six months post-treatment. This suggests a potential new psychological approach, though further clinical evidence is needed for validation.
Three studies focusing on the application of Cognitive Therapy interventions to address Post-Traumatic Stress Disorder (PTSD) within the military personnel population [17,31,32]. CT helps patients identify and change negative thoughts and beliefs, thus altering emotions and behaviors. A comparison of telehealth-CT [31] revealed no significant differences in clinical outcomes or dropout rates after three months. Another study [17] compared group-CT and group-PCT, showing no significant difference in treatment effectiveness, but a higher attendance rate in the group-CT, suggesting that group treatment may improve veteran participation in PTSD interventions. One study [32] evaluated the effectiveness of two CT interventions in veterans (Creating Change and Seeking Safety) and found no significant difference in their effectiveness on PTSD.
Beidel et al. conducted a comparative analysis of Trauma Management Therapy and Exposure Therapy (ET) [33], revealing that while ET proves effective in addressing the core symptoms of PTSD, TMT has shown a more pronounced enhancement in social participation and interpersonal functioning. TMT, a multicomponent behavioral treatment, involves individualized imaginal and in vivo exposure therapy followed by group social skills training.
The paper includes two randomized controlled trials [34,35] that utilize an app (PTSD Coach) for self-management interventions for PTSD. Self-Management Therapy is facilitated by a mobile application called PTSD Coach, which empowers patients to engage in self-directed management. This application is specifically designed to aid individuals suffering from Post-Traumatic Stress Disorder (PTSD) in enhancing their self-awareness and equipping them with the tools for more effective self-management [67]. Both studies indicate that there is no difference in symptoms and functioning among military personnel with PTSD after undergoing Self-management Therapy interventions with the assistance of the mobile PTSD Coach app. Despite the promising intervention outcomes of SMT in other populations [68], this review did not yield significant results regarding the efficacy of SMT interventions for military personnel suffering from Post-Traumatic Stress Disorder (PTSD).
Two randomized controlled trials investigated interventions with male veterans using Anger Management Treatment (AMT) vs. tele-AMT [36,37], highlighting the effectiveness and feasibility of remotely delivered cognitive-behavioral group therapy for PTSD-related anger issues. Tele-therapy demonstrated increased accessibility, reduced therapist workload, decreased treatment costs, and shortened practice time.
Efficacy of ET
The study incorporates ten randomized controlled trials focusing on Prolonged Exposure Therapy interventions for PTSD in veterans [18,38–46]. PET, a trauma-focused cognitive-behavioral therapy developed by Foa et al. [69], is standardized for PTSD and draws on exposure therapies for anxiety disorders.
In comparisons with control groups (PCT\TAU\Relaxation\Psychoeducation) [18,38–42], PET significantly reduced PTSD symptoms in veterans. The intervention targets included regular veterans [18,42], female veterans [38], active-duty military personnel [39,40], and veterans with PTSD who also suffer from substance use disorders [41]. It is also pointed out that the effectiveness of PET intervention for PTSD patients among active military personnel has been sustained up to the follow-up at four months [40]. However, for PTSD intervention among veterans, the effects of PET disappeared at the six-month follow-up [42], and the long-term benefits of the treatment still require further verification. Moreover, compared to the control group, the dropout rate among patients undergoing PET intervention for military PTSD was higher [18,38,40,41]. In comparison with tele-PET [43], which is comparable to PET in terms of intervention effectiveness and process satisfaction, tele-PET effectively intervenes in veterans with PTSD. In a 4-arm RCT with active-duty military patients, mass PET (10 sessions/2 weeks) demonstrated greater reduction in PTSD symptoms compared to controls (PCT) and was comparable to the intervention effect of spaced PET (10 sessions/8 weeks). Interestingly, there was no significant difference between spaced PET and controls (PCT) [45]. There were also two three-arm studies [44,46], one of which compared PET with Virtual Reality Exposure Therapy (VRET) [44]. The results were contrary to the study hypothesis, with no significant differences between the PET and VRET groups in terms of statistical significance, and VRET was not found to be superior to PET. At the 3-month and 6-month follow-up assessments, the PET group showed greater improvement in the reduction of PTSD symptoms compared to the VRET group. Another study compared PET with Transcendental Meditation [46], and in terms of reducing the severity of PTSD symptoms, TM was proven to be equally effective as PET. TM was significantly non-inferior to PET in the change in Clinician-Administered PTSD Scale (CAPS) scores from baseline to the 3-month follow-up test.
