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Brennan CJ, Roberts C, Cole JC. Prevalence of occupational moral injury and post-traumatic embitterment disorder: a systematic review and meta-analysis. BMJ Open 2024; 14:e071776. [PMID: 38382965 PMCID: PMC10882372 DOI: 10.1136/bmjopen-2023-071776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVES Occupational moral injury and post-traumatic embitterment disorder (PTED) describe the psychological distress caused by exposure to injustice at work. This meta-analysis aims to determine the prevalence of occupational moral injury and PTED and establish whether prevalence estimates differ depending on occupation. DESIGN A systematic review and meta-analysis. DATA SOURCES Google Scholar, PubMed, APA PsycINFO, Web of Science Core Collection, Scopus, ScienceDirect and Sage Journals Online were searched in June 2020 and updated in November 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Observational studies that measured prevalence or average scores of moral injury, or PTED in any occupational group and any geographical location. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened and coded eligible studies. Study design, participant demographics, sampling method, location, measurement tool and prevalence or average scores were extracted. Risk of bias was assessed using the Quality Assessment Checklist for Prevalence Studies tool. Meta-analysis was conducted using random effects models. Results that could not be combined were summarised qualitatively in a narrative synthesis using the Guidance for Systematic Reviews. RESULTS In total, 88 studies across armed forces and veterans, healthcare, first responders, educators, journalists, child protection service employees, the unemployed, public-sector employees and mixed occupations were included. Studies included in each separate meta-analysis based on the measure used ranged from 2 to 30. The pooled prevalence of clinically relevant moral injury in healthcare professionals was 45%, and exposure to any potentially morally injurious event (PMIE) across occupations was 67%. Exposure to transgressions by others and betrayal was significantly lower in the armed forces than civilian occupations. Pooled prevalence of PTED across occupations was 26%. CONCLUSION Exposure to PMIEs, moral injury symptoms and PTED are prevalent at work and exposure to transgressions by others and betrayal are more likely in civilian occupations than the armed forces. PROSPERO REGISTRATION NUMBER CRD42020191766.
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Affiliation(s)
| | - Carl Roberts
- Psychology, University of Liverpool, Liverpool, UK
| | - Jon C Cole
- Psychology, University of Liverpool, Liverpool, UK
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2
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Carey LB, Bambling M, Hodgson TJ, Jamieson N, Bakhurst MG, Koenig HG. Pastoral Narrative Disclosure: The Development and Evaluation of an Australian Chaplaincy Intervention Strategy for Addressing Moral Injury. JOURNAL OF RELIGION AND HEALTH 2023; 62:4032-4071. [PMID: 37891396 DOI: 10.1007/s10943-023-01930-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/01/2023] [Indexed: 10/29/2023]
Abstract
This paper describes the development and initial chaplaincy user evaluation of 'Pastoral Narrative Disclosure' (PND) as a rehabilitation strategy developed for chaplains to address moral injury among veterans. PND is an empirically informed and integrated intervention comprising eight stages of pastoral counselling, guidance and education that was developed by combining two previously existing therapeutic techniques, namely Litz et al's (2017) 'Adaptive Disclosure' and 'Confessional Practice' (Joob & Kettunen, 2013). The development and results of PND can be categorized into five phases. Phase 1: PND Strategy Formation-based upon extensive international research demonstrating that MI is a complex bio-psycho-social-spiritual syndrome with symptoms sufficiently distinct from post-traumatic stress disorder. The review also provided evidence of the importance of chaplains being involved in moral injury rehabilitation. Phase II: Development and Implementation of 'Moral Injury Skills Training' (MIST)-which involved the majority of available Australian Defence Force (ADF) Chaplains (n = 242/255: 94.9%) completing a basic 'Introduction to Moral Injury' (MIST-1) as well as an 'Introduction to PND' (MIST-2). Phase III: MIST-3-PND-Pilot evaluation-involved a representative chaplaincy cohort (n = 13) undergoing the PND eight-stage strategy to ensure the integrity and quality of PND from a chaplaincy perspective prior to wider implementation. The pilot PND evaluation indicated a favourable satisfaction rating (n = 11/13: 84.6%; M = 4.73/5.0 satisfaction). Phase IV: MIST-3-PND Implementation-involved a larger cohort of ADF Chaplaincy participants (n = 210) completing a revised and finalized PND strategy which was regarded favourably by the majority of ADF Chaplains (n = 201/210: 95.7%; M = 4.73/5.0 satisfaction). Phase V: Summation. In conclusion the positive satisfaction ratings by a significant number of ADF chaplaincy personnel completing MIST-3-PND, provided evidence that chaplains evaluated PND as a suitable counselling, guidance and education strategy, which affirmed its utilisation and justifies further research for using PND to address MI among veterans, that may also prove valuable for other chaplains working in community health and first responder contexts.
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Affiliation(s)
- Lindsay B Carey
- Palliative Care Unit, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, 3083, Australia.
