Treating complex trauma among veterans: three stage-based treatment models
Abstract
This article addresses the issue of complex trauma in veterans and treatments for symptom presentations resulting from complex trauma exposure. While various definitions have been proposed for complex trauma, the clinical issues related to it are relevant for veterans as they are at risk for cumulative trauma exposures such as multiple combat deployments and military sexual trauma. Several treatments were either developed to address and/or implemented with complex trauma. This article discusses three of these treatments that share a stage-based approach, focusing on the present (e.g., skills training and psychoeducation), which can then be followed, if needed, with a past-focused (e.g., exposure-based) treatment: Dialectical Behavior Therapy (Linehan, 1993), Seeking Safety (Najavits, 2002), Skills Training in Affective and Interpersonal Regulation (STAIR) Narrative Therapy (Cloitre, Cohen, & Koenen, 2006). This article also discusses what is currently being done to address symptom presentations resulting from complex trauma exposure and challenges and possible solutions to implementing this care.
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Veterans have high rates of mental comorbidity and experience high levels of problems that can negatively impact successful engagement with psychological treatment, such as interpersonal problems and emotional dysregulation.
“Veterans have high rates of mental comorbidity and experience high levels of problems that can negatively impact successful engagement with psychological treatment, such as interpersonal problems and emotional dysregulation [151].”
Cites
Cognitive-Behavioral Treatment of Borderline Personality Disorder
Cary, G. L. (1994) · American Journal of Psychotherapy · doi:10.1176/appi.psychotherapy.1994.48.1.155 · Cited by 6,300 · see citing works
Treating the Trauma of Rape: Cognitive Behavioral Therapy for PTSD
Ellis, E. M. (1999) · American Journal of Psychotherapy · doi:10.1176/appi.psychotherapy.1999.53.1.126 · Cited by 734 · see citing works
The Veterans Health Administration and Military Sexual Trauma
Kimerling, R. E., Gima, K. S., Smith, M. W., Street, A. E., & Frayne, S. M. (2007) · American Journal of Public Health · doi:10.2105/ajph.2006.092999 · Cited by 607 · see citing works
Treatment of complex PTSD: results of the ISTSS expert clinician survey on best practices.
Cloitre, M., Courtois, C. A., Charuvastra, A., Carapezza, R., Stolbach, B. C., & Green, B. L. (2011) · Journal of Traumatic Stress · doi:10.1002/jts.20697 · Cited by 593 · see citing works
A new generation of women veterans: Stressors faced by women deployed to Iraq and Afghanistan
Street, A. E., Vogt, D. S., & Dutra, L. (2009) · Clinical Psychology Review · doi:10.1016/j.cpr.2009.08.007 · Cited by 423 · see citing works
Seeking Safety. A Treatment Manual for PTSD and Substance Abuse.
&NA; (2002) · The Journal of Nervous and Mental Disease · doi:10.1097/00005053-200206000-00025 · Cited by 357 · see citing works
Harned, M. S., Korslund, K. E., Foa, E. B., & Linehan, M. M. (2012) · Behaviour Research and Therapy · doi:10.1016/j.brat.2012.02.011 · Cited by 288 · see citing works
Dissemination and Implementation of Evidence-Based Psychological Interventions
McHugh, R. K., & Barlow, D. H. (2015) · Oxford University Press eBooks · doi:10.1093/med:psych/9780195389050.003.0013 · Cited by 211 · see citing works
A Pilot Study of Seeking Safety Therapy with OEF/OIF Veterans
Norman, S. B., Wilkins, K. C., Tapert, S. F., Lang, A. J., & Najavits, L. M. (2010) · Journal of Psychoactive Drugs · doi:10.1080/02791072.2010.10399788 · Cited by 53 · see citing works
Flagged first, then by citations
1 of the 10 references couldn’t be matched to a known paper.
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Sorted by citations
Coventry, P. A., Meader, N., Melton, H., Temple, M., Dale, H., Wright, K., Cloitre, M., Karatzias, T., Bisson, J., Roberts, N. P., et al. (2020) · PLoS Medicine · doi:10.1371/journal.pmed.1003262 · Cited by 358 · see citing works
“Veterans have high rates of mental comorbidity and experience high levels of problems that can negatively impact successful engagement with psychological treatment, such as interpersonal problems and emotional dysregulation [151].”
