Full length articleChanges in alcohol use after traumatic experiences: The impact of combat on Army National Guardsmen
Introduction
Although the drivers of alcohol misuse and alcohol-related risk behaviors among service members are not yet fully understood (Bray et al., 2013), some research has suggested that traumatic experiences increase incidence of post-traumatic stress as well as alcohol misuse (Jacobson et al., 2008, Spera et al., 2011), decreased military work performance (Fisher et al., 2000), and increased risk taking behaviors (e.g., drinking and driving; Killgore et al., 2008). The prevalent view, as expressed in the stress-reduction model, is that stressful events trigger an increase in alcohol consumption as a means of coping with stress (i.e., self-medicating) and may subsequently manifest into an alcohol use disorder (Cooper et al., 1990, Crum et al., 2013, Gorman et al., 2011, Hasking et al., 2011, Levenson et al., 1980, North et al., 2011, Volpicelli et al., 1999). Indeed, recent research suggests that combat veterans use alcohol to help cope with stress (Keyes et al., 2012), with alcohol misuse and dependence often being comorbid with numerous other psychiatric disorders (e.g., PTSD; Marshall et al., 2012, Schumm and Chard, 2012).
This view, however, is not undisputed; research suggests that drinking behaviors are often independent of a traumatic experience (Beseler et al., 2011, Ferrier-Auerbach et al., 2009). While the media and policymakers generally focus on the negative outcomes associated with traumatic events, there are in fact three possible psychological adjustment outcomes to traumatic experiences: (1) a return to pre-event baseline levels (i.e., psychological restoration or resilience); (2) an increase in negative outcomes (i.e., psychological distress); and (3) a decrease in negative outcomes (psychological growth; Pat-Horenczyk and Brom, 2007). Thus, it is theoretically possible for traumatic events to result in positive outcomes such as a reduction in alcohol consumption or misuse (Killgore et al., 2008). That positive outcomes might emanate from trauma is not a new concept. Contemporary research in this domain harkens back to the Salutogenic Model (Antonovsky, 1987), which is based on understanding the dynamic relationships among stressors, coping, and health by not only focusing on the negative outcomes associated with a traumatic event but also identifying and understanding any potential positive outcomes emanating from the event.
In the context of drinking behavior, the absence of pre- and post-traumatic event studies leads to uncertainty about whether exposure to potentially traumatic events manifest into an increase or decrease of alcohol use disorder cases (Linley and Joseph, 2004, North et al., 2011). Therefore, research is needed to assess how potentially traumatic events are related to changes in drinking behavior to identify probable causal linkages between traumatic experiences and problematic drinking. These issues are especially salient in the military environment where traumatic combat experiences (CEs) are common (Bray et al., 2010, Bray et al., 2013, North et al., 2011), and where alcohol misuse is a significant concern because it negatively affects service member health, operational readiness, and substantially impacts healthcare expenditures (Mattiko et al., 2011, Department of Defense, 1997, Institute of Medicine, 2012, Sundin et al., 2014).
Given that previous research suggests traumatic events can have positive and negative consequences (Cann et al., 2010, Linley and Joseph, 2004), this research addresses whether exposure to potentially traumatic CEs during a military deployment is linked to a subsequent increase or decrease in alcohol use and/or misuse.
Military combat operations present numerous stressors emanating from a multitude of factors: for instance, fighting, witnessing the death and injury of non-combatants and comrades, experiencing close calls, all can impact the service members’ health (Fontana and Rosenheck, 1999). Such CEs may differ from the traumatic experiences found in civilian settings not only because of the severity of armed conflict, but due to the long-duration and repeated exposures (Fontana and Rosenheck, 1999). Service members may also respond differently than civilians as they have received training to prepare for potentially traumatic events (Adler et al., 2008). However, not all potentially traumatic events associated with combat have equal impact. For instance, a post-deployment cross-sectional study of Active Component (AC) soldiers found that a range of CE types (e.g., fighting, killing/injuring others, exposure to death/injury in others, threat to oneself, and witnessing atrocities) were associated with a positive screen for alcohol misuse; however, when the CE types were examined simultaneously in the full covariate model, threat-to-oneself emerged as the only significant predictor of screening positive for alcohol misuse (Wilk et al., 2010).
Interestingly, the literature on military populations suggests that CEs are not always positively related to alcohol use. Specifically, research assessing AC Army soldiers found that individuals reported consuming slightly less alcohol when having survived a close call (Killgore et al., 2008). While these two studies suggest that CEs might be differentially related to alcohol use, neither of these military studies was based on comparative pre- and post-deployment data. Instead, the studies drew inferences from cross-sectional data collected following a combat deployment. As such, these two studies looked at how rates of alcohol use were associated with CEs rather than an examination of how CEs relate to changes in alcohol use over time.
While some longitudinal evidence exists that National Guard (NG) soldiers exposed to combat are at increased risk of alcohol use disorders (e.g., Kehle et al., 2012), the findings are limited in that many of the studies were not planned in a true pre-post design and instead draw on secondary pre-deployment data sources (e.g., medical records) and marry those data to other post-deployment data sources (e.g., cross-sectional respondent surveys), sometimes collected long after CEs (e.g., Shen et al., 2012). The research presented here builds upon previous work by using a prospective longitudinal research design to assess the difference in alcohol use and misuse before and after deployment among NG soldiers.
This research explores the ways in which different types of CEs during deployment are related to changes, whether increases or decreases, in both general drinking and alcohol misuse. Based on Wilk et al. (2010) and Killgore et al. (2008), it is likely that certain types of CEs will be differentially related to alcohol use with some types potentially associated with decreased use. But given the exploratory nature of the study, no specific a priori hypotheses are made about which types of CEs will be associated with increased versus decreased alcohol use.
Section snippets
Sample
Members of an Army National Guard Infantry Brigade Combat Team (BCT) were invited to voluntarily partake in an anonymous self-report behavioral health survey. The BCT was surveyed 3 months prior to its deployment (pre-deployment) to Iraq and then again 3 months after its redeployment (post-deployment). The members were provided an informed consent form to read at their own pace and also received an oral briefing describing the study. Participants were assured anonymity would be protected.
Results
The means, standard deviations and correlation matrix between all independent and dependent variables are reported in Table 1. All analyses and results pertain only to the sample of matched participants. It is noteworthy that all CEs are significantly and positively related to each other with magnitudes ranging from .27 to .78.
Discussion
Clearly combat is a potentially stressful experience. However, unlike previously published research, this prospective longitudinal study shows that CEs are not linked to increases in alcohol use or misuse. In fact, the study shows that potential positive externalities can emerge from trauma and lead to positive behavioral changes, as evidenced in a reduction in substance abuse (Pat-Horenczyk and Brom, 2007, Tedeschi and Calhoun, 1996). Of particular interest is the finding that killing CEs are
Role of funding source
Funding for this project came from the Military Operational Medicine Research Area Directorate, U.S. Army Medical Research and Materiel Command, Ft. Detrick, MD.
Conflict of interest
The authors report no competing interests.
Authors’ note
The study was approved by Walter Reed Army Institute of Research Institutional Review Board. There is no objection to its presentation and/or publication. The opinions or assertions contained herein are the private views of the authors, and are not to be construed as official, or as reflecting true views of the Department of the Army or the Department of Defense.
Contributors
Dr. D. Russell, Dr. C. Russell, and Dr. Bliese participated in developing the study concept and design, statistical analysis, data interpretation, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. They have seen and approved the final version. Dr. Riviere, Dr. Thomas, and Dr. Wilk declare that they participated in the study concept and design and drafting of the manuscript. They have seen and approved the final version.
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