- Australian Institute of Ethics and Society, University of Notre Dame, Sydney, Australia.
| | - Matthew Bambling
- Brisbane Central Clinical School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Timothy J Hodgson
- School of Historical and Philosophical Enquiry, University of Queensland, Brisbane, QLD, Australia
| | | | - Melissa G Bakhurst
- School of Psychology, The University of Queensland, St Lucia, Brisbane, Australia
| | - Harold G Koenig
- Duke University Medical Center, Durham, North Carolina, USA
- King Abdulaziz University, Jeddah, Saudi Arabia
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3
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Rice EN, Xu H, Wang Z, Webb L, Thomas L, Kadhim EF, Nunes JC, Adair KC, O’Brien EC. Post-traumatic stress disorder symptoms among healthcare workers during the COVID-19 pandemic: Analysis of the HERO Registry. PLoS One 2023; 18:e0293392. [PMID: 37943749 PMCID: PMC10635468 DOI: 10.1371/journal.pone.0293392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 10/11/2023] [Indexed: 11/12/2023] Open
Abstract
Little is known about the mental health consequences of the COVID-19 pandemic in healthcare workers (HCWs). Past literature has shown that chronic strain caused by pandemics can adversely impact a variety of mental health outcomes in HCWs. There is growing recognition of the risk of stress and loss of resilience to HCWs during the COVID-19 pandemic, although the risk of post-traumatic stress disorder (PTSD) symptoms in HCWs during the COVID-19 pandemic remains poorly understood. We wanted to understand the relationship between the COVID-19 pandemic and the risk of PTDS symptoms in HCWs during the COVID-19 pandemic. We surveyed 2038 health care workers enrolled in the Healthcare Worker Exposure Response & Outcomes (HERO) study, which is a large standardized national registry of health care workers. Participants answered questions about demographics, COVID-19 exposure, job burnout, and PTSD symptoms. We characterize the burden of PTSD symptoms among HCWs, and determined the association between high PTSD symptoms and race, gender, professional role, work setting, and geographic region using multivariable regression. In a fully adjusted model, we found that older HCWs were less likely to report high PTSD symptoms compared with younger HCWs. Additionally, we found that physicians were less likely to report high PTSD symptoms compared with nurses. These data add to the growing literature on increased risks of mental health challenges to healthcare workers during the COVID-19 pandemic.
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Affiliation(s)
- Eli N. Rice
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America
| | - Ziyi Wang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America
| | - Laura Webb
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America
| | - Emilie F. Kadhim
- Social & Behavioural Health Sciences Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Julio C. Nunes
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States of America
| | - Kathryn C. Adair
- Duke Center for Healthcare Safety and Quality, Duke University Health System, Durham, NC, United States of America
| | - Emily C. O’Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America
- Department of Population Health Sciences, Duke University, Durham, NC, United States of America
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4
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Russell B, Mussap AJ. Rumination and threat-biased interpretation mediate posttraumatic stress and growth responses to military stressors. MILITARY PSYCHOLOGY 2023; 35:451-466. [PMID: 37615560 PMCID: PMC10453989 DOI: 10.1080/08995605.2022.2127618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/14/2022] [Indexed: 10/14/2022]
Abstract
We examined the role of rumination and threat-biased interpretation in stress and growth responses to military stressors. Two online surveys were completed by 183 (survey 1) and 393 (survey 2) currently serving or retired military personnel. The surveys measured exposure to potential military stressors (exposure to combat, witnessing the consequences of war, and perceived moral injury), posttraumatic stress symptomatology (PTSS), posttraumatic growth (PTG), and personal wellbeing, with survey 1 including measures of rumination, and survey 2 including a measure of threat-biased interpretation. Path analyses revealed that indirect paths from both witnessing the consequences of war and experiencing betrayal to PTSS were mediated by intrusive rumination and threat-biased interpretation, and that indirect paths from both betrayal and transgressions by others to PTG were mediated by deliberate rumination and threat-biased interpretation. The results reveal the idiosyncratic nature of military stressors, their differential involvement with cognitions that underpin rumination about past events and interpretation of current events, and their relevance to posttraumatic stress and growth in military personnel.
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Affiliation(s)
- Brenton Russell
- School of Psychology, Deakin University, Melbourne, Australia
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5
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O'Garo KGN, Koenig HG. Spiritually Integrated Cognitive Processing Therapy for Moral Injury in the Setting of PTSD: Initial Evidence of Therapeutic Efficacy. J Nerv Ment Dis 2023; 211:656-663. [PMID: 37381149 DOI: 10.1097/nmd.0000000000001686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
ABSTRACT After defining the syndrome of moral injury (MI), reviewing its relationship to posttraumatic stress disorder (PTSD), and examining its psychological consequences and impact on functioning, we describe a new psychotherapeutic treatment for MI called spiritually integrated cognitive processing therapy (SICPT). SICPT builds on cognitive processing therapy (CPT), a commonly used trauma-focused treatment for PTSD. To our knowledge, SICPT is the first one-on-one individualized psychotherapeutic treatment that integrates a person's spiritual and religious beliefs into the treatment for MI, using the latter to work through and process the psychological, spiritual, and religious symptoms of this condition. Here, we describe the initial results obtained from a single-group experimental study examining the treatment of three patients with significant symptoms of both MI and PTSD. Given the effects of SICPT on reducing both MI and PTSD symptoms, we have decided to report these early results before study completion to alert the scientific community about this potentially effective new treatment.