Treatment of Posttraumatic Stress Disorder: A State-of-the-art Review
Burback, L., Brémault‐Phillips, S., Nijdam, M. J., McFARLANE, A. C., & Vermetten, E. H. G. J. M. (2023) · Current Neuropharmacology · doi:10.2174/1570159x21666230428091433 · Cited by 232 · see citing works
Gilmore, A. K., López, C. M., Muzzy, W. A., Brown, W. J., Grubaugh, A. L., Oesterle, D. W., & Acierno, R. E. (2020) · Women s Health Issues · doi:10.1016/j.whi.2020.07.004 · Cited by 42 · see citing works
Landes, S. J., Rodriguez, A. L., Smith, B. N., Matthieu, M. M., Trent, L. R., Kemp, J. E., & Thompson, C. (2017) · Translational Behavioral Medicine · doi:10.1007/s13142-017-0465-5 · Cited by 41 · see citing works
Self-citationYalch, M. M., Hebenstreit, C. L., & Maguen, S. (2017) · Addictive Behaviors · doi:10.1016/j.addbeh.2017.12.026 · Cited by 38 · see citing works
Exploring complex-PTSD comorbidity in trauma-exposed Northern Ireland veterans
Spikol, E., Robinson, M., McGlinchey, E., Ross, J., & Armour, C. (2022) · European Journal of Psychotraumatology · doi:10.1080/20008198.2022.2046953 · Cited by 35 · see citing works
“Similarly, these analyses sought to examine salient association with class membership, those identified to be related to PTSD and CPTSD symptomology (Cloitre, 2021; Landes et al., 2013), to interrogate potential differences between identified classes.”
BackgroundInterpersonal Features in Complex Trauma Etiology, Consequences, and Treatment: A Literature Review
Nieuwenhove, K. V., & Meganck, R. (2017) · Journal of Aggression Maltreatment & Trauma · doi:10.1080/10926771.2017.1405316 · Cited by 32 · see citing works
“Accordingly, it has been suggested that exposure should always be applied amenably and with caution (Landes et al., 2013).”
BackgroundDeaths of Despair: Conceptual and Clinical Implications
Rehder, K. L., Lusk, J., & Chen, J. I. (2019) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2019.10.002 · Cited by 32 · see citing works
Tay, A. K., Rees, S., Steel, Z., Liddell, B., Nickerson, A., Tam, N., & Silove, D. (2017) · Epidemiology and Psychiatric Sciences · doi:10.1017/s2045796016000317 · Cited by 26 · see citing works
“Elements of these two components already form part of existing interventions, including cognitive behavioural therapy for grief (Murray et al. 2008), Interpersonal Therapy (Markowitz et al. 2009), Acceptance and Commitment Therapy (Hofmann et al. 2011) and Schema Therapy (Landes et al. 2013).”
BackgroundMeyers, L. L., Landes, S. J., & Thuras, P. (2014) · Military Medicine · doi:10.7205/milmed-d-14-00248 · Cited by 25 · see citing works
Self-citationBrowne, K. C., Chen, J. A., Hundt, N. E., Hudson, T. J., Grubbs, K. M., & Fortney, J. C. (2019) · Psychological Services · doi:10.1037/ser0000375 · Cited by 24 · see citing works
Prevalence of Adverse Childhood Experiences Among Veterans
Laird, C. W., & Alexander, P. (2019) · Clinical Social Work Journal · doi:10.1007/s10615-019-00703-5 · Cited by 23 · see citing works
Holliday, R. P., Smith, N. B., Holder, N. D., Gross, G. M., Monteith, L. L., Maguen, S., Hoff, R. A., & Harpaz‐Rotem, I. (2019) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2019.12.012 · Cited by 22 · see citing works
Dedert, E. A., LoSavio, S. T., Wells, S. Y., Steel, A. L., Reinhardt, K. M., Deming, C. A., Ruffin, R. A., Berlin, K. L., Kimbrel, N. A., Wilson, S. M., et al. (2020) · Psychological Services · doi:10.1037/ser0000425 · Cited by 21 · see citing works
Silove, D. M., Rees, S. J., Mohsin, M., Tam, N., Kareth, M., & Tay, A. K. (2018) · BJPsych Open · doi:10.1192/bjo.2018.49 · Cited by 19 · see citing works
Clinician Concerns About Cognitive Processing Therapy: A Review of the Evidence
LoSavio, S. T., Holder, N. D., Wells, S. Y., & Resick, P. A. (2022) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2022.08.005 · Cited by 18 · see citing works
Tarquinio, C., Houllé, W. A., & Tarquinio, P. (2016) · Sexologies · doi:10.1016/j.sexol.2016.03.007 · Cited by 18 · see citing works
Effectiveness of an MP3 Christian mindfulness intervention on mindfulness and perceived stress
Trammel, R. C. (2018) · Mental Health Religion & Culture · doi:10.1080/13674676.2018.1505837 · Cited by 17 · see citing works
“based mindfulness interventions have shown to be, such as in decrease symptomatology of depression, anxiety and trauma as well as in improving emotional regulation (Bonifas & Napoli, 2014; Foulk et al., 2014; Hick & Chan, 2010; Kuyken et al., 2014; Landes et al., 2013).”