In 2018, Sloan et al. [12] conducted a comparative efficacy study of Written Exposure Therapy and Cognitive Processing Therapy for treating PTSD among veterans. Their findings indicated that WET was equally effective in mitigating PTSD’s symptomatology as CPT, even with a condensed treatment schedule. Furthermore, Imagery Exposure Therapy, which involves the systematic and repetitive exposure to traumatic imagery within a secure environment, demonstrated statistical significance in treating PTSD specifically in female veterans, as reported in another study [47]. However, a distinct investigation examining the efficacy of group trauma-focused exposure therapy for PTSD within a group of male Vietnam veterans [48] did not reveal substantial therapeutic advantages for this demographic.
Efficacy of mindfulness intervention
This study encompasses 10 papers on Mindfulness interventions for PTSD in military personnel [19,46,49–56], comprising a total sample of 617 military personnel. Mindfulness is often defined as the non-judgmental focusing of attention on the current experience, encouraging practitioners to experience the present moment with non-judgmental openness and acceptance.
Three randomized controlled trials focused on Mindfulness-Based Stress Reduction (MBSR) interventions for PTSD in veterans [49–51]. MBSR is a stress management model based on positive thinking, delivered through an 8-week series of classes [70]. In comparison to the control group (TAU) [49], service members showed improved mindfulness skills, but more evaluation is needed on its effects on PTSD. In another comparison with Group-PCT [50], MBSR demonstrated greater reductions in veterans with severe PTSD symptoms. A study by Niles et al. [51] conducted an 8-week telehealth-MBSR vs. tele-psychoeducation intervention, revealing clinically significant improvements in PTSD scores. However, these improvements were not maintained at the 6-week follow-up, suggesting that brief Mindfulness interventions may not have sufficient intensity to sustain effects on PTSD symptoms. Further investigation into the long-term therapeutic benefits of Mindfulness interventions is warranted.
Two papers on Mindfulness-Based Cognitive Therapy for PTSD in veterans [19,52] were included in the study. MBCT, a group-based program based on Mindfulness therapy, combines Mindfulness Meditation Technique with Cognitive Behavioral Therapy in an 8-week group treatment modality, it has become one of the most valued psychological treatment methods in recent years due to its portability and effectiveness [71]. Compared to the control group (TAU), the MBCT group significantly reduced veterans’ PTSD symptoms and alleviated symptoms of depression, anxiety, and stress, making it a promising psychotherapy for PTSD in military personnel. Further examination of the validity of the randomized controlled experimental design and identification of factors affecting acceptability and validity is needed.
This article also discusses the research on Mantram Repetition Program for PTSD in veterans [53,54]. MRP is a portable meditation-based intervention that teaches three tools for training attention and regulating emotion [72]. In comparison to the control group (TAU/PCT), the MRP group was more effective for chronic PTSD in military personnel. MRP does not focus on trauma, and veterans can seek this form of treatment. However, further empirical research is needed to validate its effectiveness.
In 2016, Lang et al. [55] explored the effectiveness of Acceptance and Commitment Therapy for PTSD in military personnel. ACT, considered a major psychotherapeutic theory alongside cognitive-behavioral therapy, requires further investigation to understand why it does not perform as well as expected in veteran samples [73].
An RCT on Transcendental Meditation noted that TM is no less effective than Prolonged Exposure Therapy as an intervention for PTSD in military personnel [46]. TM is a non-invasive, simple, and relaxing treatment involving sitting for 20 min twice a day with eyes closed, allowing ordinary thought processes to become calmer [74]. While TM may be an option for PTSD patients unwilling or unable to expose trauma, its therapeutic benefits need further validation.
Additionally, a 3-arm RCT study [56] noted that Internet-based Mindfulness interventions had a reduction in PTSD symptoms for military personnel compared to a waitlist control group, while face-to-face Mindfulness training had a greater benefit for military personnel with PTSD relative to online training.
Efficacy of new technology-based treatment
This study incorporates eight investigations into the effects of new technology-based treatment modalities on military PTSD interventions, comprising 4 studies on Internet and Computer-based treatment and 4 studies utilizing real-time computer graphics and a head-mounted visual display device for virtual reality exposure therapy. Virtual Reality Exposure Therapy proves to be more effective in activating or altering the structure of patients’ fear, facilitating repeated exposure to specific fearful stimuli for PTSD intervention. However, VRET environments need careful pre-designing, are highly individualized, and have limited applicability.