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Affiliation(s)
- Keisha-Gaye N O'Garo
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
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6
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Maguen S, Nichter B, Norman SB, Pietrzak RH. Moral injury and substance use disorders among US combat veterans: results from the 2019-2020 National Health and Resilience in Veterans Study. Psychol Med 2023; 53:1364-1370. [PMID: 34409932 PMCID: PMC10009375 DOI: 10.1017/s0033291721002919] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/24/2021] [Accepted: 07/01/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Exposure to potentially morally injurious events (PMIEs) is associated with increased risk for substance use disorders (SUDs), although population-based studies remain limited. The goal of this study was to better understand the relationships between PMIE exposure and lifetime and past-year alcohol use disorder (AUD), drug use disorder (DUD), and SUD. METHODS Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 1321 combat veterans. Multivariable analyses examined associations between three types of PMIE exposure (perpetration, witnessing, and betrayal), and lifetime and past-year AUD, DUD, and SUD, adjusting for sociodemographic variables, combat exposure severity, prior trauma, and lifetime posttraumatic stress disorder and major depressive disorder. RESULTS Perpetration was associated with increased odds of lifetime AUD (OR 1.15; 95% CI 1.01-1.31) and lifetime SUD (OR 1.18; 95% CI 1.03-1.35). Witnessing was associated with greater odds of past-year DUD (OR 1.20; 95% CI 1.04-1.38) and past-year SUD (OR 1.14; 95% CI 1.02-1.28). Betrayal was associated with past-year AUD (OR 1.20; 95% CI 1.03-1.39). A large proportion of the variance in past-year AUD was accounted for by betrayal (38.7%), while witnessing accounted for 25.8% of the variance in past-year DUD. CONCLUSIONS Exposure to PMIEs may be a stronger contributor to SUDs among veterans than previously known. These findings highlight the importance of targeted assessment and treatment of moral injury among veterans with SUDs, as well as attending to specific types of morally injurious experiences when conceptualizing and planning care.
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Affiliation(s)
- Shira Maguen
- San Francisco VA Health Care System, San Francisco, CA, USA
- University of California – San Francisco, San Francisco, CA, USA
| | - Brandon Nichter
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Sonya B. Norman
- National Center for PTSD, White River Junction, VT, USA
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- VA Center of Excellence for Stress and Mental Health, San Diego, CA, USA
| | - Robert H. Pietrzak
- National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
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7
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Parry KJ, Hicken BL, Chen W, Leng J, Allen S, Burningham Z. Impact of moral injury and posttraumatic stress disorder on health care utilization and suicidality in rural and urban veterans. J Trauma Stress 2023; 36:117-128. [PMID: 36330588 DOI: 10.1002/jts.22889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 08/25/2022] [Accepted: 09/07/2022] [Indexed: 11/06/2022]
Abstract
This study explored the impact of moral injury (MI) and posttraumatic stress disorder (PTSD) on health care utilization, mental health complexity, and suicidality in rural and urban veterans. Analyses combined data from the Salt Lake City PTSD Clinic Intake Database and the Department of Veterans Affairs Corporate Data Warehouse. Participants (N = 1,545; Mage = 45.9 years) were predominately male (88.3%) and White (87.8%). Adjusted analyses indicated associations between a 1-unit increase in Moral Injury Events Scale (MIES) score and increased mental health complexity, RR = 1.01, 95% CI [1.01, 1.02], p < .001; psychotropic medication utilization, RR = 1.01, 95% CI [1.01, 1.03], p < .001; VA drug class count, RR = 1.01, 95% CI [1.00, 1.01], p = .030; outpatient utilization, RR = 1.01, 95% CI [1.01, 1.02], p < .001; and mental health outpatient utilization, RR = 1.01, 95% CI [1.00, 1.03], p < .001. For the MIES x PTSD interaction, all associations remained statistically significant with similar estimated effects. However, for rural veterans, this interaction did not significantly affect utilization. Among those with PTSD, a 1-unit MIES increase was associated with an increased risk of suicidality, OR = 1.02, 95% CI [1.01, 1.04], and psychiatric admission, OR = 1.02, 95% CI [1.00, 1.04]. Findings suggest that higher MIES scores predict increased health care utilization and mental health complexity. Further, PTSD combined with higher MIES scores may increase the risk of suicidality and psychiatric admission. Rural veterans with PTSD and higher MIES scores may require additional outreach and intervention.
