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Fry KM, Bennett DC, Roberge EM, McClain CM, Rugo-Cook K, Brewczynski J, Pryor C. The effects of Religiosity, Spirituality, and sense of purpose on posttraumatic stress disorder treatment outcomes among Veterans. J Psychiatr Res 2024; 176:276-281. [PMID: 38905760 DOI: 10.1016/j.jpsychires.2024.05.054] [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] [Received: 12/18/2023] [Revised: 05/17/2024] [Accepted: 05/29/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Religion/spirituality (R/S) is an important and commonly used resource for coping with difficult experiences and has been shown to reduce the development of posttraumatic stress disorder (PTSD) symptoms following a trauma. However, it is not clear how R/S affects response to treatment of PTSD. OBJECTIVE The aim of this paper was to understand how Veterans' R/S and sense of purpose were related to clinical outcomes when engaging in Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE). It was predicted that Veterans identifying as R/S would have a higher sense of purpose, be more likely to complete treatment, and have greater symptom change during treatment. METHOD The study included 91 military Veterans from a VA Medical Center outpatient PTSD Clinical Team who initiated CPT or PE and responded to a question about the importance of R/S in their lives at intake. RESULTS Forty nine percent of the Veterans in this sample reported R/S were important to them and had mixed feelings about whether their life had a clear sense of purpose. Neither R/S nor sense of purpose were associated with treatment completion or response to PTSD treatment. CONCLUSION These findings suggest that once PTSD has developed, R/S or sense of purpose may not play a significant role in completion of or response to evidence-based psychotherapies (EBPs) for PTSD. EBPs for PTSD are equally effective for Veterans identifying as R/S and those who do not, which may be reflective of administering EBPs in a culturally responsive manner.
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Affiliation(s)
- Katie M Fry
- VA Salt Lake City Healthcare System, United States.
| | - Diana C Bennett
- VA Salt Lake City Healthcare System, United States; Department of Psychiatry, University of Utah Spencer Fox Eccles School of Medicine, United States
| | - Erika M Roberge
- VA Salt Lake City Healthcare System, United States; Department of Psychiatry, University of Utah Spencer Fox Eccles School of Medicine, United States
| | | | | | - Jacek Brewczynski
- VA Salt Lake City Healthcare System, United States; Department of Psychiatry, University of Utah Spencer Fox Eccles School of Medicine, United States; Department of Psychology, University of Utah, United States
| | - Cosette Pryor
- VA Salt Lake City Healthcare System, United States; Department of Psychology, University of Utah, United States
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Fleming WH, Smigelsky MA. Enhancing the Utility of the Moral Injury Experience Wheel: Manualized Applications for Diverse Contexts. JOURNAL OF RELIGION AND HEALTH 2024:10.1007/s10943-024-02082-9. [PMID: 38992253 DOI: 10.1007/s10943-024-02082-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/20/2024] [Indexed: 07/13/2024]
Abstract
Moral injury has emerged as an important construct for understanding the distress experienced in the aftermath of a moral violation, initially among combat veterans and increasingly among other populations, such as healthcare workers and first responders. While numerous measures have been validated to assess for exposure to potentially morally injurious events and/or sequelae, additional tools are needed to facilitate nuanced discussion of the experience of moral injury in therapeutic encounters. The Moral Injury Experience Wheel (MIEW; Fleming, 2023) is an infographic instrument that is designed to elicit precise language and help differentiate feelings in an effort to process morally perplexing circumstances. This paper describes the contents and potential clinical applications of a newly developed manual to guide the use of the MIEW. The MIEW and manual are designed to be used independently or alongside existing moral injury interventions. A case study featuring the use of the MIEW and manual demonstrates how the tools can be used in a professional healthcare setting. Recommendations for moral injury care practitioners are provided.
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Affiliation(s)
- Wesley H Fleming
- Clinical Chaplain, Syracuse VAMC, 800 Irving Ave, Syracuse, NY, 13210, USA.
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Levy A, Gross ML. From active duty to activism: how moral injury and combat trauma drive political activism and societal reintegration among Israeli veterans. Front Public Health 2024; 12:1336406. [PMID: 38932767 PMCID: PMC11200126 DOI: 10.3389/fpubh.2024.1336406] [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: 11/10/2023] [Accepted: 05/15/2024] [Indexed: 06/28/2024] Open
Abstract
Trigger warning This article deals with combat experiences and their consequences and could be potentially disturbing. Introduction Moral injury (MI) is a severe form of combat trauma that shatters soldiers' moral bearings as the result of killing in war. Among the myriad ways that moral injury affects veterans' reintegration into civilian life, its impact on political and societal reintegration remains largely unstudied but crucial for personal, community, and national health. Methods 13 in-depth interviews examine combat soldiers' exposure to potentially morally injurious events (PMIEs) that include killing enemy combatants, harming civilians, and betrayal by commanders, the military system, and society. Interviewees also described their political activities (e.g., voting, fundraising, advocacy, protest) and social activism (e.g., volunteering, teaching, charitable work). Interviewees also completed the Moral Injury Symptom Scale. Results Two distinct narratives process PMIEs. In a humanitarian narrative, soldiers hold themselves or their in-group morally responsible for perpetrating, witnessing, or failing to prevent a morally transgressive act such as killing or injuring civilians or placing others at unnecessary risk. In contrast, a national security perspective blames an out-group for leaving soldiers with no choice but to act in ways that trigger moral distress. Associated with shame and guilt, the humanitarian perspective triggered amends-making and social activism after discharge. In contrast, a national security perspective associated with anger and frustration fostered protest and intense political activism. Discussion Despite its harmful health effects, moral trauma and injury can drive intense political and social activism, depending upon the narrative veterans adopt to interpret PMIEs. Aside from moral injury's personal, familial, and social effects, moral injury drives veterans' return to the political arena of civil society. As such, veterans play a central role in politics and dramatically affect post-war policy in democratic nations following conflict.
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Affiliation(s)
- Adi Levy
- Department of Jewish Studies and Political Science, Florida Atlantic University, Boca Raton, FL, United States
- Israel Institute and Florida Atlantic University, Boca Raton, FL, United States
| | - Michael L. Gross
- School of Political Science, The University of Haifa, Haifa, Israel
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Williamson V, Murphy D, Bonson A, Biscoe N, Leightley D, Aldridge V, Greenberg N. Restore and Rebuild (R&R): a protocol for a phase 2, randomised control trial to compare R&R as a treatment for moral injury-related mental health difficulties in UK military veterans to treatment as usual. BMJ Open 2024; 14:e082562. [PMID: 38754887 PMCID: PMC11097824 DOI: 10.1136/bmjopen-2023-082562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/21/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Exposure to potentially morally injurious events is increasingly recognised as a concern across a range of occupational groups, including UK military veterans. Moral injury-related mental health difficulties can be challenging for clinicians to treat and there is currently no validated treatment available for UK veterans. We developed Restore and Rebuild (R&R) as a treatment for UK veterans struggling with moral injury-related mental health difficulties. This trial aims to examine whether it is feasible to conduct a pilot randomised controlled trial (RCT) of R&R treatment compared with a treatment-as-usual (TAU) control group. METHODS We will use a feasibility single-blind, single-site RCT design. The target population will be UK military veterans with moral injury-related mental health difficulties. We will recruit N=46 veteran patients who will be randomly allocated to R&R (n=23) or TAU (n=23). Patients randomised to R&R will receive the 20-session one-to-one treatment, delivered online. Veterans allocated to TAU, as there are currently no manualised treatments for moral injury-related mental health problems available, will receive the one-to-one treatment (online) typically provided to veterans who enter the mental health service for moral injury-related mental health difficulties. We will collect outcome measures of moral injury, post-traumatic stress disorder (PTSD), alcohol misuse, common mental disorders and trauma memory at pretreatment baseline (before randomisation), end of treatment, 12 weeks and 24 weeks post-treatment. The primary outcome will be the proportion of patients who screen positive for PTSD and moral injury-related distress post-treatment. ETHICS AND DISSEMINATION This trial will establish whether R&R is feasible, well-tolerated and beneficial treatment for veterans with moral injury-related mental health difficulties. If so, the results of the trial will be widely disseminated and R&R may improve access to effective care for those who struggle following moral injury and reduce the associated negative consequences for veterans, their families and wider society. TRIAL REGISTRATION NUMBER ISRCTN99573523.