BackgroundInfluentialApplying contemporary interpersonal theory to the study of trauma
Yalch, M. M., & Burkman, K. M. (2019) · European Journal of Trauma & Dissociation · doi:10.1016/j.ejtd.2019.01.003 · Cited by 16 · see citing works
Evans, E., Glover, D. L., Washington, D. L., & Hamilton, A. B. (2018) · Substance Use & Misuse · doi:10.1080/10826084.2018.1441309 · Cited by 15 · see citing works
Dabovich, P. A., Eliott, J., & McFARLANE, A. C. (2019) · Social Science & Medicine · doi:10.1016/j.socscimed.2019.01.012 · Cited by 15 · see citing works
Lofgreen, A. M., Tirone, V., Carroll, K. K., Rufa, A. K., Smith, D. L., Bagley, J. M., Zalta, A. K., Brennan, M. B., Horn, R. V., Pollack, M. H., et al. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.03.036 · Cited by 15 · see citing works
“MST has been associated with several clinical characteristics consistent with those associated with cumulative interpersonal trauma histories, such as disturbances in relationships, emotion dysregulation, dissociative symptoms, and somatic distress (Landes et al., 2013; Luterek et al., 2011; Surìs et al., 2007).”
BackgroundResultInfluentialBenfer, N., Grunthal, B., Dondanville, K. A., Young‐McCaughan, S., Blankenship, A. E., Abdallah, C. G., Back, S. E., Flanagan, J. C., Foa, E. B., Fox, P. T., et al. (2023) · Psychological Trauma Theory Research Practice and Policy · doi:10.1037/tra0001537 · Cited by 15 · see citing works
Holder, N. D., Holliday, R. P., & Surís, A. (2018) · Stress and Health · doi:10.1002/smi.2838 · Cited by 14 · see citing works
Scheiderer, E. M., Carlile, J. A., Aosved, A. C., & Barlow, A. S. (2017) · Clinical Case Studies · doi:10.1177/1534650116688557 · Cited by 12 · see citing works
Öyküsel Terapinin Dışavurumcu Sanat Uygulamaları ile Bütünleşmesi
BAŞTEMUR, Ş., & BAŞ, E. (2021) · Psikiyatride Guncel Yaklasimlar - Current Approaches in Psychiatry · doi:10.18863/pgy.771319 · Cited by 10 · see citing works
Ewert, A. (2014) · Ecopsychology · doi:10.1089/eco.2013.0035 · Cited by 9 · see citing works
Military Sexual Trauma among Men: A Review of the Literature and a Call for Research
Romaniuk, J. R., & Loue, S. (2024) · Best practices in mental health · doi:10.70256/502356imqjjv · Cited by 9 · see citing works
PTSD, complex PTSD and the dissociative subtype of PTSD in patients with eating disorders
Brewerton, T. D., Nguyen, C., Bishop, N., & Dennis, K. (2025) · Journal of Eating Disorders · doi:10.1186/s40337-025-01449-x · Cited by 8 · see citing works
“Meanwhile, integrated, trauma-informed treatment plans can be successfully employed to relieve suffering and symptoms [3, 8, 14, 15, 15, 18, 18, 23–26, 55, 64, 83, 84].”