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Affiliation(s)
- Kimber J Parry
- U.S. Department of Veterans Affairs, Veterans Health Administration (VHA) Office of Rural Health, Veterans Rural Health Resource Center, Salt Lake City, Utah, USA
| | - Bret L Hicken
- U.S. Department of Veterans Affairs, Veterans Health Administration (VHA) Office of Rural Health, Veterans Rural Health Resource Center, Salt Lake City, Utah, USA
| | - Wei Chen
- VA Salt Lake City Medical Center, Health Services Research and Development, Information, Decision-Enhancement, and Analytic Science Center of Innovation, Salt Lake City, Utah, USA.,Division of Epidemiology, Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jianwei Leng
- VA Salt Lake City Medical Center, Health Services Research and Development, Information, Decision-Enhancement, and Analytic Science Center of Innovation, Salt Lake City, Utah, USA.,Division of Epidemiology, Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Steven Allen
- George E. Whalen Department of Veterans Affairs, Salt Lake City PTSD Clinic, Salt Lake City, Utah, USA
| | - Zachary Burningham
- U.S. Department of Veterans Affairs, Veterans Health Administration (VHA) Office of Rural Health, Veterans Rural Health Resource Center, Salt Lake City, Utah, USA.,VA Salt Lake City Medical Center, Health Services Research and Development, Information, Decision-Enhancement, and Analytic Science Center of Innovation, Salt Lake City, Utah, USA.,Division of Epidemiology, Internal Medicine, University of Utah, Salt Lake City, Utah, USA
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8
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Szabó D, Békés V, Lévay EE, Salgó E, Unoka ZS. Moral injury in psychiatric patients with personality and other clinical disorders: development, psychometric properties, and validity of the Moral Injury Events Scale-Civilian Version. Eur J Psychotraumatol 2023; 14:2247227. [PMID: 37650250 PMCID: PMC10472878 DOI: 10.1080/20008066.2023.2247227] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 09/01/2023] Open
Abstract
Background: Moral injury emerges when someone perpetrates, fails to prevent, or witnesses acts that violate their own moral or ethical code. Nash et al. [(2013). Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646-652] developed a short measure, the Moral Injury Events Scale (MIES) to facilitate the empirical study of moral injury in the military. Our study aimed to develop a civilian version of the measure (MIES-CV) and examine its psychometric properties in a sample of psychiatric inpatients .Methods: In this cross-sectional study, the sample comprised 240 adult patients (71.7% female) with a mean age of 31.57 (SD = 11.69). The most common diagnoses in the sample were anxiety disorders (58.3%), depressive disorders (53.8%), and borderline personality disorder (39.6%). Participants were diagnosed using structured clinical interviews and filled out psychological questionnaires.Results: Exploratory factor analysis suggested that Nash et al.'s model (Perceived Transgressions, Perceived Betrayals) represents the data well. This two-factor solution showed an excellent fit in the confirmatory factor analysis, as well. Meaningful associations were observed between moral injury and psychopathology dimensions, shame, reflective functioning, well-being, and resilience. The Perceived Betrayals factor was a significant predictor of bipolar disorders, PTSD, paranoid personality disorder, borderline personality disorder, and avoidant personality disorder.Conclusions: Our study demonstrated that this broad version of the MIES is a valid measure of moral injury that can be applied to psychiatric patients.
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Affiliation(s)
- Dominik Szabó
- Doctoral School of Mental Health Sciences, Semmelweis University, Budapest, Hungary
| | - Vera Békés
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA
| | - Erika Evelyn Lévay
- Doctoral School of Mental Health Sciences, Semmelweis University, Budapest, Hungary
| | - Ella Salgó
- Doctoral School of Mental Health Sciences, Semmelweis University, Budapest, Hungary
| | - Zsolt Szabolcs Unoka
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
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9
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Chesnut RP, Richardson CB, Morgan NR, Bleser JA, Mccarthy KJ, Perkins DF. The Moral Injury Symptoms Scale-Military Version-Short Form: Further Scale Validation in a U.S. Veteran Sample. JOURNAL OF RELIGION AND HEALTH 2022; 61:3384-3401. [PMID: 35790578 DOI: 10.1007/s10943-022-01606-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/23/2022] [Indexed: 06/15/2023]
Abstract
This study assessed the Moral Injury Symptoms Scale - Military Version - Short Form's (MISS-M-SF) factor structure and construct validity. Participants included 3650 combat-deployed U.S. veterans who answered all 10 MISS-M-SF items from the sixth wave of The Veterans Metric Initiative (TVMI). EFA results suggested a two-factor solution, based on item wording, fit best. CFA results indicated a bifactor model (one general factor and two method factors, based on item wording) fit best. Further investigation revealed that a one-factor model could be used despite the data's multidimensionality. Item-level analyses revealed four items represented the general factor exceptionally well, potentially simplifying assessment in research and clinical applications. Construct validity was also demonstrated through moderate to high correlations with conceptually related measures.
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Affiliation(s)
- Ryan P Chesnut
- Clearinghouse for Military Family Readiness, The Pennsylvania State University, 402 Marion Place, University Park, PA, 16802, USA.