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Affiliation(s)
- Victoria Williamson
- Department of Psychology, University of Exeter, Exeter, UK
- King's College London, London, UK
| | - Dominic Murphy
- King's College London, London, UK
- Combat Stress, Leatherhead, UK
| | - Amanda Bonson
- King's College London, London, UK
- Combat Stress, Leatherhead, UK
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Vismaya A, Gopi A, Romate J, Rajkumar E. Psychological interventions to promote self-forgiveness: a systematic review. BMC Psychol 2024; 12:258. [PMID: 38725052 PMCID: PMC11084121 DOI: 10.1186/s40359-024-01671-3] [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: 08/30/2023] [Accepted: 03/17/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Being able to forgive one's own wrongdoings improves the health and well-being of a person. People find it difficult to forgive themselves due to different reasons. It is essential to enhance the ability to accept one's deeds and thereby enhance self-forgiveness. The current systematic review's objective is to comprehend the application and efficiency of numerous interventions that improve self-forgiveness. METHODS The search was done on electronic databases such as PubMed, ERIC, Web of Science, PsycNet, Science Direct, and Google Scholar. The initial search yielded 399 articles. After the duplicate removal, 19 articles met the eligibility criteria. Two studies were identified through related references. Thus, 21 articles were finalized for review. The study adhered to the PRISMA recommendations for systematic reviews. RESULTS The 21 finalized articles varied in method, participants, research design, duration, measurement tools used, and observed outcomes. Thirteen of the 21 finalized articles followed interventions specifically designed to promote self-forgiveness. Interventions are seen to be applied at both individual and group levels. CONCLUSION The review categorizes the interventions into self-directed and group. The self-directed interventions, notably those based on Enright's process model, demonstrate its efficiency in nurturing self-forgiveness. Self-forgiveness interventions are also found to be effective in promoting other positive psychological and clinical variables. Further implications and future research avenues are outlined.
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Affiliation(s)
- A Vismaya
- Department of Psychology, Central University of Karnataka, 585367, Kalaburagi, India.
| | - Aswathy Gopi
- Department of Psychology, Central University of Karnataka, 585367, Kalaburagi, India.
| | - John Romate
- Department of Psychology, Central University of Karnataka, 585367, Kalaburagi, India
| | - Eslavath Rajkumar
- Department of Liberal Arts, Indian Institute of Technology Bhilai, 492015, Chhattisgarh, India
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Harris JI, Dunlap S, Xanthos D, Pyne JM, Hermes E, Griffin BJ, Kondrath SR, Kim SY, Golden KB, Cooney NJ, Usset TJ. Implementing a Multi-Disciplinary, Evidence-Based Resilience Intervention for Moral Injury Syndrome: Systemic Barriers and Facilitators. Behav Sci (Basel) 2024; 14:281. [PMID: 38667079 PMCID: PMC11047717 DOI: 10.3390/bs14040281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/11/2024] [Accepted: 03/14/2024] [Indexed: 04/29/2024] Open
Abstract
Moral injury syndrome (MIS) is a mental health (MH) problem that substantially affects resilience; the presence of MIS reduces responsiveness to psychotherapy and increases suicide risk. Evidence-based treatment for MIS is available; however, it often goes untreated. This project uses principles of the Consolidated Framework for Implementation Research (CFIR) to assess barriers and facilitators to the implementation of Building Spiritual Strength (BSS), a multi-disciplinary treatment for MIS. Interviews were conducted with chaplains and mental health providers who had completed BSS facilitator training at six sites in the VA. Data were analyzed using the Hamilton Rapid Turnaround method. Findings included multiple facilitators to the implementation of BSS, including its accessibility and appeal to VA chaplains; leadership by VA chaplains trained in the intervention; and effective collaboration between the chaplains and mental health providers. Barriers to the implementation of BSS included challenges in engaging mental health providers and incorporating them as group leaders, veterans' lack of familiarity with the group format of BSS, and the impact of the COVID-19 pandemic. Results highlight the need for increased trust and collaboration between VA chaplains and mental health providers in the implementation of BSS and treatment of MIS.
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Affiliation(s)
- J. Irene Harris
- VA Maine Healthcare System, Augusta, ME 04330, USA; (S.R.K.); (N.J.C.); (T.J.U.)
- Department of Psychology, University of Maine, Orono, ME 04469, USA
| | - Shawn Dunlap
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA; (S.D.); (K.B.G.)
| | | | - Jeffrey M. Pyne
- Center for Mental Health Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR 72114, USA; (J.M.P.)
- Psychiatric Research Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Eric Hermes
- Veterans Affairs Northeast Program Evaluation Center, Orange, CT 06516, USA
| | - Brandon J. Griffin
- Center for Mental Health Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR 72114, USA; (J.M.P.)
- Psychiatric Research Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Susannah Robb Kondrath
- VA Maine Healthcare System, Augusta, ME 04330, USA; (S.R.K.); (N.J.C.); (T.J.U.)
- Department of Psychology, University of Maine, Orono, ME 04469, USA
| | - Se Yun Kim
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA; (S.D.); (K.B.G.)
| | - Kristin B. Golden
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA; (S.D.); (K.B.G.)
| | - Nathaniel J. Cooney
- VA Maine Healthcare System, Augusta, ME 04330, USA; (S.R.K.); (N.J.C.); (T.J.U.)
| | - Timothy J. Usset
- VA Maine Healthcare System, Augusta, ME 04330, USA; (S.R.K.); (N.J.C.); (T.J.U.)
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN 55455, USA
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Phelps AJ, Adler AB, Belanger SAH, Bennett C, Cramm H, Dell L, Fikretoglu D, Forbes D, Heber A, Hosseiny F, Morganstein JC, Murphy D, Nazarov A, Pedlar D, Richardson JD, Sadler N, Williamson V, Greenberg N, Jetly R. Addressing moral injury in the military. BMJ Mil Health 2024; 170:51-55. [PMID: 35705259 DOI: 10.1136/bmjmilitary-2022-002128] [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: 03/29/2022] [Accepted: 06/04/2022] [Indexed: 11/03/2022]
Abstract
Moral injury is a relatively new, but increasingly studied, construct in the field of mental health, particularly in relation to current and ex-serving military personnel. Moral injury refers to the enduring psychosocial, spiritual or ethical harms that can result from exposure to high-stakes events that strongly clash with one's moral beliefs. There is a pressing need for further research to advance understanding of the nature of moral injury; its relationship to mental disorders such as posttraumatic stress disorder and depression; triggering events and underpinning mechanisms; and prevalence, prevention and treatment. In the meantime, military leaders have an immediate need for guidance on how moral injury should be addressed and, where possible, prevented. Such guidance should be theoretically sound, evidence-informed and ethically responsible. Further, the implementation of any practice change based on the guidance should contribute to the advancement of science through robust evaluation. This paper draws together current research on moral injury, best-practice approaches in the adjacent field of psychological resilience, and principles of effective implementation and evaluation. This research is combined with the military and veteran mental health expertise of the authors to provide guidance on the design, implementation and evaluation of moral injury interventions in the military. The paper discusses relevant training in military ethical practice, as well as the key roles leaders have in creating cohesive teams and having frank discussions about the moral and ethical challenges that military personnel face.
