Stories - Blogs

By Mitch Duque   

Remote-piloted drone technology has quickly become one of the most prominent staples in the modern landscape of large-scale combat operations. Given the prominence of this technology to current and future warfighters, members of the Research Special Interest Group (SIG) at the Consortium for Defense Psychology (CDP) decided to focus its monthly journal club on the mental health implications of drone warfare for remotely piloted aircraft (RPA) personnel. The article selected for review was a narrative review titled "Remote Warfare with Intimate Consequences: Psychological Stress in Service Member and Veteran Remotely-Piloted Aircraft (RPA) Personnel" by Norrholm and colleagues (2023). SIG members read the article and discussed the possible mental health implications of drone warfare for RPA crew members using this technology in their day-to-day lives.

The RPA career field has a variety of unique qualities that can potentially lead to adverse psychological effects. One of the most notable is the cognitive dissonance crew members can experience as a result of their geographical distance from their targets when conducting military operations. Despite being physically distant from their area of operation, RPA crew members experience disproportionate levels of intimacy with their targets based on the immersive nature of their weapon systems. This juxtaposition of physical distance and emotional proximity can lead warfighters serving in RPA crews to experience emotional turmoil regarding their role in conflict, particularly when executing lethal strikes on individuals that they’ve formed a remote bond with through days, months, or even years of surveillance. There can also be ‘psychological whiplash’ that occurs, with operations moving quickly from surveillance activities to kinetic action to after action-assessment, all in the span of minutes. This rapid shift is one of the central psychological challenges of RPA work.

Another dynamic worth noting in this population is the domestic nature of their work. Individuals working on RPA crews frequently execute their missions in garrison, meaning that they work in shifts and maintain personal lives when not on duty. This makes it uniquely possible for RPA crew members to play pivotal roles in potentially lethal operations akin to “mini-deployments,” mere hours before driving home from work to participate in their personal, family, and social lives. Per the article, it can be beneficial for conventionally deployed service members to have a period of decompression prior to returning home following combat operations. However, crews are not likely given adequate opportunities to decompress following this harrowing work. In other words, RPA personnel may be required to transition almost immediately from combat-related activities back to their everyday lives.

Additionally, the article identifies stigma surrounding RPA crews in the military, with crew members frequently viewed as “less than” or “inferior” for being assigned to remote aircraft instead of serving in a manned fighter or bomber aircraft. Coupled with long hours and shift work schedules that disrupt natural sleeping patterns, service members operating RPA are at a disproportionately high risk for adverse mental health outcomes and can experience symptoms of post-traumatic stress disorder and moral injury.

After learning about RPA crews and the unique challenges associated with their career field, the CDP research team discussed several important considerations for working with this population. The team was particularly interested in understanding the emotional dynamics within RPA units, especially those related to moral injury. Of particular interest was how traditional concepts of honor and military service may be difficult to reconcile for personnel who conduct remote warfare. Discussions surrounding responsibility for the deaths of enemy combatants were especially noteworthy, as many RPA crew members frequently report feeling guilt or shame for the way in which they conduct military operations, per the article.

The team discussed a handful of clinical considerations when treating these individuals. A clinical member of the team raised the possibility that psychotherapy could focus largely on stigma reduction and validation, given the isolating and invalidating nature of the environment surrounding this career field. The team also raised that cognitive-focused, evidence-based psychotherapy for PTSD, such as Cognitive Processing Therapy, may be effective in addressing experiences of guilt. Clinicians can assess and treat standard PTSD symptoms, but may also consider working with the client to target interventions toward acceptance and understanding given possible experiences of guilt, shame, stigma, and moral conflict unique to RPA service.

The unique operational environment of RPA personnel presents significant psychological challenges, characterized by a difficult juxtaposition of physical distance and emotional intimacy, compounded by the domestic setting of their work, irregular schedules, and persistent stigma. Future clinical approaches can address the prevalence of traumatic stress, moral injury, guilt, and shame in this population by prioritizing stigma reduction and employing therapies that aim to address guilt while promoting acceptance and self-understanding.

Ultimately, remote warfare may be physically distant, but it is not necessarily psychologically distant. RPA personnel may benefit from clinical approaches that recognize both the traumatic and moral dimensions of their work.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of War.