| | - Cameron B Richardson
- Clearinghouse for Military Family Readiness, The Pennsylvania State University, 402 Marion Place, University Park, PA, 16802, USA
| | - Nicole R Morgan
- Clearinghouse for Military Family Readiness, The Pennsylvania State University, 402 Marion Place, University Park, PA, 16802, USA
| | - Julia A Bleser
- Clearinghouse for Military Family Readiness, The Pennsylvania State University, 402 Marion Place, University Park, PA, 16802, USA
- National Network of Public Health Institutes, Washington D.C., USA
| | - Kimberly J Mccarthy
- Clearinghouse for Military Family Readiness, The Pennsylvania State University, 402 Marion Place, University Park, PA, 16802, USA
| | - Daniel F Perkins
- Clearinghouse for Military Family Readiness, The Pennsylvania State University, 402 Marion Place, University Park, PA, 16802, USA
- Department of Agricultural Economics, Sociology and Education, The Pennsylvania State University, University Park, PA, USA
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10
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Jin J, Weiman K, Bremault-Phillips S, Vermetten E. Moral Injury and Recovery in Uniformed Professionals: Lessons From Conversations Among International Students and Experts. Front Psychiatry 2022; 13:880442. [PMID: 35774092 PMCID: PMC9237246 DOI: 10.3389/fpsyt.2022.880442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction In the course of service, military members, leaders, and uniformed professionals are at risk of exposure to potentially morally injurious events (PMIEs). Serious mental health consequences including Moral Injury (MI) and Post-traumatic stress disorder (PTSD) can result. Guilt, shame, spiritual/existential conflict, and loss of trust are described as core symptoms of MI. These can overlap with anxiety, anger, re-experiencing, self-harm, and social problems commonly seen in PTSD. The experiences of General (retired) Romeo Dallaire and other international experts who have led in times of crisis can help us better understand MI and recovery. Objectives In honor of Dallaire, online opportunities were created for international students and leaders/experts to discuss topics of MI, stigma, and moral codes in times of adversity as well as the moral impact of war. We aimed to (1) better understand MI and moral dilemmas, and (2) identify key insights that could inform prevention of and recovery from MI. Materials and Methods Webinars and conversations of 75-90 min duration on MI and recovery were facilitated by Leiden University, the University of Alberta and the Dallaire Institute for Children, Peace and Security between General Dallaire, world experts, and graduate students. Sessions were recorded, transcribed and thematically analyzed with NVivo using standard qualitative methodology. Results Ninety four participants engaged in conversations. Student engagements were attended by participants [N = 51; female (29), male (22)] from the Netherlands and Canada. Conversations were held with international experts [N = 43; female (19) and male (24)] from North America, Europe, Australia and the global south. Themes included: (1) recognizing the impact of exposure to PMIEs, (2) reducing stigma around MI, and (3) embracing the spiritual depth of humanity. Conclusion Exposure to PMIEs can have devastating impacts on military members, leaders and other uniformed professionals. This may lead to development of MI and PTSD. Recognizing MI as honorable may reduce stigma and psychological harm, and facilitate help-seeking among uniformed personnel and other trauma-affected populations. Salient efforts to address MI must include use of accurate measurements of MI and integrated holistic therapeutic approaches, inclusive of spiritual and social components. Urgency remains regarding the prediction, identification and treatment of MI.
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Affiliation(s)
- Jonathan Jin
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Kyle Weiman
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Suzette Bremault-Phillips
- Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Eric Vermetten
- Department of Psychiatry, Leiden University Medical Center, Leiden, Netherlands
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11
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Nieuwsma JA, O'Brien EC, Xu H, Smigelsky MA, Meador KG. Patterns of Potential Moral Injury in Post-9/11 Combat Veterans and COVID-19 Healthcare Workers. J Gen Intern Med 2022; 37:2033-2040. [PMID: 35381899 PMCID: PMC8982664 DOI: 10.1007/s11606-022-07487-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/09/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Moral injury has primarily been studied in combat veterans but might also affect healthcare workers (HCWs) due to the COVID-19 pandemic. OBJECTIVE To compare patterns of potential moral injury (PMI) between post-9/11 military combat veterans and healthcare workers (HCWs) surveyed during the COVID-19 pandemic. DESIGN Cross-sectional surveys of veterans (2015-2019) and HCWs (2020-2021) in the USA. PARTICIPANTS 618 military veterans who were deployed to a combat zone after September 11, 2001, and 2099 HCWs working in healthcare during the COVID-19 pandemic. MAIN MEASURES Other-induced PMI (disturbed by others' immoral acts) and self-induced PMI (disturbed by having violated own morals) were the primary outcomes. Sociodemographic variables, combat/COVID-19 experience, depression, quality of life, and burnout were measured as correlates. KEY RESULTS 46.1% of post-9/11 veterans and 50.7% of HCWs endorsed other-induced PMI, whereas 24.1% of post-9/11 veterans and 18.2% of HCWs endorsed self-induced PMI. Different types of PMI were significantly associated with gender, race, enlisted vs. officer status, and post-battle traumatic experiences among veterans and with age, race, working in a high COVID-19-risk setting, and reported COVID-19 exposure among HCWs. Endorsing either type of PMI was associated with significantly higher depressive symptoms and worse quality of life in both samples and higher burnout among HCWs. CONCLUSIONS The potential for moral injury is relatively high among combat veterans and COVID-19 HCWs, with deleterious consequences for mental health and burnout. Demographic characteristics suggestive of less social empowerment may increase risk for moral injury. Longitudinal research among COVID-19 HCWs is needed. Moral injury prevention and intervention efforts for HCWs may benefit from consulting models used with veterans.
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Affiliation(s)
- Jason A Nieuwsma
- Integrative Mental Health, Department of Veterans Affairs, Durham, NC, USA. .,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA. .,VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA.