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Affiliation(s)
- Andrea J Phelps
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, Victoria, Australia
| | - A B Adler
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - S A H Belanger
- Royal Military College of Canada, Kingston, Ontario, Canada
- Canadian Institute for Military and Veteran Health Research, Kingston, Ontario, Canada
| | - C Bennett
- New Zealand Defence Force, Wellington, New Zealand
| | - H Cramm
- School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
| | - L Dell
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, Victoria, Australia
| | - D Fikretoglu
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - D Forbes
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, Victoria, Australia
| | - A Heber
- Veterans Affairs Canada, Charottetown, Prince Edward Island, Canada
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - F Hosseiny
- Canadian Centre of Excellence on PTSD and Related Mental Health Conditions, Ottawa, Ontario, Canada
| | - J C Morganstein
- Center for the Study of Traumatic Stress, Department of Psychiatry, School of Medicine, Uniformed Services University, Bethesda, Maryland, USA
| | - D Murphy
- Combat Stress, Leatherhead, UK
- King's Centre for Military Health Research, King's College London, London, UK
| | - A Nazarov
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Ontario, Canada
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - D Pedlar
- Canadian Institute for Military and Veteran Health Research, Kingston, Ontario, Canada
- School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
| | - J D Richardson
- MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Ontario, Canada
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - N Sadler
- Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, Victoria, Australia
| | - V Williamson
- Institute of Psychiatry Psychology, and Neuroscience, King's College London, London, UK
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - N Greenberg
- King's Centre for Military Health Research, King's College London, London, UK
| | - R Jetly
- Institute of Mental Health Research, University of Ottawa, Ottawa, Ontario, Canada
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Kachadourian LK, Duek O, Tsai J, Harpaz-Rotem I, Pietrzak RH. Not all traumas are created equal: Phenotypic heterogeneity of PTSD symptoms in relation to index traumas in U.S. military veterans. J Affect Disord 2023; 340:728-731. [PMID: 37572698 PMCID: PMC10754253 DOI: 10.1016/j.jad.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 08/14/2023]
Abstract
Posttraumatic stress disorder (PTSD) is prevalent in military veterans. Although exposure to trauma is subsumed under the diagnostic criteria for PTSD, there is great variability in index traumatic events, and the clinical presentation of PTSD may vary in individuals depending on the type of event experienced. We examined the relationship between different index traumas and PTSD symptoms in 3507 trauma-exposed U.S. military veterans who participated in the National Health and Resilience in Veterans Study. Results showed that interpersonal violence and combat/captivity was associated with greater overall severity of PTSD symptoms relative to illness/injury and disaster/accident. Interpersonal violence and combat/captivity were also associated with greater severity of intrusive, avoidance, negative affect, anhedonia, externalizing behaviors, and anxious and dysphoric arousal symptoms, relative to the other two categories. Implications of these findings for tailoring treatment approaches for PTSD in veterans are discussed.
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Affiliation(s)
- Lorig K Kachadourian
- United States Department of Veterans Affairs National Center for PTSD, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.
| | - Or Duek
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Jack Tsai
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Ilan Harpaz-Rotem
- United States Department of Veterans Affairs National Center for PTSD, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Robert H Pietrzak
- United States Department of Veterans Affairs National Center for PTSD, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
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Borges LM, Holliman BD, Farnsworth JK, Barnes SM. Perceptions of Military Experience Among Veterans Reporting Lifetime Warzone Moral Injury. J Nerv Ment Dis 2023; 211:796-801. [PMID: 37782522 DOI: 10.1097/nmd.0000000000001676] [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: 10/03/2023]
Abstract
ABSTRACT Exposures to potentially morally injurious events (PMIEs) and possible moral injury are risk factors for a range of difficulties impacting individual functioning. Although exposure to PMIEs is a somewhat common product of war, qualitative methods to understand Veterans' experiences of moral injury and Veterans Affairs treatment are limited. To better characterize Veterans' experiences, 14 male warzone Veterans who reported moral injury post-warzone deployment and completed posttraumatic stress disorder treatment in the past year were asked to describe their military service as part of a qualitative study. Through thematic analysis, we found two moral injury-consistent themes and four subthemes. The first theme was "military experiences were associated with morally questioning one's self" with subthemes of "moral shift" and "depersonalization." The second theme was "military experiences were associated with morally questioning others" with subthemes of "disillusionment" and "resignation." Based on these findings, we conclude with a discussion of treatment implications for moral injury.
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Serfioti D, Murphy D, Greenberg N, Williamson V. Professionals' perspectives on relevant approaches to psychological care in moral injury: A qualitative study. J Clin Psychol 2023; 79:2404-2421. [PMID: 37310171 DOI: 10.1002/jclp.23556] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 04/12/2023] [Accepted: 05/31/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Despite the increasing consensus that moral injury (MI) is a unique type of psychological stressor, there is an ongoing debate about best practices for psychological care. This qualitative study explored the perceptions of UK and US professionals in the field of MI investigating advances and challenges in treatment or support delivery and issues relating to treatment/support feasibility and acceptability. METHODS 15 professionals were recruited. Semi-structured, telephone/online interviews were carried out, and transcripts were analyzed using thematic analysis. RESULTS Two interconnected themes emerged: perceived barriers to appropriate care for MI cases and recommendations for providing effective care to MI patients. Professionals highlighted the challenges that occur due to the lack of empirical experience with MI, the negligence of patients' unique individual needs and the inflexibility in existing manualised treatments. CONCLUSIONS These findings illustrate the need to evaluate the effectiveness of current approaches and explore alternative pathways, which will effectively support MI patients in the long-term. Key recommendations include the use of therapeutic techniques which lead to a personalised and flexible support plan to meet patients' needs, increase self-compassion and encourage patients to reconnect with their social networks. Interdisciplinary collaborations (e.g., religious/spiritual figures), could be a valuable addition following patients' agreement.