Mitch Duque is a previous Research Assistant and HJF employee collaborating with the Consortium for Deployment Psychology, DoW and Uniformed Service Contractor

12.9%

The percentage "of adults age 18 and older used sleep aids most days or every day in the past 30 days to help them fall or stay asleep," according to a statistical brief published by the National Center for Health Statistics -- Use of Sleep Aids Among Adults Age 18 and Older: United States, 2024.

Women were more likely than men to use any sleep aids (14.8% compared with 10.8%), prescription medications (6.4% compared with 3.9%), or OTC medications or supplements (7.0% compared with 4.3%) most days or every day in the past 30 days to help them fall or stay asleep (Table). No significant difference was seen between the percentage of men and women who used marijuana or CBD products as sleep aids.

The percentage of adults using any sleep aids most days or every day in the past 30 days increased with age, from 10.5% of adults ages 18–34 to 15.8% of adults 65 and older (Table). Use of prescription medications to help fall or stay asleep increased with age (from 2.2% for adults ages 18–34 to 8.8% for adults 65 and older) as did the use of OTC medications or supplements (from 3.9% for adults ages 18–34 to 7.6% for adults 65 and older). However, the percentage of adults using marijuana or CBD products as sleep aids declined with age (from 5.5% of adults ages 18–34 to 1.7% of adults 65 and older).

By Kristian Krslovic   

Most people have experienced a poor night's sleep at some point in their lives, but experiences of insomnia go beyond the occasional restless night. It involves frequently waking up, having trouble falling back asleep, and feeling unrested after a night’s sleep, which in turn can leave a person feeling tired, fatigued, and irritable during the day. 

While insomnia affects millions of people, it is especially common among veterans and active-duty service members, with as many as a quarter of service members and veterans reporting insomnia symptoms 1. Military-specific factors, including frequent deployments, irregular sleep schedules, and prolonged exposure to high-stress situations, can make healthy sleep difficult to maintain 1.

The most supported frontline treatment for insomnia is Cognitive Behavioral Therapy for Insomnia (CBT-I).2 CBT-I restores healthy sleep by shaping unhelpful thoughts surrounding sleeplessness, coupled with behavioral interventions such as stimulus control (e.g., reassociating one’s bed with sleep) to collectively improve sleep efficiency. 3 For many service members and veterans, however, insomnia does not occur on its own: it often overlaps with conditions like post-traumatic stress disorder (PTSD), depression, anxiety or nightmares. 2 Living with multiple conditions at once can be challenging for service members or veterans as they might not have the time, resources, or support to pursue separate treatments for each disorder. This raises an important question: Could CBT-I support symptoms of these co-morbid conditions in addition to improving insomnia symptoms?

A growing body of research does suggest that CBT-I may help common psychological comorbidities. In one study of veterans experiencing both insomnia and PTSD, participants who received a CBT-I intervention showed improvements in PTSD symptoms, with effect sizes ranging from medium to large. 4 The same study found that nightmare frequency decreased in participants who received a sleep-focused intervention. In another study with veterans deployed during Operation Enduring Freedom and Operation Iraqi Freedom, participants who received CBT-I treatment had reduced PTSD symptom severity compared to veteran participants who did
not receive CBT-I. 5 Lastly, CBT-I also showed significant improvements in depression and anxiety scores in a sample of U.S. Army Soldiers diagnosed with insomnia. 6

Taken together, this research suggests that CBT-I may offer benefits beyond improving sleep. It is not a replacement for treatments for PTSD, depression, or anxiety, but it may be a helpful place to start, particularly for veterans who are managing several concerns at once. Learning CBT-I skills could also give service members practical tools to use throughout their careers and after leaving the military.

Leveraging technology to increase access to CBT-I

As mentioned earlier, interventions like CBT-I can be difficult for individuals to access. Modern technology can help increase access to and engagement in insomnia-focused care. Right now there are sleep apps that create a tailored user experience by tracking sleep habits and designing customized sleep plans aimed at improving sleep and combating insomnia symptoms, such as Insomnia Coach. 7 Although Insomnia Coach is not meant to replace professional care, it is one example of how an app can provide service members and veterans with important tools, such as psychoeducation and self-care strategies, as a first step towards addressing insomnia.