Finnegan, A. P., Kip, K. E., Hernández, D., McGhee, S., Rosenzweig, L., Hynes, C., & Thomas, M. D. (2015) · Journal of the Royal Army Medical Corps · doi:10.1136/jramc-2015-000417 · Cited by 8 · see citing works
Davis, L. W., Luedtke, B. L., Monson, C. M., Siegel, A., Daggy, J., Yang, Z., Bair, M. J., Brustuen, B., & Ertl, M. (2021) · Couple and Family Psychology Research and Practice · doi:10.1037/cfp0000148 · Cited by 7 · see citing works
“…for example, dialectical behavior therapy along with weekly writing assignments about positive and negative experiences (Bradley & Follingstad, 2003), STAIR narrative therapy without exposure (Landes et al., 2013) and structured approach therapy, a conjoint PTSD treatment (Sautter et. al., 2015).”
BackgroundIntegrating process and structure in group therapy for survivors of trauma
Yalch, M. M., Moreland, M. L., & Burkman, K. M. (2022) · European Journal of Trauma & Dissociation · doi:10.1016/j.ejtd.2022.100272 · Cited by 6 · see citing works
Holliday, R. P., Wiblin, J. L., Holder, N. D., Gerard, G. R., Matarazzo, B. B., & Monteith, L. L. (2020) · Psychiatric Annals · doi:10.3928/00485713-20200908-01 · Cited by 6 · see citing works
McCormack, L., & Strezov, J. (2020) · Journal of Refugee Studies · doi:10.1093/jrs/feaa069 · Cited by 6 · see citing works
Giesler, M. A., & Juarez, A. (2019) · Journal of Veterans Studies · doi:10.21061/jvs.v5i1.148 · Cited by 5 · see citing works
Considerations in the Treatment of Veterans with Posttraumatic Stress Disorder
McCaslin, S. E., Turchik, J. A., & Hatzfeld, J. J. (2015) · Springer eBooks · doi:10.1007/978-3-319-07109-1_22 · Cited by 4 · see citing works
Trauma cue-elicited emotional response profiles influence acute experiences of alcohol urge
Rodriguez, L., & Read, J. P. (2022) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2022.101772 · Cited by 3 · see citing works
Treating the Adult Sexual Assault Victim: Evidence-Based Assessment and Treatment
Leach, N. R., & Orchowski, L. M. (2019) · Springer eBooks · doi:10.1007/978-3-030-23645-8_29 · Cited by 3 · see citing works
Cooper, G. F., Zink, A., & Jordan, S. E. (2021) · Clinical Case Studies · doi:10.1177/15346501211049452 · Cited by 3 · see citing works
“In such cases, DBT may be a needed precursor to trauma-focused treatment, so as to stabilize risk for self-harm and establish emotion regulation and distress tolerance skills to support the individual in focusing on their trauma memories (e.g., Landes et al., 2013).”
BackgroundTrauma in Specialized Treatment Diversion – Problem-Solving Court Contexts (PSCs)
Lamade, R. V., & Lee, R. (2020) · Springer eBooks · doi:10.1007/978-3-030-33106-1_19 · Cited by 3 · see citing works
Dialectical behavior therapy research and program evaluation in the Department of Veterans Affairs
Landes, S. J., Decker, S. E., McBain, S. A., Goodman, M. S., Smith, B. N., Sullivan, S. R., Spears, A. P., & Meyers, L. L. (2020) · Elsevier eBooks · doi:10.1016/b978-0-12-816384-9.00012-9 · Cited by 3 · see citing works
Self-citationTreatment of Posttraumatic Stress Disorder Related to Military Sexual Trauma
Matt, L. M., Thompson, K., Lofgreen, A. M., & Horn, R. V. (2020) · Psychiatric Annals · doi:10.3928/00485713-20200916-01 · Cited by 2 · see citing works
Morgan-Mullane, A. (2023) · Essential clinical social work series · doi:10.1007/978-3-031-28823-4_4 · Cited by 2 · see citing works
Spouses of First Responders: Support for Living With Posttraumatic Stress
Geiger, J. D. (2024) · The Family Journal · doi:10.1177/10664807241237229 · Cited by 2 · see citing works
“Complex trauma is caused by several traumatic events/experiences/critical incidents, and tends to occur in early childhood and adolescence, predisposing individuals to PTSD in adulthood (e.g., with military veterans; Landes et al., 2013).”