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Affiliation(s)
- Danai Serfioti
- Department of Psychology, School of Social Sciences, Nottingham Trent University, Nottingham, UK
| | - Dominic Murphy
- Department of Psychological Medicine, King's Centre for Military Health Research, King's College London, London, UK
- Research Department, Combat Stress, Surrey, UK
| | - Neil Greenberg
- Department of Psychological Medicine, King's Centre for Military Health Research, King's College London, London, UK
| | - Victoria Williamson
- Department of Psychological Medicine, King's Centre for Military Health Research, King's College London, London, UK
- Department of Experimental Psychology, Anna Watts Building, University of Oxford, Oxford, UK
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11
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Williamson V, Murphy D, Bonson A, Aldridge V, Serfioti D, Greenberg N. Restore and Rebuild (R&R) - a feasibility pilot study of a co-designed intervention for moral injury-related mental health difficulties. Eur J Psychotraumatol 2023; 14:2256204. [PMID: 37732994 PMCID: PMC10515691 DOI: 10.1080/20008066.2023.2256204] [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] [Received: 04/28/2023] [Accepted: 06/27/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Moral injury can significantly negatively impact mental health, but currently no validated treatment for moral injury-related mental health difficulties exists in a UK context. This study aimed to examine whether the Restore and Rebuild (R&R) treatment was feasible to deliver, acceptable and well tolerated by UK military veterans with moral injury related mental health difficulties. METHOD The R&R treatment was delivered to 20 patients who reported distress related to exposure to a morally injurious event(s) during military service. R&R is a 20-session psychotherapy with key themes of processing the event, self compassion, connecting with others and core values. Treatment was delivered online, weekly, one-to-one by a single therapist. Qualitative interviews with patients and the therapist who delivered R&R were conducted to explore acceptability and analysed using thematic analysis. RESULTS Following treatment, patients experienced a significant reduction in symptoms of post-traumatic stress disorder, depression, alcohol misuse and moral injury related distress. R&R was found to be well tolerated by patients and improved their perceived wellbeing. CONCLUSIONS These results provide preliminary evidence that veterans struggling with moral injury related mental ill health can benefit from R&R treatment.
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Affiliation(s)
- Victoria Williamson
- Department of Experimental Psychology, Anna Watts Building, University of Oxford, Oxford, UK
- Institute of Psychiatry, Psychology and Neuroscience, King’s Centre for Military Health Research, King’s College London, London, UK
| | | | | | | | - Danai Serfioti
- Institute of Psychiatry, Psychology and Neuroscience, King’s Centre for Military Health Research, King’s College London, London, UK
- Department of Psychology, School of Social Sciences, Nottingham Trent University, Nottingham, UK
| | - Neil Greenberg
- Institute of Psychiatry, Psychology and Neuroscience, King’s Centre for Military Health Research, King’s College London, London, UK
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12
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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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13
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Diekmann C, Issels L, Alliger-Horn C, Rau H, Fischer C, Thiel T, Willmund G, Zimmermann P. Traumatized German soldiers with moral injury - value-based cognitive-behavioral group therapy to treat war-related shame. Front Psychiatry 2023; 14:1173466. [PMID: 37533887 PMCID: PMC10390695 DOI: 10.3389/fpsyt.2023.1173466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/03/2023] [Indexed: 08/04/2023] Open
Abstract
Introduction During deployment, soldiers are confronted with potentially morally injurious events. In many cases, these events violate their personal values and belief systems, resulting in feelings of anger, alienation, guilt, and shame. The psychological distress caused by such transgressions is defined as moral injury. It remains unclear to date, which therapeutic interventions are most appropriate for addressing this specific psychological condition. This study examines the effectiveness of value-based cognitive-behavioral group therapy combining elements of cognitive-behavioral therapy, acceptance and commitment therapy, spiritual care, and adaptive disclosure therapy. Materials and methods This controlled study uses the Compass of Shame Scale to assess symptom severity among participants both before and after a three-week inpatient group therapy regimen for moral injury. An intervention group (n = 45) was compared to a waiting-list control group (n = 40). A one-way between subjects ANOVA was conducted to determine the differences between the two measurement points in the intervention group compared to the control group. A positive ethics vote from the Humboldt University Berlin (Charité) was available (No.EA1/092/15). Results A significant difference was found on the shame-associated maladaptive strategies subscales of attack self (F (1, 83) = 5.942, p = 0.017, Cohen's f = 0,27), withdrawal (F (1, 83) = 8.263, p = 0.005, Cohen's f = 0,32), and attack others (F (1, 83) = 10.552, p = 0.002, Cohen's f = 0,36) of the Compass of Shame Scale between the intervention group and the control group at the p < 0.05 level in the pre- and post-treatment (t1-t2) comparison. Conclusion This study suggests that the special therapeutic focus in cognitive-behavioral group therapy can alter shame-based maladaptive coping behaviors in response to war-related moral injury. This study provides further evidence that therapeutic approaches - through fostering a reconciliatory, compassionate, and forgiving approach toward oneself and others - target the underlying mechanisms of moral injury. Therefore, value-based cognitive-behavioral interventions should be considered as a standard element of trauma care in a military setting. Future studies should further examine such interventions in randomized control trials. It would also be particularly valuable for future studies to include a follow-up time point.
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Affiliation(s)
- Caroline Diekmann
- Department of Psychiatry, Psychotherapy and Psychotraumatology, Military Hospital Berlin, Berlin, Germany
- Charité - Berlin University of Medicine, Humboldt University of Berlin, Berlin, Germany
| | - Leonie Issels
- Department of Psychiatry, Psychotherapy and Psychotraumatology, Military Hospital Berlin, Berlin, Germany
| | - Christina Alliger-Horn
- Department of Psychiatry, Psychotherapy and Psychotraumatology, Military Hospital Berlin, Berlin, Germany
| | - Heinrich Rau
- Department of Psychiatry, Psychotherapy and Psychotraumatology, Military Hospital Berlin, Berlin, Germany
| | | | - Thomas Thiel
- Military Chaplaincy Central Office, Berlin, Germany
| | - Gerd Willmund
- Department of Psychiatry, Psychotherapy and Psychotraumatology, Military Hospital Berlin, Berlin, Germany
| | - Peter Zimmermann
- Department of Psychiatry, Psychotherapy and Psychotraumatology, Military Hospital Berlin, Berlin, Germany
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14
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Bonson A, Murphy D, Aldridge V, Greenberg N, Williamson V. Veterans' experiences of moral injury, treatment and recommendations for future support. BMJ Mil Health 2023:military-2022-002332. [PMID: 37192765 DOI: 10.1136/military-2022-002332] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/01/2023] [Indexed: 05/18/2023]
Abstract
INTRODUCTION Moral injury (MI) significantly impacts the lives of many UK military veterans however, there is a lack of manualised treatment to address the needs of this population. To develop future treatments that are acceptable and well tolerated, veterans should be consulted on their experiences of existing psychological treatments and suggestions for future treatments. METHODS 10 UK military veterans were interviewed about their experiences of receiving treatment for psychological difficulties after MI, and beliefs about core components of future treatments. Thematic analysis of these interviews were conducted. RESULTS 2 superordinate themes were identified: experiences of previous mental health treatment and perceptions of the proposed treatments. Reflections on cognitive behavioural therapy were mixed, with some describing that it did not ameliorate their guilt or shame. In future treatments, focusing on values, using written letters and including therapy sessions with close companions were considered beneficial. Veterans reported that a strong rapport with therapist was key for MI treatment. CONCLUSION Findings provide a useful account of how current post-trauma treatments may be experienced by patients with MI. Although limited by sample size, the results highlight therapeutic approaches that may be helpful in future and provide important considerations for therapists treating MI.