Additionally, researchers at CDP led by Dr. Tim Rogers, and collaborating institutions nationwide are evaluating the effectiveness of Insomnia Coach with brief check-ins versus group CBT-I, delivered by either clinicians or behavioral health technicians, on insomnia symptoms, alongside secondary outcomes of depression, anxiety, and PTSD. By bridging the gap between innovative technology and evidence-based sleep care, service members can be equipped with tools and support to restore their sleep, build resilience, and strengthen overall mission readiness.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of War.

Kristian Krslovic joined the Consortium for Defense Psychology (CDP) as a Research Assistant in October 2025. He received a Bachelor of Arts degree in Psychology from Bard College in 2023. At Bard, Kristian was an undergraduate research assistant in the Affective Science Lab identifying factors that contribute to mood disorders.

References:
1. Hughes, J. M., Ulmer, C. S., Gierisch, J. M., Nicole Hastings, S., & Howard, M. O.
(2018a). Insomnia in United States military veterans: An integrated theoretical model.
Clinical Psychology Review, 59, 118-125. https://doi.org/10.1016/j.cpr.2017.11.005

2. Bramoweth, A. D., & Germain, A. (2013). Deployment-related insomnia in military
personnel and Veterans. Current Psychiatry Reports, 15(10).
https://doi.org/10.1007/s11920-013-0401-4

3. Walker, J., Muench, A., Perlis, M. L., & Vargas, I. (2022). Cognitive behavioral therapy
for insomnia (CBT-I): A Primer. Clinical Psychology and Special Education, 11(2),
123–137. https://doi.org/10.17759/cpse.2022110208

4. Ulmer, C. S., Edinger, J. D., & Calhoun, P. S. (2011). A multi-component
cognitive-behavioral intervention for Sleep disturbance in veterans with PTSD: A pilot
study. Journal of Clinical Sleep Medicine, 7(1), 57–68.
https://doi.org/10.5664/jcsm.28042

5. Margolies, S. O., Rybarczyk, B., Vrana, S. R., Leszczyszyn, D. J., & Lynch, J. (2013).
Efficacy of a cognitive‐behavioral treatment for insomnia and nightmares in Afghanistan
and Iraq veterans with PTSD. Journal of Clinical Psychology, 69(10), 1026–1042.
https://doi.org/10.1002/jclp.21970

6. Taylor, D. J., Peterson, A. L., Pruiksma, K. E., Hale, W. J., Young-McCaughan, S.,
Wilkerson, A., Nicholson, K., Litz, B. T., Dondanville, K. A., Roache, J. D., Borah, E. V.,
Brundige, A., & Mintz, J. (2018). Impact of cognitive behavioral therapy for insomnia
disorder on sleep and comorbid symptoms in military personnel: A randomized clinical
trial. Sleep, 41(6). https://doi.org/10.1093/sleep/zsy069

7. Insomnia coach - PTSD: National Center for PTSD. (n.d.).
https://www.ptsd.va.gov/appvid/mobile/insomnia_coach.asp

9.4 million
 

The number of beneficiaries under the care of the Department of Defense (DOD) military health system, according to a report from the Government Accountability Office (GAO) -- National Security Snapshot: DOD's Military Health System Reforms and Challenges

This care is delivered through over 700 medical facilities with more than 100,000 military, civilian, and contractor employees, and a vast network of private sector health care providers. DOD estimates that it will spend over $72.5 billion for the military health system in fiscal year 2027.

The weekly Research Update contains the latest news, journal articles, and useful links from around the web. Some of this week's topics include:

● Group-Based Suicide Safety Planning and Skills Training for Veterans With High Suicide Risk: A Randomized Clinical Trial.
● An Exploratory Assessment of Service Dog Training for the Treatment of Military Members with Posttraumatic Stress: A Pre-post Interventional Trial.
● Cognitive Decline and Household Firearm Storage Among Older Adults.
● Association between state-level kratom regulations and poison center-reported severe medical outcomes and healthcare use: A United States national analysis.
● Changes in Dietary Supplement Use Among Children and Adolescents in the United States, 2015–2016 to 2021–2023.

CLICK HERE TO READ THE 23 JULY 2026 RESEARCH UPDATE

By Dr. Andrew Devendorf

If we each had a choice, none of us would choose to develop a mental health difficulty. None of us would choose to feel the devastation of depression, the tribulations of trauma, or the suffering of being so hopeless, trapped, and alone that we want to end our own lives. We label these experiences as difficulties for good reason.