| | | | - Haolin Xu
- Duke Clinical Research Institute, Durham, NC, USA
| | - Melissa A Smigelsky
- Integrative Mental Health, Department of Veterans Affairs, Durham, NC, USA.,VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA
| | | | | | - Keith G Meador
- Integrative Mental Health, Department of Veterans Affairs, Durham, NC, USA.,VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA.,Department of Psychiatry and Preventative Medicine, Center for Biomedical Ethics and Society, & Graduate Department of Religion, Vanderbilt University, Nashville, TN, USA
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12
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Fleming WH. Complex Moral Injury: Shattered Moral Assumptions. JOURNAL OF RELIGION AND HEALTH 2022; 61:1022-1050. [PMID: 35274226 DOI: 10.1007/s10943-022-01542-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/26/2022] [Indexed: 06/14/2023]
Abstract
An infographic model of moral injury (MI) is introduced in this conceptual paper that distinguishes the development of a worldview discrepancy-induced genus of MI, called complex moral injury (C-MI), from a standard expression of moral injury (S-MI), clearly delineated as perpetration-focused and a violation of moral belief in the contemporary view. It builds upon a previous essay that examined the potential of paradoxical circumstance (e.g., clashes of value, competing moral expectations, and moral paradox) to inflict MI among military personnel during wartime (Fleming in J Relig Health 60(5):3012-3033, 2021). Accordingly, it heeds Litz et al.'s recommendation to expand the research of MI beyond the effects of perpetration and investigate the impact of morally injurious events that shake one's core moral beliefs about the world and self (Litz et al. in Clin Psychol Rev 29(8):695-706, 2009). A review of definitional, scale, and qualitative studies shows evidence of a nuanced and complex form of MI that presents as moral disorientation and is a response to a disruption and subsequent failure of foundational moral beliefs to adequately appraise ethical problems and inform moral identity. Interrelations between MI, assumptive world, and meaning theories suggest the mechanism of C-MI and potential therapies. Case studies from a Veterans Administration hospital in the United States and a walk through the diagram will help illustrate the model. Clinical implications of a definition that includes morally injurious events that shatter fundamental moral assumptions are discussed. The role of chaplains in facilitating acceptance and meaning-making processes is recommended for C-MI recovery. Acknowledging the model's need for empirical support, a plausible scale is discussed for future research.
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Affiliation(s)
- Wesley H Fleming
- Clinical Chaplain, Syracuse VAMC, 800 Irving Ave, Syracuse, NY, 13210, USA.
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13
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Nieuwsma JA, Smigelsky MA, Grossoehme DH. Introduction to the special issue "Moral injury care: Practices and collaboration". J Health Care Chaplain 2022; 28:S3-S8. [PMID: 35254952 DOI: 10.1080/08854726.2022.2047564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Since moral injury was introduced in the psychological literature little more than a decade ago, it has received substantial attention from mental health professionals as well as chaplains. This special issue features ways that chaplains are and can be engaged in addressing moral injury within health care contexts, especially the Department of Veterans Affairs. The efforts highlighted in this special issue provide building blocks for advancing moral injury care practices, research agendas, and interdisciplinary collaborations into the future.
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Affiliation(s)
- Jason A Nieuwsma
- Integrative Mental Health, Department of Veterans Affairs, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, USA.,Vanderbilt Divinity School, USA
| | | | - Daniel H Grossoehme
- Haslinger Family Pediatric Palliative Care Center, Rebecca D. Considine Research Institute, Akron Children's Hospital, USA
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14
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Pernicano PU, Wortmann J, Haynes K. Acceptance and forgiveness therapy for veterans with moral injury: spiritual and psychological collaboration in group treatment. J Health Care Chaplain 2022; 28:S57-S78. [PMID: 35135436 DOI: 10.1080/08854726.2022.2032982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The authors developed Acceptance and Forgiveness Therapy (AFT), a psychospiritual group intervention that guides veterans with moral injury experientially from a trauma-focused (damaged, broken, guilty, unforgivable, hopeless, unacceptable) to restorative (worthy, connected, hopeful, forgiven, responsible) view of self. A mental health (MH)-trained chaplain and MH provider, as co-leaders, provide psychoeducation, facilitate therapeutic interaction, and encourage home practice. The curriculum includes evidence-driven psychological interventions, spiritually oriented practices, and metaphor, story, and art to illustrate concepts and facilitate self-expression. Scores on the Brief Symptom Inventory-18 and Acceptance and Action Questionnaire-2 showed decreased distress and increased flexibility. Post-group drawings reflect renewed purpose, greater self-acceptance, and meaningful engagement with others. Retention rate across seven group administrations ranged from 50% to 100%. Outcomes suggest AFT is a promising practice for veteran moral injury meriting further study and implementation.
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Affiliation(s)
| | - Jennifer Wortmann
- Department of Veterans Affairs, Integrative Mental Health, Durham, NC, USA
| | - Kerry Haynes
- South Texas Veterans Health Care System, San Antonio, TX, USA
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15
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Kopacz M, Bishop TM, Ayre A, Boska RL, Goldstrom D, Tomberlin D, Baxter S, Dunlap S, Harris JI. Feasibility of using moral injury screening instruments in VA chaplaincy spiritual assessments. J Health Care Chaplain 2022; 28:S89-S100. [PMID: 35130126 DOI: 10.1080/08854726.2022.2032980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Some veterans experience symptoms of moral injury after being exposed to the ethical and moral challenges associated with military service. While it is well known that moral injury is associated with an increased risk for suicide as well as other mental health concerns, few tools exist to systematically screen for moral injury in chaplaincy settings. This preliminary study examines the psychometric properties as well as feasibility of applying two new moral injury screening tools that could be used with routine spiritual assessments, purposefully designed to assess for moral injury in chaplaincy settings at Department of Veterans Affairs (VA) Medical Centers. The results provide preliminary psychometric evidence to support the reliability and validity of these two new screening tools, which were shown to be feasible for use in VA chaplaincy settings.