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Affiliation(s)
| | - D Murphy
- Research Department, Combat Stress, Leatherhead, UK
- King's Centre for Military Health Research, King's College London, London, UK
| | - V Aldridge
- Research Department, Combat Stress, Leatherhead, UK
| | - N Greenberg
- King's Centre for Military Health Research, King's College London, London, UK
| | - V Williamson
- King's Centre for Military Health Research, King's College London, London, UK
- Department of Experimental Psychology, Ann Watts Building, University of Oxford, Oxford, UK
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15
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Maguen S, Griffin BJ, Vogt D, Hoffmire CA, Blosnich JR, Bernhard PA, Akhtar FZ, Cypel YS, Schneiderman AI. Moral injury and peri- and post-military suicide attempts among post-9/11 veterans. Psychol Med 2023; 53:3200-3209. [PMID: 35034682 PMCID: PMC10235653 DOI: 10.1017/s0033291721005274] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 11/29/2021] [Accepted: 12/06/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Our goal was to examine the association between moral injury, mental health, and suicide attempts during military service and after separation by gender in post-9/11 veterans. METHODS A nationally representative sample of 14057 veterans completed a cross-sectional survey. To examine associations of exposure to potentially morally injurious events (PMIEs; witnessing, perpetrating, and betrayal) and suicidal self-directed violence, we estimated two series of multivariable logistic regressions stratified by gender, with peri- and post-military suicide attempt as the dependent variables. RESULTS PMIE exposure accounted for additional risk of suicide attempt during and after military service after controlling for demographic and military characteristics, current mental health status, and pre-military history of suicidal ideation and attempt. Men who endorsed PMIE exposure by perpetration were 50% more likely to attempt suicide during service and twice as likely to attempt suicide after separating from service. Men who endorsed betrayal were nearly twice as likely to attempt suicide during service; however, this association attenuated to non-significance after separation in the fully adjusted models. In contrast, women who endorsed betrayal were over 50% more likely to attempt suicide during service and after separation; PMIE exposure by perpetration did not significantly predict suicide attempts before or after service among women in the fully adjusted models. CONCLUSIONS Our findings indicate that suicide assessment and prevention programs should consider the impact of moral injury and attend to gender differences in this risk factor in order to provide the most comprehensive care.
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Affiliation(s)
- Shira Maguen
- San Francisco VA Healthcare System, San Francisco, CA, USA
- University of California – San Francisco, San Francisco, CA, USA
| | - Brandon J. Griffin
- Central Arkansas VA Healthcare System, Little Rock, AR, USA
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Dawne Vogt
- VA Boston Healthcare System, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Claire A. Hoffmire
- VA Eastern Colorado Health Care System, Aurora, Colorado, USA
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - John R. Blosnich
- University of Southern California, Los Angeles, CA, USA
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Paul A. Bernhard
- Health Outcomes of Military Exposures, Epidemiology Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, USA
| | - Fatema Z. Akhtar
- Health Outcomes of Military Exposures, Epidemiology Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, USA
| | - Yasmin S. Cypel
- Health Outcomes of Military Exposures, Epidemiology Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, USA
| | - Aaron I. Schneiderman
- Health Outcomes of Military Exposures, Epidemiology Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, USA
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16
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LoSavio ST, Hale W, Straud CL, Wachen JS, Mintz J, Young-McCaughan S, Vacek SN, Yarvis JS, Sloan DM, McGeary DD, Taylor DJ, Keane TM, Peterson AL, Resick PA. Impact of morally injurious traumatic event exposure on cognitive processing therapy outcomes among Veterans and service members. JOURNAL OF MILITARY, VETERAN AND FAMILY HEALTH 2023. [DOI: 10.3138/jmvfh-2022-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
LAY SUMMARY Military personnel frequently report actions taken by themselves or others that violate deeply held moral beliefs, which can be experienced as a kind of moral injury. Some have questioned whether existing treatments for posttraumatic stress disorder (PTSD), such as cognitive processing therapy, are effective for those who have been exposed to a morally injurious traumatic event. These analyses demonstrate that active duty service members and Veterans seeking treatment for PTSD who reported potentially morally injurious trauma had PTSD and depression outcomes that were as good as those whose traumas were not primarily seen as morally injurious, suggesting that cognitive processing therapy is an efficacious treatment for PTSD in the context of morally injurious trauma.
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Affiliation(s)
- Stefanie T. LoSavio
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
| | - Willie Hale
- Department of Psychology, University of Texas at San Antonio, San Antonio, Texas, United States
| | - Casey L. Straud
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
| | - Jennifer Schuster Wachen
- Women’s Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, United States
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
| | - Sarah N. Vacek
- Department of Psychology, University of Texas at San Antonio, San Antonio, Texas, United States
| | - Jeffrey S. Yarvis
- School of Social Work, Tulane University, New Orleans, Louisiana, United States
| | - Denise M. Sloan
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, United States
| | - Donald D. McGeary
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
| | - Daniel J. Taylor
- Department of Psychology, University of Arizona, Tucson, Arizona, United States
| | - Terence M. Keane
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, United States
| | - Alan L. Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
| | - Patricia A. Resick
- Department of Psychiatry and Behavioral Sciences, Duke Health, Durham, North Carolina, United States
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17
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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: 12] [Impact Index Per Article: 12.0] [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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18
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Li J, Gao L, Bao R, Ji R, He Q, Tang X, Zhang W, Qu Z. Comparative efficacy for different age groups of psychological or psychosocial treatments on post-traumatic stress disorder: protocol for systematic review, meta-analysis and meta-regression analysis. BMJ Open 2023; 13:e066569. [PMID: 36639203 PMCID: PMC9843179 DOI: 10.1136/bmjopen-2022-066569] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION It remains unknown whether psychological or psychosocial treatments for post-traumatic stress disorder (PTSD) have comparable effects across the life span. This study aims at comparing the effects of psychological/psychosocial treatments for PTSD between different age groups of youth, early-middle adults and late adults. METHODS AND ANALYSIS A systematic search will be conducted among thirteen electronic databases, including Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, EMBASE, ERIC, PubMed, SCOPUS, Web of Science, Published International Literature on Traumatic Stress, China National Knowledge Infrastructure Database, the Wanfang database, the Chinese Scientific Journal Database (VIP Database) and ProQuest Dissertations and Theses, from inception to 15 May 2022. Electronic searches will be supplemented by a comprehensive grey literature search in Conference proceedings and trial registries. Randomised controlled trials (RCTs) comparing psychological or psychosocial treatments for PTSD with control conditions in all age groups will be included. The primary outcome is the between-treatments efficacy for PTSD that refers to the outcomes of the RCTs included in the meta-analysis. Effect sizes will be calculated for all comparisons and pooled with a fixed effects model or a random effects model. Differences in the efficacy of psychological/psychosocial therapies for PTSD across the age groups will be examined by stratified analyses and meta-regression analyses. ETHICS AND DISSEMINATION Data used in this study will be anonymised. These data will not be used for other purposes than research. Authors who supply the data will be acknowledged. The authors declare that no conflicts of interest exist. The findings of this study will be disseminated through briefing reports, publications and presentations. TRIAL REGISTRATION NUMBER CRD42022334305.