One study [60] separately intervened with VRET and PCT in veterans with PTSD, revealing a moderate effect size for VRET during a 6-month follow-up period. McLay et al. [61] demonstrated a 70% effective improvement with VRET compared to the control group (TAU) after a 10-week VRET intervention in PTSD patients. In a 3-arm RCT [44], both VRET and PET were more effective than the control group in intervening in PTSD in military personnel. However, at follow-up, the PET group showed greater effectiveness than the VRET group in active-duty military personnel. The research results of Beidel et al. [62] also support the use of VRET as an effective treatment for combat-related PTSD. Although limited by factors like small sample sizes, lack of blinding, and single therapists, the results support VRET as a safe and effective treatment for combat-related PTSD.
Two studies [57,58] demonstrated the significant effectiveness of ICT-based Cognitive Processing Therapy in intervening in veterans’ PTSD symptoms. Litz et al. [59] indicated that ICT-based Cognitive Behavioral Therapy was more effective than the control group (supportive counseling) in intervening in PTSD symptoms and overall depression levels in active-duty military personnel, with sustained symptom improvement at the 6-month follow-up. In another 3-arm RCT [56], both ICT-based Mindfulness intervention and face-to-face Mindfulness intervention showed high clinical significance, with face-to-face Mindfulness intervention demonstrating better outcomes compared to the control group. Preliminary data suggest that psychotherapy utilizing ICT is equally effective as traditional psychotherapy and can provide more convenient treatment, especially for PTSD patients in the veteran population facing high levels of pathogenic stigma, distant geographic locations, and challenging economic circumstances.
Efficacy of other psychotherapy
PTSD in the military population, especially during war, is a complex and challenging disorder to treat. Experts and scholars are exploring more psychotherapeutic treatments for the military PTSD population (Table 6). Examples include Emotional Freedom Techniques, based on the traditional Chinese medical system [63], is a brief form of exposure therapy that includes both physical and cognitive components. It involves tapping on acupuncture points with the fingers in a way that encourages individuals to remember or verbalize somatic symptoms or negative memories. This process aids in releasing life stress and physical problems from the body’s energy system, facilitating a return to a state of physical and mental well-being. Another therapeutic approach is Imagery Rehearsal (IR) [64], which controls the reconstruction of situations by controlling imagery. In the first phase, the entire process of exposure and restructuring is recorded using a tape recorder as homework for the patient to repeatedly listen to. In the second phase, imagery exercises are focused on altering the pathogenic patterns. Furthermore, telephone care management [65] represents an intervention method that employs a telephonic therapy approach to provide remote support and guidance.
Accelerated Resolution Therapy (ART) is an innovative psychological treatment approach that assists patients in processing and reshaping their psychological trauma by re-describing painful events and utilizing metaphors as key elements in the therapeutic process. During ART sessions, therapists guide patients to identify and re-experience the negative memories and images that lead to Post-Traumatic Stress Disorder. Subsequently, positive imagery and metaphors are employed to help patients reconstruct these memories in a healthier and more constructive manner [75]. As early as 2013, Kip et al. [76] explored its effectiveness in intervening PTSD within military populations, but since then, there have been few further inquiries. And in 2019, Kehle-Forbes et al. [77] explored the efficacy of integrated Motivational Enhancement Therapy (MET) and PET interventions. These therapies use a series of question-and-answer exchanges and reflective techniques to assist patients in identifying and modifying their negative behaviors and perceptions. The goal of these interventions is to enhance patients’ motivation and autonomy, thereby promoting behavioral change. Additionally, Harris et al. [78] explored the impact of Building Spiritual Strength (BSS) on PTSD in veterans in 2018. BSS is an 8-week group therapy approach that integrates spiritual elements into the treatment process, aimed at alleviating symptoms of PTSD. It facilitates a resolution of spiritual distress and helps individuals develop a new, more adaptive, and holistic understanding of their traumatic experiences. This method views spiritual health as an essential component of overall well-being, and through group support and spiritual practices, it can enhance an individual’s inner strength and resilience [79]. Lastly, Jain et al. [80] explored the Skills Training in Affective and Interpersonal Regulation (STAIR) intervention in 2020. STAIR is a comprehensive approach that combines 8–12 sessions of trauma-focused work, which are based on skill-building exercises tailored to enhance emotional and interpersonal regulation. This method contributes to the ongoing efforts to develop effective treatment strategies that address the complex needs of individuals dealing with PTSD.
Psychotherapeutic approaches for treating Post-Traumatic Stress Disorder in military personnel are continuously evolving and being refined through ongoing research efforts. However, due to the limited number of studies and small sample sizes, there is still a significant need for further exploration and investigation in this field.