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Affiliation(s)
- Marek Kopacz
- Military Analytics, Fors Marsh Group, Arlington, VA, USA
| | - Todd M Bishop
- VA Center of Excellence for Suicide Prevention, Washington, DC, USA.,Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - Amanda Ayre
- VA Bedford Health Care System, Bedford, MA, USA
| | - Rachel L Boska
- VA Center of Excellence for Suicide Prevention, Washington, DC, USA
| | | | | | | | - Shawn Dunlap
- Center for Healthcare Organization and Implementation Research, Bedford, MA, USA
| | - J Irene Harris
- VA Bedford Health Care System, Bedford, MA, USA.,University of Minnesota Medical School, Minneapolis, MN, USA
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16
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Denov M. Encountering children and child soldiers during military deployments: the impact and implications for moral injury. Eur J Psychotraumatol 2022; 13:2104007. [PMID: 35979504 PMCID: PMC9377244 DOI: 10.1080/20008066.2022.2104007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: During a deployment, soldiers must make seemingly impossible decisions, including having to engage with child soldiers. Such moral conflicts may continue to affect service members and veterans in the aftermath of a deployment, sometimes leading to severe moral distress, anguish, and personal crises. Service providers have increasingly argued that as a diagnosis, Post-Traumatic Stress Disorder (PTSD) cannot account for these deeply personal and painful moral conflicts. In light of this, the concept of moral injury has been introduced to better capture the profound forms of guilt and shame that may be experienced by service members and veterans. Objective: This paper addresses encounters with children and child soldiers during military deployments, as well as the risk for moral injury during and following these encounters, and their implications. This exploratory paper brings together existing literature on the topic to introduce, illustrate, and offer potential and promising interventions. Results: Given the potential moral conflicts that may ensue, military personnel who encounter child soldiers during a military deployment may be at risk for moral injury during and following these encounters. The introduction of the concept of moral injury provides a way for these largely unnamed personal and painful moral conflicts and violations to be recognized, addressed, and with appropriate care, remedied. Although there is limited research into their effectiveness at treating moral injury, individual and group-based interventions have been identified as potentially beneficial. Conclusion: As encounters with children during deployments are likely to continue, systematic research, training, healing interventions and prevention strategies are vital to support and protect children in conflict settings, as well as to ensure the mental health and well-being of service members and veterans. HIGHLIGHTS Profound moral conflicts may affect service members and veterans in the aftermath of a military deployment, sometimes leading to severe moral distress, anguish, and personal crises. The concept of moral injury has been introduced to better capture the profound forms of guilt and shame that may be experienced by service members and veterans.Encountering children and child soldiers during a military deployment, may present unique challenges, stress, and moral crises leading to potentially moral injurious events. In particular, transgression-based events which result from an individual perpetrating or engaging in acts that contravene his or her deeply held moral beliefs and expectations such as harming children, and betrayal-based events, which results from witnessing or falling victim to the perceived moral transgressions of others, may lead to lasting psychological, biological, spiritual, behavioural and social impairments.Interventions applied in both an individual-based context such as Cognitive Processing Therapy, Impact of Killing, Adaptive Disclosure, and a group-based context such as Acceptance and Commitment Therapy and Resilience Strength Training, have been identified as potentially beneficial to addressing moral injury. However, more research is required to ascertain appropriate and effective intervention and healing strategies.
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Affiliation(s)
- Myriam Denov
- School of Social Work, McGill University, Montreal, Canada
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17
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Wortmann JH, Nieuwsma JA, King HA, Fernandez P, Jackson GL, Smigelsky MA, Cantrell W, Meador KG. Collaborative spiritual care for moral injury in the veterans Affairs Healthcare System (VA): Results from a national survey of VA chaplains. J Health Care Chaplain 2021; 28:S9-S24. [PMID: 34825859 DOI: 10.1080/08854726.2021.2004847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The psychospiritual nature of moral injury invites consideration regarding how chaplains understand the construct and provide care. To identify how chaplains in the VA Healthcare System conceptualize moral injury, we conducted an anonymous online survey (N = 361; 45% response rate). Chaplains responded to a battery of items and provided free-text definitions of moral injury that generally aligned with key elements in the existing literature, though with different emphases. Over 90% of chaplain respondents indicated that they encounter moral injury in their chaplaincy care, and a similar proportion agreed that chaplains and mental health professionals should collaborate in providing care for moral injury. Over one-third of chaplain respondents reported offering or planning to offer a moral injury group. Separately, nearly one-quarter indicated present or planned collaboration with mental health to provide groups that in some manner address moral injury. Previous training in evidence-based and collaborative care approaches appears to contribute to the likelihood of providing integrated psychosocial-spiritual care. Results and future directions are discussed, including a description of moral injury that may be helpful to understand present areas of emphasis in VA chaplains' care for moral injury.