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Affiliation(s)
- Jia Li
- Center for Behavioral Health & School of Social Development and Public Policy, Beijing Normal University, Beijing, China
| | - Liru Gao
- Center for Behavioral Health & School of Social Development and Public Policy, Beijing Normal University, Beijing, China
| | - Ruiji Bao
- Center for Behavioral Health & School of Social Development and Public Policy, Beijing Normal University, Beijing, China
| | - Rui Ji
- Center for Behavioral Health & School of Social Development and Public Policy, Beijing Normal University, Beijing, China
| | - Qianyun He
- Center for Behavioral Health & School of Social Development and Public Policy, Beijing Normal University, Beijing, China
| | - Xinfeng Tang
- Department of Psychology, Renmin University, Beijing, China
| | - Weijun Zhang
- Center for Behavioral Health & School of Social Development and Public Policy, Beijing Normal University, Beijing, China
| | - Zhiyong Qu
- Center for Behavioral Health & School of Social Development and Public Policy, Beijing Normal University, Beijing, China
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19
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Ranney RM, Maguen S, Bernhard PA, Holder N, Vogt D, Blosnich JR, Schneiderman AI. Moral injury and chronic pain in veterans. J Psychiatr Res 2022; 155:104-111. [PMID: 36027646 DOI: 10.1016/j.jpsychires.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/28/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022]
Abstract
Posttraumatic stress disorder (PTSD) and chronic pain are highly prevalent and co-morbid among veterans. Moral injury (MI), which results from traumatic experiences that conflict with deeply held moral beliefs, is also associated with pain. However, relationships between different types of exposures to potentially morally injurious events (PMIEs) and pain have not yet been investigated. In the current study, we investigated these relationships between exposure to PMIEs (betrayal, witnessing, and perpetration) and different types of pain (joint pain, muscle pain, and overall pain intensity), while controlling for other relevant variables (including PTSD symptoms, combat exposure, adverse childhood experiences, age, gender, and race/ethnicity). We also examined gender differences in these associations. Participants were 11,871 veterans drawn from a nationwide, population-based survey who self-reported exposure to PMIEs, PTSD symptoms, frequency of adverse childhood experiences, combat exposure, sociodemographic information, past six-month joint pain, past six-month muscle pain, and past week overall pain intensity. Population weighted regression models demonstrated that PMIEs were not significantly associated with joint or muscle pain, but that betrayal was associated with past week overall pain intensity, even when controlling for all other variables. Models investigating men and women separately found that for women, betrayal was associated with joint pain and pain intensity, but for men, betrayal was not associated with any pain outcome. These findings suggest that it may be especially important to assess betrayal when treating patients with a history of trauma and chronic pain.
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Affiliation(s)
- Rachel M Ranney
- San Francisco VA Health Care System, 4150 Clement St, San Francisco, CA, 94121, USA; University of California - San Francisco, 401 Parnassus Ave, San Francisco, CA, 94143, USA; Sierra Pacific Mental Illness Research Education, and Clinical Center, 4150 Clement St, San Francisco, CA, 94121, USA.
| | - Shira Maguen
- San Francisco VA Health Care System, 4150 Clement St, San Francisco, CA, 94121, USA; University of California - San Francisco, 401 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Paul A Bernhard
- Health Outcomes of Military Exposures, Epidemiology Program, Office of Patient Care Services, Veterans Health Administration, 810 Vermont Ave NW, Washington, DC, 2057, USA
| | - Nicholas Holder
- San Francisco VA Health Care System, 4150 Clement St, San Francisco, CA, 94121, USA; University of California - San Francisco, 401 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Dawne Vogt
- VA Boston Health Care System, 150 S Huntington Ave, Boston, MA, 02130, USA; Boston University School of Medicine, 72 E Concord St, Boston, MA, 02118, USA
| | - John R Blosnich
- University of Southern California, 669 W 34th St, Los Angeles, CA, 90089-0411, USA; VA Pittsburgh Healthcare System, 4100 Allequippa St, Pittsburgh, PA, 15240, USA
| | - Aaron I Schneiderman
- Health Outcomes of Military Exposures, Epidemiology Program, Office of Patient Care Services, Veterans Health Administration, 810 Vermont Ave NW, Washington, DC, 2057, USA
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20
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Williamson V, Murphy D, Aldridge V, Bonson A, Seforti D, Greenberg N. Development of an intervention for moral injury-related mental health difficulties in UK military veterans: a feasibility pilot study protocol. Eur J Psychotraumatol 2022; 13:2138059. [PMID: 36340009 PMCID: PMC9629100 DOI: 10.1080/20008066.2022.2138059] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 09/27/2022] [Accepted: 10/02/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Experiencing potentially morally injurious events (PMIEs) has been found to be significantly associated with poor mental health outcomes in military personnel/veterans. Currently, no manualised treatment for moral injury-related mental health difficulties for UK veterans exists. This article describes the design, methods and expected data collection of the Restore & Rebuild (R&R) protocol, which aims to develop procedures to treat moral injury related mental ill health informed by a codesign approach. Methods: The study consists of three main stages. First, a systematic review will be conducted to understand the best treatments for the symptoms central to moral injury-related mental ill health (stage 1). Then the R&R manual will be co-designed with the support of UK veteran participants with lived experience of PMIEs as well as key stakeholders who have experience of supporting moral injury affected individuals (stage 2). The final stage of this study is to conduct a pilot study to explore the feasibility and acceptability of the R&R manual (stage 3). Results: Qualitative data will be analysed using thematic analysis. Conclusions: This study was approved by the King's College London's Research Ethics Committee (HR-20/21-20850). The findings will be disseminated in several ways, including publication in academic journals, a free training event and presentation at conferences. By providing information on veteran, stakeholder and clinician experiences, we anticipate that the findings will not only inform the development of an acceptable evidence-based approach for treating moral injury-related mental health problems, but they may also help to inform broader approaches to providing care to trauma exposed military veterans.
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Affiliation(s)
| | - Dominic Murphy
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Research Department, Combat Stress, Surrey, UK
| | | | | | - Danai Seforti
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Neil Greenberg
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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21
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Kelley ML, Strowger M, Chentsova VO, Bravo AJ, Gaylord SA, Burgin EE, Vinci C, Ayers KL, Agha E. Mindfulness to Manage Moral Injury: Rationale and development of a live online 7-week group intervention for veterans with moral injury. Contemp Clin Trials Commun 2022; 30:101011. [PMID: 36340697 PMCID: PMC9626875 DOI: 10.1016/j.conctc.2022.101011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/27/2022] [Accepted: 10/01/2022] [Indexed: 11/14/2022] Open
Abstract
Background Military service puts service members at risk for moral injury. Moral injury is an array of symptoms (e.g., guilt, shame, anger) that develop from events that violate or transgress one's moral code. Objective We describe adaption of in-person mindfulness training program, Mindfulness to Manage Chronic Pain (MMCP), to address symptoms of moral injury to be delivered live via the web. We discuss how we will assess benchmarks (i.e., recruitment, credibility and acceptability, completion rates, and adherence) of the Mindfulness to Manage Moral Injury (MMMI) program. Methods Aim 1: To develop and then adapt the MMCP program based on feedback from experts and veterans who took part in Study 1. Aim 2: To develop an equally intensive facilitator-led online Educational Support (ES) program to serve as a comparison intervention and conduct a run-through of each program with 20 veterans (10 MMMI; 10 ES). Aim 3: To conduct a small-scale randomized controlled trial (N = 42 veterans; 21 MMMI; 21 ES) in which we will collect pre-post-test and weekly benchmark data for both refined intervention arms. Results Study 1 and 2 are completed. Data collection for Study 3 will be completed in 2022. Conclusion MMMI is designed to provide a live facilitated mindfulness program to address symptoms of moral injury. If Study 3 demonstrates good benchmarks, with additional large-scale testing, MMMI may be a promising treatment that can reach veterans who may not seek traditional VAMC care and/or who prefer a web-based program.