The thing is—it’s not a choice to endure these challenges. Most people in their lifetimes will experience a mental health difficulty. For some, these experiences can be easily managed; for others, they can dramatically alter their lives. Zooming out, almost everyone knows, or will know, a loved one affected by a mental health condition. Although these experiences are normal, many people with lived experience of depression, posttraumatic stress disorder (PTSD), and suicidal thoughts continue to feel immense stigma.

I have seen this stigma play out in my clinical work, my research, and my own life. As a former psychologist at the Department of Veteran Affairs, I worked with many Veterans who expressed shame about seeking therapy. I’d hear things like, “My PTSD has made me a shell of my former self,” and, “I’m weak...I can’t believe I need to seek help.” Even after a person improves or recovers, they may feel reluctant to share their experience for fears of being negatively judged or mischaracterized. These fears are not without foundation. Research shows that acceptance of mental health treatment has improved over the years, yet the public continues to have negative attitudes about mental illness. Some members of the public still see depression as “laziness,” PTSD as “dangerousness,” or suicidal thoughts as a “weakness.”

What perpetuates this stigma? And how can we reduce it?

The Deficits-view
There are many drivers of stigma. In this post, I want to focus on a systemic factor: that our American society takes a predominantly deficits-view of mental health difficulties—we see them only as something wrong with the person. This deficits-view, in my perspective, stems from how we define mental illness.

In the United States, we use the Diagnostic and Statistical Manual (DSM) of Mental Disorders to diagnosis mental health conditions. There is much utility of the DSM. It was developed to establish a consensus for diagnoses and help patients receive insurance reimbursement via diagnostic codes. It has thus helped legitimize psychopathology that may otherwise be considered “invisible” or “just in someone’s head.” It does this through giving clinicians a common language to identify and treat patterns of mental, behavioral, and emotional “symptoms.”

But an unintended design flaw of the DSM is that it takes a purely deficits-view of mental health experiences. In other words, the DSM is designed to characterize disorders without consideration of the potential value in specific mental health experiences. For instance, although sadness can be a sign that something is wrong in someone’s life (as a way to motivate making a change), the DSM does not—and was not designed to—list the potential value in this emotional experience.

This deficits-view is likely a big reason why clinicians, patients, and the public at-large will, by default, have only negative associations with depression, PTSD, and other diagnoses. Diagnostic labels have helped patients receive compassion, yes. But also, these labels carry the weight of being primarily defined by dysfunction, impairment, and distress. Thus, it makes sense why there is public acceptance about the treatment of mental illness but continued stigma toward people with lived experience.

A Strengths-based View
While we do not need to dismantle the DSM, I believe we can reduce stigma by being open- minded to the strengths, value, and assets that accompany mental health difficulties. I want to be clear—we should not discount the distress that comes with psychopathology. But, among people with these experiences, we can extract the “silver linings” of the experience to improve coping and self-acceptance.

There is a quote by Dr. Victor Frankl, a psychiatrist who documented his experiences in a concentration camp, that comes to mind. In his memoir, A Man’s Search for Meaning, Frankl advocates that we seek to find meaning in our suffering:

“We must never forget that we may also find meaning in life even when confronted with a hopeless situation, when facing a fate that cannot be changed. For what then matters is to bear witness to the uniquely human potential at its best, which is to transform a personal tragedy into triumph, to turn one's predicament into a human achievement.” (Frankl, 1985, p. 112).

Here, Frankl is presenting a strengths-based view of tragedy, which we can apply to mental health difficulties. In my own practice, I’ve heard many patients reflect on how their depression, PTSD, or suicidal thoughts have helped them grow.

I list some strengths-based themes below and give an example.

• Leveraging emotions as a signal: “My depression helps me determine if something is going wrong in my life.”
• Self-awareness and insight: “Battling suicidal thoughts, it’s made me grapple with what’s really important, and how I want to spend my time.”
• Compassion for others: “My trauma has given me perspective about what it’s like to go through hell.”
• Resilience and self-confidence: “Overcoming my dark times taught me that I can overcome just about anything.”
• Meaning and purpose: “Having gone through this, my new mission is to get other people the help they need.”

Enhancing Clinical Practice
As clinicians, we can embed this strengths-based view into our practice to help reduce feelings of shame, brokenness, and worthlessness. Of course, we should not enforce a strengths-based view onto our patients. But, we can help clients explore the potential value and meaning from their suffering with focused reflections and open-ended questions.