BackgroundResultUnderstanding and Treating Posttraumatic Stress Disorder (PTSD) in Veterans
McCaslin, S. E., Ortigo, K. M., Simon, E., & Ruzek, J. I. (2018) · Springer eBooks · doi:10.1007/978-1-4939-7438-2_15 · Cited by 2 · see citing works
Holens, P. L., Buhler, J. N., Yacucha, S., Romaniuk, A., & Joyal, B. (2021) · Journal of Military, Veteran and Family Health · doi:10.3138/jmvfh-2019-0067 · Cited by 1 · see citing works
Presseau, C., Carney, J. R., Kline, N. K., Grimshaw, A. A., DeMoss, L., Gunderson, C. G., & Portnoy, G. A. (2024) · Trauma Violence & Abuse · doi:10.1177/15248380241234345 · Cited by 1 · see citing works
“…(Steenkamp, 2016) and/or adapting treatments to account for specific types of exposures (e.g., child trauma, IPV, MST) and their accumulating effects (Landes et al., 2013) represent practical approaches to addressing the variability of trauma sequalae for specialized populations of veterans.”
Military Sexual Trauma among Men: A Review of the Literature and a Call for Research
Romaniuk, J. R., & Loue, S. (2017) · Best practices in mental health · doi:10.70256/653015gnbnsl · Cited by 1 · see citing works
Humble, N. (2016) · UST Research Online (University of St. Thomas - Minnesota) · Cited by 1 · see citing works
Military sexual trauma: a content analysis
Curnutt, K. A. (2014) · CSUN ScholarWorks (California State University, Northridge)
Intervention with Traumatized Populations
Regehr, C., & Treffers, S. R. (2011) · doi:10.1093/obo/9780195389678-0130
Using Recent Traumatic Episode Protocol in College Counseling Centers
Irish, A. J. (2020) · Journal of College Counseling · doi:10.1002/jocc.12158
(2015) · Vandenhoeck & Ruprecht eBooks · doi:10.13109/9783666402470.553
(2016) · Vandenhoeck & Ruprecht eBooks · doi:10.13109/9783666402616.639
Considerations in the Treatment of Veterans with Posttraumatic Stress Disorder
McCaslin, S. E., Turchik, J. A., & Hatzfeld, J. J. (2022) · Springer eBooks · doi:10.1007/978-3-030-97802-0_23
Comparison of Different Therapies on Reducing Self-Injury Behaviors in PTSD Veterans
Eyni, S. (2023) · مجله طب جانباز · doi:10.58209/ijwph.15.3.271
Van, B. N., Zarling, A., & Berta, M. (2024) · doi:10.1080/10926771.2026.2657532
- Authors
- Landes, S. J., Garovoy, N. D., & Burkman, K. M.
- Affiliations
- VA Palo Alto Health Care System (US)
- San Francisco VA Medical Center (US)
- Corresponding author
- Landes, Sara J.
- Venue
- Journal of Clinical Psychology
- Publisher
- Wiley
- Published
- 2013-03-25
- Volume
- 69
- Issue
- 5
- Pages
- 523-533
- ISSN
- 0021-9762 (ISSN-L)
- 1097-4679
- OpenAlex
- W2103000496
- Cited by
- 60
- References
- 10
- Citations by year
- 2025: 1 · 2024: 4 · 2023: 4 · 2022: 5 · 2021: 4 · 2020: 10 · 2019: 8 · 2018: 6 · 2017: 6 · 2016: 4 · 2015: 4 · 2014: 3
- FWCI
- 4.08
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Clinical Psychology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- complex trauma, veterans, dialectical behavior therapy, Seeking Safety, military sexual trauma, cumulative trauma, psychoeducation, skills training, exposure therapy
- MeSH terms
- Behavior Therapy, Borderline Personality Disorder, Combat Disorders, Humans, Military Personnel, Safety, Sex Offenses, Stress Disorders, Post-Traumatic, Veterans, Comorbidity, Domestic Violence, Adult Survivors of Child Abuse, Narrative Therapy
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