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Affiliation(s)
- Michelle L. Kelley
- Old Dominion University, Old Dominion University, Norfolk, VA, USA
- Virginia Consortium Program in Clinical Psychology, Norfolk, VA, USA
- Corresponding author. Department of Psychology, Old Dominion University, 250 Mills Godwin Building, Norfolk, VA, 23529, USA.
| | - Megan Strowger
- Old Dominion University, Old Dominion University, Norfolk, VA, USA
| | | | - Adrian J. Bravo
- Department of Psychological Sciences, William & Mary, Williamsburg, VA, USA
| | - Susan A. Gaylord
- Program on Integrative Medicine, Department of Physical Medicine and Rehabilitation, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Elizabeth E. Burgin
- School Psychology and Counselor Education, William & Mary, Williamsburg, VA, USA
| | - Christine Vinci
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA
| | - Kenneth L. Ayers
- Virginia Consortium Program in Clinical Psychology, Norfolk, VA, USA
| | - Erum Agha
- Program on Integrative Medicine, Department of Physical Medicine and Rehabilitation, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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22
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Moral injury among U.S. combat veterans with and without PTSD and depression. J Psychiatr Res 2022; 154:190-197. [PMID: 35947898 DOI: 10.1016/j.jpsychires.2022.07.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/01/2022] [Accepted: 07/19/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Questions persist about how often potentially morally injurious events (PMIEs) are associated with posttraumatic stress disorder (PTSD) and depression. METHODS This study examined the overlap of morally injurious events with probable PTSD and depression in a nationally representative sample of U.S. combat veterans (n = 1,321, mean age 59.1, 93.7% male). RESULTS Most veterans with probable PTSD (72.2%), probable depression (72.4%), and probable PTSD and/or depression (68.4%), endorsed experiencing PMIEs; 31.1-35.3% of these participants endorsed perpetration, 45.1-50.4% endorsed witnessing others, and 52.6-55.7% endorsed betrayal. The prevalence of PMIEs among veterans without current probable PTSD and/or depression was 33.7%, 32.3%, and 31.5%, respectively; 7.9-9.1% of these participants endorsed perpetration-based PMIEs, 19.2-20.3% witnessing, and 19.8-21.8% endorsed betrayal. PMIEs were more prevalent among veterans with probable PTSD or depression relative to those without (ORs ranging 2.14-3.32; p's < 0.001). CONCLUSIONS This is the first nationally representative study to examine the prevalence of PMIEs among veterans with and without probable PTSD or depression. Results highlight the importance of understanding distress and functional impairment in these veterans to evaluate whether they may benefit from intervention. PMIEs were strikingly more prevalent among veterans with probable PTSD and depression, suggesting that veterans without PMIEs are the minority among combat veterans with these disorders.
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Maguen S, Griffin BJ, Copeland LA, Perkins DF, Richardson CB, Finley EP, Vogt D. Trajectories of functioning in a population-based sample of veterans: contributions of moral injury, PTSD, and depression. Psychol Med 2022; 52:2332-2341. [PMID: 33234177 PMCID: PMC9527674 DOI: 10.1017/s0033291720004249] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/15/2020] [Accepted: 10/22/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Although research has shown that exposure to potentially traumatic and morally injurious events is associated with psychological symptoms among veterans, knowledge regarding functioning impacts remains limited. METHODS A population-based sample of post-9/11 veterans completed measures of intimate relationship, health, and work functioning at approximately 9, 15, 21, and 27 months after leaving service. Moral injury, posttraumatic stress, and depression were assessed at ~9 months post-separation. We used Latent Growth Mixture Models to identify discrete classes characterized by unique trajectories of change in functioning over time and to examine predictors of class membership. RESULTS Veterans were assigned to one of four functioning trajectories: high and stable, high and decreasing, moderate and increasing, and moderate and stable. Whereas posttraumatic stress, depression, and moral injury associated with perpetration and betrayal predicted worse outcomes at baseline across multiple functioning domains, moral injury associated with perpetration and depression most reliably predicted assignment to trajectories characterized by relatively poor or declining functioning. CONCLUSIONS Moral injury contributes to functional problems beyond what is explained by posttraumatic stress and depression, and moral injury due to perpetration and depression most reliably predicted assignment to trajectories characterized by functional impairment over time.
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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 J. Griffin
- Central Arkansas VA Healthcare System, Little Rock, AR, USA
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Laurel A. Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, MA, USA
- University of Massachusetts Medical School, Worcester, MA, USA
| | | | | | - Erin P. Finley
- South Texas Veterans Health Care System, San Antonio, TX, USA
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Dawne Vogt
- National Center for PTSD at VA Boston Health Care System, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
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Gherman MA, Arhiri L, Holman AC, Soponaru C. Injurious Memories from the COVID-19 Frontline: The Impact of Episodic Memories of Self- and Other-Potentially Morally Injurious Events on Romanian Nurses' Burnout, Turnover Intentions and Basic Need Satisfaction. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:9604. [PMID: 35954961 PMCID: PMC9368272 DOI: 10.3390/ijerph19159604] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 12/14/2022]
Abstract
Nurses have been frequently exposed to Potentially Morally Injurious Events (PMIEs) during the COVID-19 pandemic. Due to resource scarcity, they both perpetrated (self-PMIEs) and passively witnessed (other-PMIEs) moral transgressions toward the patients, severely violating their moral values. Our study investigated the impact of self- and other-PMIEs on work outcomes by exploring nurses' episodic memories of these events and the basic psychological need thwarting associated with them. Using a quasi-experimental design, on a convenience sample of 463 Romanian nurses, we found that PMIEs memories were uniquely associated with burnout and turnover intentions, after controlling for socio-demographic characteristics, general basic psychological need satisfaction at work and other phenomenological characteristics. Both self- and other-PMIEs memories were need thwarting, with autonomy and competence mediating their differential impact on burnout, and with relatedness-on turnover intentions. Our findings emphasize the need for organizational moral repair practices, which should include enhancing nurses' feelings of autonomy, relatedness and competence. Psychological counseling and psychotherapy should be provided to nurses to prevent their episodic memories of PMIEs to be (fully) integrated in autobiographical knowledge, because this integration could have severe consequences on their psycho-social function and occupational health, as well as on the organizational climate in healthcare institutions.