Here are some reflections.

• Depression: “You’ve been through a lot, and it shows your resilience.”
• PTSD: “From what I’m hearing, your trauma has given you new perspective.”
• Suicide attempt: “You know what extreme pain feels like, and it’s given you compassion for others.”

And here are some questions.

• “I recognize you’ve been through a lot. And, I’m wondering, what have you learned from your experience?”
• “How has your experience made you grow?”
• “Has going through your depression changed your perspective on anything? If so, how?”

By adopting a strengths-based view of lived experience, I believe we are better positioned to empower our clients and reduce stigma.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of War.

Andrew Devendorf, Ph.D., is a Military Behavioral Health Psychologist with the Henry M. Jackson Foundation for the Advancement of Military Medicine. He serves as a subject matter expert in suicide prevention for the VA SAFEGUARD project.

References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders, Text Revision (DSM-5-TRTM). American Psychiatric Pub.

Devendorf, A. R. (2022). Is “me-search” a kiss of death in mental health research?. Psychological Services, 19(1), 49..

Frankl, V. E. (1985). Man's search for meaning. Simon and Schuster. Gruber, J., Lyman, C., Plaisance, C., & Rottenberg, J. (2026). Silver linings in psychological disorders: an agenda for research and social change. Current Directions in Psychological Science, 35(1), 49-55..

McGrath, J. J., Al-Hamzawi, A., Alonso, J., Altwaijri, Y., Andrade, L. H., Bromet, E. J., ... & Zaslavsky, A. M. (2023). Age of onset and cumulative risk of mental disorders: a cross-national analysis of population surveys from 29 countries. The Lancet Psychiatry, 10(9), 668-681..

Rüsch, N., Angermeyer, M. C., & Corrigan, P. W. (2005). Mental illness stigma: Concepts, consequences, and initiatives to reduce stigma. European Psychiatry, 20(8), 529-539..

Schomerus, G., Schindler, S., Sander, C., Baumann, E., & Angermeyer, M. C. (2022). Changes in mental illness stigma over 30 years–Improvement, persistence, or deterioration?. European Psychiatry, 65(1), e78..

Schroder, H. S., Devendorf, A., & Zikmund-Fisher, B. J. (2023). Framing depression as a functional signal, not a disease: rationale and initial randomized controlled trial. Social Science & Medicine, 328, 115995.

8.6%

The percentage of Ukrainians who "had probable PTSD three years into the war" following Russia's full-scale invasion, according to an article in the European Journal of Psychotraumatology -- Moral injury and PTSD among Ukrainians exposed to full-scale war.

• PTSD severity correlated moderately to strongly with moral injury (r = .47–.58).
   
• Probable PTSD predicted higher shame (η²p = .09) and trust-violation (η²p =  .13) moral injury outcomes.
   
• Trust-violation moral injury notably exceeded shame-related moral injury in this sample.
   
• Ukrainian PCL-5 and MIOS Part 2 showed strong validity and excellent reliability.

By Justin Tash, MSW

“I Must Not Fear. Fear Is The Mind Killer.”
To anyone who has even a passing interest in the genre of science fiction, these words likely ring a bell. They are the opening lines of the Litany Against Fear from American author Frank Herbert’s 1965 sci-fi masterpiece DUNE. This book is, to this day, the best-selling science fiction novel, with well over 20 million copies sold worldwide. The saga has influenced everything from Star Wars to Avatar, offering readers a sprawling universe of political intrigue, ecological philosophy, and deeply human struggle. However, beneath the sandworms, spice, and shifting dunes of Arrakis, lies something far more grounded: a remarkably accurate portrait of what trauma does to children.

I have had this fact proven to me again and again as a social worker who works with adolescents and military families. Unfortunately, many of my clients have faced difficult situations that individuals their age should never have to go through. But, the power of human storytelling teaches us about what is happening internally for all of us and our clients. Even though trauma affects everyone differently, by examining these incredible worlds and characters, we can take away important, universal lessons. 

Paul Atreides and the Burden of the Parentified Child 
When Paul Atreides, the main character in many ways of DUNE, is introduced, he is a teenager who has already begun to carry weight no adolescent should bear. The fall of his Great House and the death of his father, the Duke, strips away his childhood overnight. These events thrust him into a leadership role among the planet's indigenous population, the Fremen, molding him into a de facto father figure for an entire people. 