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Affiliation(s)
- Jennifer H Wortmann
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - Jason A Nieuwsma
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Department of Population Health Sciences, Duke University, Durham, NC, USA.,Division of General Internal Medicine, Duke University, Durham, NC, USA
| | - Paola Fernandez
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Department of Psychology, University of South Alabama, Mobile, AL, USA
| | - George L Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Department of Population Health Sciences, Duke University, Durham, NC, USA.,Division of General Internal Medicine, Duke University, Durham, NC, USA.,Department of Family Medicine and Community Health, Duke University, Durham, NC, USA
| | - Melissa A Smigelsky
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - William Cantrell
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - Keith G Meador
- Integrative Mental Health, Veterans Affairs Healthcare System, Durham, NC, USA.,VA Mid-Atlantic MIRECC, Durham Veterans Affairs Healthcare System, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Vanderbilt University, Nashville, TN, USA.,Center for Biomedical Ethics and Society, Vanderbilt University, Nashville, TN, USA.,Department of Health Policy, Vanderbilt University, Nashville, TN, USA.,Graduate Department of Religion, Vanderbilt University, Nashville, TN, USA
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18
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Fleming WH. Moral Injury and the Absurd: The suffering of moral paradox. JOURNAL OF RELIGION AND HEALTH 2021; 60:3012-3033. [PMID: 33725298 DOI: 10.1007/s10943-021-01227-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/04/2021] [Indexed: 05/15/2023]
Abstract
Drawing upon qualitative and construct validity evidence within MI research and the oral histories of combat-exposed Veterans, this paper explores the role of moral paradox (MP) as a precondition of moral injury (MI). Research is recommended to clearly delineate MP as a causative factor leading to more intractable cases of MI in the definitional literature, beyond the recognized impact of perpetration and betrayal-based conditions. Veteran stories collected during the normal course of providing spiritual care to combat-exposed Veterans and used by permission will provide insight into the theoretical concepts and interrelations of MP; proposed here as: circumstances in which moral obligations and/or ethical values come into conflict, forcing a choice between sides, none of which can be honored without violating the other. Acquainted with religious traditions that elucidate the perplexity and liberating effects of paradox, the work of Chaplains will also be recommended to address the problem of MP in wartime situations, highlighting the efficacy of acceptance-based spiritual interventions and therapeutic programs. Psychological and spiritual interventions that facilitate self-transcendence and non-dual awareness through experiential acceptance and a subscale measuring paradox-induced injury will be recommended for future research as well.
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19
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Koenig HG, Al Zaben F. Moral Injury: An Increasingly Recognized and Widespread Syndrome. JOURNAL OF RELIGION AND HEALTH 2021; 60:2989-3011. [PMID: 34245433 PMCID: PMC8270769 DOI: 10.1007/s10943-021-01328-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 05/05/2023]
Abstract
Moral injury (MI), originally discussed in relationship to transgressing moral beliefs and values during wartime among military personnel, has expanded beyond this context to include similar emotions experienced by healthcare professionals, first responders, and others experiencing moral emotions resulting from actions taken or observations made during traumatic events or circumstances. In this article, we review the history, definition, measurement, prevalence, distinctiveness, psychological consequences, manifestations (in and outside of military settings), and correlates of MI in different settings. We also review secular psychological treatments, spiritually integrated therapies, and pastoral care approaches (specific for clergy and chaplains) used to treat MI and the evidence documenting their efficacy. Finally, we examine directions for future research needed to fill the many gaps in our knowledge about MI, how it develops, and how to help those suffering from it.
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Affiliation(s)
- Harold G Koenig
- Departments of Psychiatry and Medicine, Duke University Health System, Durham, NC, 27705, USA.
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
- School of Public Health, Ningxia Medical University, Yinchuan, People's Republic of China.
- Department of Psychiatry, Shiraz University of Medical Sciences, Shiraz, Iran.
- Department of Psychiatry, Duke University Medical Center, Box 3400, Durham, NC, 27710, USA.
| | - Faten Al Zaben
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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20
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Held P, Klassen BJ, Steigerwald VL, Smith DL, Bravo K, Rozek DC, Van Horn R, Zalta A. Do morally injurious experiences and index events negatively impact intensive PTSD treatment outcomes among combat veterans? Eur J Psychotraumatol 2021; 12:1877026. [PMID: 34025919 PMCID: PMC8128118 DOI: 10.1080/20008198.2021.1877026] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Background: It has been suggested that current frontline posttraumatic stress disorder (PTSD) treatments are not effective for the treatment of moral injury and that individuals who have experienced morally injurious events may respond differently to treatment than those who have not. However, these claims have yet to be empirically tested. Objective: This study evaluated the rates of morally injurious event exposure and morally injurious index trauma and their impact on PTSD (PCL-5) and depression symptom (PHQ-9) reductions during intensive PTSD treatment. Method: Data from 161 USA military combat service members and veterans (91.3% male; mean age = 39.94 years) who participated in a 3-week Cognitive Processing Therapy (CPT)-based intensive PTSD treatment programme (ITP) was utilized. Morally injurious event exposure was established via the Moral Injury Event Scale (MIES). Index traumas were also coded by the treating clinician. Linear mixed effects regression analyses were conducted to examine if differences in average effects or trends over the course of treatment existed between veterans with morally injurious event exposure or index trauma and those without. Results: Rates of morally injurious event exposure in this treatment sample were high (59.0%-75.2%). Morally injurious event exposure and the type of index trauma did not predict changes in symptom outcomes from the ITP and veterans reported large reductions in PTSD (d = 1.35-1.96) and depression symptoms (d = 0.95-1.24) from pre- to post-treatment. Non-inferiority analyses also demonstrated equivalence across those with and without morally injurious event exposure and index events. There were no significant gender differences. Conclusions: The present study suggests that PTSD and depression in military veterans with morally injurious event exposure histories may be successfully treated via a 3-week CPT-based ITP.
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Affiliation(s)
- Philip Held
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Brian J Klassen
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Victoria L Steigerwald
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Dale L Smith
- Department of Behavioral Sciences, Olivet Nazarene University, Burbonnais, IL, USA
| | - Karyna Bravo
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | - David C Rozek
- UCF RESTORES and Department of Psychology, University of Central Florida, Orlando, FL, USA
| | - Rebecca Van Horn
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Alyson Zalta
- Department of Psychological Science, University of California, Irvine, CA, USA
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