Patient-reported voice and swallowing outcomes and their impact on quality of life in the late postoperative period following total thyroidectomy.

Military sexual trauma is defined by the Veterans Affairs healthcare system as sexual assault or sexual harassment during military service (). A meta-analysis indicated prevalences of military sexual trauma of about 38.4% for harassment and sexual assault, 52.5% for harassment alone, and 23.6% for sexual assault alone (). Exposure to interpersonal violence and combat are associated with increased posttraumatic stress disorder (PTSD) severity among veterans (), but military sexual trauma is even more likely to result in PTSD in comparison to either exposure to civilian sexual trauma (e.g., Holder et al., 2023; ) or combat (e.g., ; ). Untreated PTSD can become chronic (; ) and contribute to significant mental and physical health disability and morbidity, which subsequently can diminish the quality of life among veterans (; ; ; ). Thus, to limit emotional and financial costs associated with these negative health sequelae, researchers must identify strategies to optimize effective treatments for PTSD. Dropout from evidence-based PTSD treatment is common, with a systematic review and meta-analysis indicating an average rate of dropout of 24% among military and veteran participants (). Notably, dropout rates are even more pronounced for cases of military sexual trauma-related PTSD with rates ranging between 40–60% (; ; ). This latter finding may be related to core components of evidence-based PTSD treatment (e.g., Prolonged Exposure), which include emotional processing and vivid review of traumatic events, and require patients to tolerate and regulate their emotions within and between sessions (i.e., during exposure to traumatic memories and when confronting external reminders of the event). There is a consistent association between difficulties in emotion regulation and PTSD symptoms (e.g., ; ); and veterans who have experienced military sexual trauma report more difficulties in emotion regulation than those who have not experienced military sexual trauma (e.g., ). Further, veterans with military sexual trauma-related PTSD are more likely to drop out of PE if they have increased difficulties with emotion regulation (). Importantly, PTSD treatment outcomes do not differ based on military sexual trauma status if evidence-based treatment is completed (). Thus, it is essential to investigate strategies to retain veterans with military sexual trauma-related PTSD in evidence-based treatment. PE is grounded in emotional processing theory (Foa & Kozak, 1986; ), which notes that chronic PTSD is due to the use of more ineffective emotion regulation strategies, such as emotional avoidance, suppression, and rumination (Moore et al., 2008; Pugach et al., 2020). PE and other trauma-focused treatments require emotional engagement to activate and correct maladaptive fear structure confrontation of traumatic memories and stimuli. Individuals with emotion regulation difficulties show higher levels of avoidance behaviors during treatment, which may negatively impact treatment engagement and completion (, Jaycox et al., 1998). Prior research recommended that trauma-focused treatment approaches emphasize adaptive regulation strategies to address dissociative and dysregulation symptoms in individuals with PTSD (Powers et al., 2015). Consistent with emotional processing theory and cognitive models of PTSD, emotion dysregulation plays a direct role in maintaining PTSD symptoms (Ehlers & Clark, 2000, Foa & Kozak, 1986). For example, emotional avoidance prevents activation of the trauma memory, which can block inhibitory and corrective learning, thus maintaining maladaptive fear structures and learning. Research indicates that emotion dysregulation can lead to premature avoidance or dissociation during exposure exercises, preventing full activation and modification of the trauma memory structure (Foa & Kozak, 1986). Similarly, avoidance of trauma-related cues provides short-term relief from distress; however, over time, this negative reinforcement of anxiety and fear-based avoidance perpetuates symptoms (Rauch & Foa, 2006). Longitudinal studies show that emotion regulation difficulties can worsen PTSD symptoms, which can in turn exacerbate emotion dysregulation (Bardeen et al., 2013). Therefore, incorporating evidence-based strategies to enhance emotion regulation abilities within trauma-focused treatment may increase distress tolerance, thereby facilitating engagement with trauma memories and related cues that is essential for reducing PTSD symptoms. Emotion regulation is broadly defined as the set of self-regulatory functions related to emotional self-awareness and understanding, acceptance and tolerance of negative emotion, use of goal-directed behavior and management of impulsive behavior, and consideration of social context in the selection of emotion regulation strategies (). There is a consistent association between difficulties in emotion regulation and PTSD symptoms in general (; ; ) and among veterans with military sexual traum