Clinicians can easily recognize this dynamic because they are often faced with young clients who are being subjected to a similar situation, although not usually on such a grand scale. When a family experiences a loss, or abuse that leads to absence of one parent in some way, the child can become the caretaker or the protector and thus shoulder the responsibility and expectations of holding it all together. 

Children who experience early loss or abuse frequently develop what we call "parentification." They learn to read the emotional temperature of a room, suppress their own needs, and derive their sense of worth from how well they manage the people around them. Paul believes, with complete sincerity, that he is destined for greatness and uniquely equipped to bear this burden that has been thrust on him. This is not an uncommon reaction or complex to develop for trauma victims, especially young victims. Trauma has an insidious way of convincing the victim that they are capable of handling something that will ultimately cause intense harm. The gap that is created between that perceived resilience and a person’s actual capacity is one of trauma’s most dangerous distortions. 

Alia of the Knife and Memories Out of Order 
Paul's sister Alia presents an even more striking clinical metaphor. Born later in the story with the full ancestral memory of every generation before her, she enters the world already saturated with experiences she did not live, has no context for, and cannot process in any developmentally appropriate sequence. 

This is, in an extreme and fantastical form, what trauma does to the brain. Trauma packages memories incorrectly. Traumatic events are stored as present threats rather than being filed as past experiences due to how the amygdala interrupts the regular memory processing that occurs between the frontal cortex, hippocampus, and cerebellum. These memories are often intrusive, disorganized, and stripped of context. Much of trauma-focused therapy is about carefully pulling those neural pathways apart and rebuilding them in a safer, more coherent order, in an environment where the body finally understands it is no longer in danger. It turns out fear truly is the mind killer. 

What Adolescents (and these Children of Dune) Keep Teaching Me 
One of the most important lessons I have learned from my work with adolescents is that trauma affects every child differently. After all, the adolescent brain is still actively developing, still redistributing and consolidating information across its architecture. In many cases, that neurological flexibility allows young people to process difficult experiences before they calcify into symptomatic patterns. They moved through something hard before the brain had the context to commit to storing the experience as a wound. Due to this, there is no guaranteed response to these experiences, there is not even a guarantee that PTSD will manifest. I consistently encounter young people who have experienced events that meet the clinical definition of trauma but do not develop any symptoms. 

Children and adolescents are often seemingly unbothered by experiences we assume must be devastating because they are seeing all of this for the first time. Paul nor Alia responded to their experiences as if they were traumatic, although, objectively, they very much were. Frequently, it is the fear, the alarm, and the urgency in the reactions of the adults around them that teaches a child that what happened was catastrophic. Confusion and fear are often learned responses and not inherent ones. 

Voices from an Outer World 
Paul “Muad’Dib” Atreides and his sister Alia, however fictional they may be, are excellent, microcosmic examples of childhood trauma and adverse childhood experiences. These masterful characterizations can offer an up-close-and-personal perspective on what it means to exist as a young person who has experienced trauma. Impactful clinical lessons like these can be found in unlikely places, even from outer worlds like DUNE, but if we as providers listen to these voices, we can gain access to a deeper understanding of the human condition that no textbook could ever hope to provide.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of War.

Justin Tash, MSW, is a Military Behavioral Health Social Worker at the Consortium for Defense Psychology (CDP) at the Uniformed Services University for the Health Sciences in Bethesda, Maryland and the Project Lead/Instructor and for the Prevention of Harmful Behaviors in the Military Project. Mr. Tash completed his Bachelor of Arts in Communications at Texas A&M University in 2015 and his Masters of Social Work at the University of South Florida in 2025. He is now working toward the goal of becoming a Licensed Clinical Social Worker (LCSW).

By Kathryn Monsey, LCSW

We come together to learn, to teach, to solve problems, and to support one another. Throughout my career, collaboration has taken many forms, but one lesson has remained constant: some of the most meaningful work happens when people come together around a shared mission. There is a certain energy created through gathering that is difficult to replicate in any other way. Whether exchanging ideas or learning from one another’s experiences, these opportunities leave us better equipped to serve our communities. Some of my most important work—both professionally and personally—has happened in those moments of connection.

That spirit is at the heart of the Star Behavioral Health Providers Convening Event. Since its launch in 2022, the event has brought together Directors of Psychological Health (DPHs), Behavioral Health Officers (BHOs), and the SBHP team from across the country to strengthen the partnerships that support Service Members and their families. Because Reserve Component members rely on civilian behavioral health providers at higher rates than their Active-Duty counterparts, strong civilian-military collaboration is essential. To support those connections, SBHP developed a directory of civilian providers who have completed our training and have access to ongoing consultation and support. Through shared learning, professional development, and meaningful collaboration, the Convening Event helps increase awareness of this resource while creating opportunities for partners nationwide to connect, exchange ideas, and unite around our common goal of addressing the unique behavioral health needs of the National Guard community.

One aspect of the Convening Event that I particularly appreciate is our ability to remain responsive to the needs of the field. By listening to the experiences and feedback of our DPH and BHO partners, we can focus on topics that reflect current challenges, emerging trends, and areas of growing interest within military behavioral health. This year's agenda includes discussions on suicide safety planning, lethal means safety counseling, strategic patient management, brief strength-based interventions, structured case management strategies, and skills-based therapies that support readiness and resilience among National Guard members and their families.

Four years later, SBHP remains committed to supporting these dedicated behavioral health staff through a convening event that continues that tradition. At its core, SBHP is built on this collaborative spirit. The DPHs and BHOs of the National Guard are critical collaborators in our shared mission to improve access to high-quality behavioral healthcare for military-connected communities. Convening events like this provide an opportunity to strengthen those relationships, learn from one another, and continue building the connections that help service members, veterans, and their families receive the care they deserve. I am confident that this year's Convening Event will continue to strengthen those relationships and advance behavioral healthcare across the National Guard community.

Interested in learning more about SBHP or have any questions? Please contact us at sbhpsupport_ggg@usuhs.edu.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of War.

Kathryn E Monsey, LCSW, LCDC, is a Military Behavioral Health Social Worker for the Consortium for Defense Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. She assists in the implementation and expansion of the Star Behavioral Health Providers Program (SBHP). SBHP trains civilian behavioral health providers to work with service members, veterans, and their families. The mission is to expand the availability of high-quality behavioral health services, especially for those in the National Guard and Reserve Component.

By Dr. Andrew Devendorf

As a therapist, it feels devastating when a patient drops out of treatment. Queue the automatic thoughts, "What did I do wrong?" "What could I have done differently?" "Am I failing my patients?" These thoughts flooded my brain when I was trained in Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) for patients with posttraumatic stress disorder (PTSD) (Foa et al., 2009; Resick et al., 2016).

CPT and PE are both gold-standard treatments for PTSD. They are among the most studied treatments that reduce PTSD symptoms compared to control groups (Lewis et al., 2020; Powers et al., 2010) . In addition to Eye Movement Desensitization and Reprocessing therapy, they are two of the three psychotherapies that are recommended by the Department of Veteran Affairs (VA/DoD CPGs, 2025).

CPT and PE are mostly delivered in 8-15 weekly sessions. CPT involves challenging and modifying unhelpful beliefs related to the trauma, while PE involves repeatedly confronting trauma-related memories and avoidance to habituate fear responses. Each treatment asks patients to do 1-2 hours of daily homework.

I was excited to learn these evidence-based psychotherapies during my graduate training at the VA—rates of PTSD are high in military populations, and they deserve the best care. Before diving in, I prided myself on having a near 0% dropout rate with my previous clients. My specialty was in treating depression and anxiety disorders, which are like cousins of PTSD.

But when I saw my first caseload of veterans with PTSD, my optimism quickly waned. My no-show rate shot up to almost 40%. I’d usually be 3 sessions into CPT or PE—right before really “diving into” the trauma—when patients started to reschedule, cancel, or “ghost” me entirely. Why was this happening? My process to self-reflect, “what could I have done better?” could only take me so far, since my other patients were benefiting from treatment.

Fortunately, some of my patients shared with me why they prematurely ended therapy. Several said that they stopped due to logistical reasons: not having enough time, getting a new job, or not realizing the level of commitment needed until they started. Others said they weren’t ready to confront their trauma (“It’s too much, right now.”), and some even admitted to engaging in avoidance. For patients I didn’t hear from, it’s possible that they didn’t see me, or the treatment, as the “right fit.” Or...maybe something else? Regardless, I felt defeated, and so I consulted the research literature to learn more.

Dropout Rates for CPT and PE

What I found in the research was staggering. Among combat Veterans with PTSD who served in Iraq and Afghanistan, a meta-analysis found that the overall dropout rates for trauma treatments were 36% (Goetter et al., 2015). This number mirrored my own clinical experience! More recently, in a different a meta-analysis of trauma treatments for military and veteran populations, researchers found that dropout rates were 40% for weekly CPT, and 35% for weekly PE (Penix-Smith & Swift, 2025).

These results made me feel validated. I thought, “I wasn’t the problem. The treatment schedule was.” But then, that idea disappointed me—is this really the best we can do? How can we call a treatment “gold-standard” when almost half of patients don’t finish it? Fortunately, there is light in this story. In the same meta-analysis, the researchers found that when CPT and PE were done in rapid care settings (i.e., a few weeks to a month of treatment), the dropout rates plummeted to just 9% and 6%, respectively. Is this for real? Can you actually treat PTSD in just a few weeks? And still have 90% of people complete treatment?

Enter the conversation: "massed delivery" of PTSD treatments. 

What is “massed” PTSD treatment? 

Massed treatment is when an evidence-based psychotherapy is delivered in 3 sessions or more per week. Given the intensity, this delivery is also called “accelerated” treatment. Massed PTSD treatments are usually done in intensive outpatient or partial hospitalization programs (IOP/PHP), as well as residential settings. However, massed treatment can be adapted into an outpatient setting.

Much of what is known about massed treatment has emerged in the last 10-15 years. As a result, there is no primary model, yet, for how to implement massed CPT and PE. For instance, some intensive care settings will bring in “supplemental” treatments for patients. These could include support via exercise programs, yoga, meditation, or seeing a nutritionist; they may also include helping a patient with other mental health difficulties, such as providing supplemental therapy for depression, anxiety, sleep, or substance use disorders.

Does accelerated CPT and PE work?

The short answer—yes, but research is still emerging.

In multiple randomized clinical trials, massed PE was found to be just as effective as weekly PE for reducing PTSD symptoms at 3-months (Dell et al., 2023; Foa et al., 2018) . Importantly, treatment gains are also similar between massed PE and standard PE after 1-year follow-up (Dell et al., 2023).

There is less research on massed CPT, but initial work shows that it is effective for reducing PTSD symptoms (Baez et al., 2026.; Held et al., 2023) . However, there is a soon-to-be published randomized clinical trial that shows massed CPT is, indeed, as effective as standard CPT in a U.S. military population (Wachen et al., in press). One interesting finding is that CPT can be delivered effectively in 1-week, 2-week, and 3 week formats (Held et al., 2022, 2023).

Lastly, interview research shows that providers really enjoy doing massed PTSD treatments—you have the chance to see a patient make improvements in 2-3 weeks vs. waiting 3-4 months. That said, providers emphasize that the healthcare system needs to provide a reasonable infrastructure for massed treatment to be feasible; this includes protected time for preparation, documentation, and having supportive leadership (Wells et al., 2026).

Who is appropriate for massed treatment? 

The inclusion and exclusion criteria are the same as CPT and PE: patients who meet PTSD criteria and have sufficient memory of the traumatic event is appropriate. These treatments are not appropriate for patients with imminent threat of suicidal or homicidal behavior, current and serious self-injurious behavior, current psychosis, or at imminent risk of domestic violence or assault. However, once these conditions or circumstances are addressed, a patient may be appropriate.

Questions to Be Answered

The initial data on massed PTSD therapies are promising. But a few questions remain unanswered before widespread adoption:

• How long are treatment gains maintained?
• How do providers feel about massed compared to standard treatment?
• What are the best ways to implement massed CPT and PE?
• What is the most economical way to implement these treatments?
• How can providers be reimbursed for massed treatment?
• What is the feasibility for community outpatient providers to implement massed treatment?

A Bright Future

Accelerating treatments are...accelerating. There is good reason for patients and providers to be excited about the future. Patients and providers, alike, can now make similar progress in a few weeks, rather than months. If the last decade was focused on innovation PTSD treatments for massed delivery, then I hope the next decade sees the widespread adoption and dissemination of these promising interventions.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of War.

Andrew Devendorf, Ph.D., is a Military Behavioral Health Psychologist with the Henry M. Jackson Foundation for the Advancement of Military Medicine. He serves as a subject matter expert in suicide prevention for the VA SAFEGUARD project.

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