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Affiliation(s)
| | | | - Andrei Corneliu Holman
- Faculty of Psychology and Education Sciences, Alexandru Ioan Cuza University, Str. Toma Cozma 3, 700554 Iasi, Romania
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25
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Hollis J, Hanna P, Perman G. Recontextualising moral injury among military veterans: An integrative theoretical review. JOURNAL OF COMMUNITY & APPLIED SOCIAL PSYCHOLOGY 2022. [DOI: 10.1002/casp.2643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jake Hollis
- Department of Psychological Interventions University of Surrey Guildford UK
| | - Paul Hanna
- Department of Psychological Interventions University of Surrey Guildford UK
| | - Gemma Perman
- Department of Psychological Interventions University of Surrey Guildford UK
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26
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Borges LM, Barnes SM, Farnsworth JK, Drescher KD, Walser RD. Case Conceptualizing in Acceptance and Commitment Therapy for Moral Injury: An Active and Ongoing Approach to Understanding and Intervening on Moral Injury. Front Psychiatry 2022; 13:910414. [PMID: 35845442 PMCID: PMC9279691 DOI: 10.3389/fpsyt.2022.910414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/10/2022] [Indexed: 11/18/2022] Open
Abstract
Acceptance and Commitment Therapy for Moral Injury (ACT-MI; 10-11), is an application of Acceptance and Commitment Therapy principles designed to help individuals live their values, even in the presence of moral pain. ACT-MI differs from other emerging treatments for moral injury in that ACT-MI is not based on a traditional syndromal approach to conceptualizing moral injury, which treats moral injury as a collection of signs and symptoms to be reduced. Rather than assuming moral injury causes suffering through a constellation of symptoms that a person has, in ACT-MI, moral injury is defined by what a person does in response to moral pain. Consistent with this framework, we present a unique approach to moral injury case conceptualization that emphasizes function over form, providing clients the opportunity to break free from the patterns of behavior that cause moral injury-related suffering to persist. Rooted in approaches to conceptualizing that have demonstrated utility in extant interventions (e.g., ACT), ACT-MI clinicians conduct ongoing functional analyses to inform case conceptualization and intervention. Functional analysis is used to disrupt the processes maintaining moral injury, as the client and therapist work to identify and intervene on the behaviors reinforcing avoidance and control of painful internal experiences causing moral injury. In the current article, we guide the reader through a framework for applying functional analysis to the conceptualization of moral injury where the reinforcers driving moral injury are explored. We also provide examples of questions that can be used to help uncover the functions of moral injury consistent behavior. Case examples based on our experiences treating moral injury are presented to demonstrate how various types of morally injurious events can evoke different features of moral pain which in turn motivate different repertoires of avoidance and control. These inflexible patterns of avoidance and control create suffering by engaging in behavior designed to escape moral pain, such as social isolation, spiritual disconnection, reduced self-care, suicidal ideation, and substance use. We discuss how to target this suffering using functional analysis to guide treatment decisions, matching interventional processes within ACT-MI to the specific functions that moral injury-related behavior is serving for an individual. We suggest that the use of functional analytic case formulation procedures described herein can assist clients in disrupting behavioral patterns maintaining moral injury and thereby free them to pursue lives of greater meaning and purpose.
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Affiliation(s)
- Lauren M. Borges
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Sean M. Barnes
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | | | | | - Robyn D. Walser
- National Center for PTSD, Palo Alto, CA, United States
- Department of Psychology, University of California, Berkeley, Berkeley, CA, United States
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27
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Borges LM, Desai A, Barnes SM, Johnson JPS. The Role of Social Determinants of Health in Moral Injury: Implications and Future Directions. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2022; 9:202-214. [PMID: 35756696 PMCID: PMC9208749 DOI: 10.1007/s40501-022-00272-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/29/2022]
Abstract
Purpose of Review Exposure to potentially morally injurious events (PMIEs) and the development of moral injury have yet to be conceptualized as they relate to social determinants of health (SDoH).Recent Findings.In this paper, the extant literature on moral injury and SDoH is reviewed. Specific individual-level SDoH, including gender, sex, sexual orientation, race, and ethnicity, are explored relative to PMIEs and moral injury. The relationship among environmental SDoH, including childhood environment, justice involvement, and homelessness, is described. Summary Assessment and treatment implications are discussed, and future research directions highlighting the need for additional work addressing health inequities in moral injury are presented.
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Affiliation(s)
- Lauren M. Borges
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, 1700 N Wheeling St., Aurora, CO 80045 USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Alisha Desai
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, 1700 N Wheeling St., Aurora, CO 80045 USA
| | - Sean M. Barnes
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, 1700 N Wheeling St., Aurora, CO 80045 USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Jacob P. S. Johnson
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, 1700 N Wheeling St., Aurora, CO 80045 USA
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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: 2] [Impact Index Per Article: 1.0] [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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29
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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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30
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Bonfils KA, Tennity CL, Congedo BA, Dolowich BA, Hammer LA, Haas GL. Functional outcomes from psychotherapy for people with posttraumatic stress disorder: A meta-analysis. J Anxiety Disord 2022; 89:102576. [PMID: 35580437 DOI: 10.1016/j.janxdis.2022.102576] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 03/24/2022] [Accepted: 04/27/2022] [Indexed: 01/08/2023]
Abstract
People with posttraumatic stress disorder (PTSD) experience a wide array of symptoms, often accompanied by significant functional and quality of life impairments. Evidence-based psychotherapies are effective for alleviating symptoms in this group, but functional outcomes following psychotherapy are understudied. This study aimed to synthesize existing work on functional outcomes of psychotherapy to conduct a meta-analytic investigation examining whether people with PTSD experience significant improvements in functioning and quality of life following a course of psychotherapy. A literature search was conducted for studies reporting results of randomized clinical trials of psychotherapies for people diagnosed with PTSD that included a functional or quality of life outcome measured at pre- and post-intervention. Both between-groups and within-groups analyses were conducted using a random effects model. Fifty-six independent samples were included. Results suggest that, on average, people with PTSD experience significant, moderate improvement in functional outcomes after a course of psychotherapy. Taken together, this meta-analysis represents a substantial advance in our understanding of functional outcomes of psychotherapy for people with PTSD. Findings suggest that psychotherapy is one vehicle through which functional outcomes may be improved for this group, though notably to a lesser degree than symptom improvement.
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Affiliation(s)
- Kelsey A Bonfils
- Department of Psychology, University of Southern Mississippi, 118 College Dr., Hattiesburg, MS 39406, United States; VISN 4 Mental Illness Research, Education, and Clinical Center (MIRECC), VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240, United States.
| | - Cassidy L Tennity
- Department of Psychology, University of Southern Mississippi, 118 College Dr., Hattiesburg, MS 39406, United States.
| | - Benjamin A Congedo
- VISN 4 Mental Illness Research, Education, and Clinical Center (MIRECC), VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240, United States.
| | - Benjamin A Dolowich
- Department of Psychology, University of Southern Mississippi, 118 College Dr., Hattiesburg, MS 39406, United States.
| | - Lillian A Hammer
- Department of Psychology, University of Southern Mississippi, 118 College Dr., Hattiesburg, MS 39406, United States.
| | - Gretchen L Haas
- VISN 4 Mental Illness Research, Education, and Clinical Center (MIRECC), VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240, United States; Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara Street, Pittsburgh, PA 15213, United States.
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Hamrick HC, Ehlke SJ, Davies RL, Higgins JM, Naylor J, Kelley ML. Moral Injury as a Mediator of the Associations Between Sexual Harassment and Mental Health Symptoms and Substance Use Among Women Veterans. JOURNAL OF INTERPERSONAL VIOLENCE 2022; 37:NP10007-NP10035. [PMID: 33435809 DOI: 10.1177/0886260520985485] [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] [Indexed: 06/12/2023]
Abstract
Moral injury is an array of symptoms theorized to develop in response to morally injurious events, defined as events that challenge one's core moral beliefs and expectations about the self, others, and world. Recent measures of moral injury have distinguished self-directed moral injury (e.g., moral injury symptoms that emerge following the perpetration of morally injurious events) from other-directed moral injury, the symptoms of which are believed to stem from one's response to actions that others have committed (e.g., within-rank violence, failures of leadership, and acts of betrayal committed by trusted others or institutions). Using a convenience sample of 154 primarily former military women, the present study examined if other-directed moral injury symptoms (e.g., anger, betrayal, and mistrust) associated with military experience would mediate the association between military sexual harassment and mental health and substance abuse symptoms. Results demonstrated that 85.8% (n = 127) of the of this sample of women veterans reported experiencing sexual harassment during their military service. Using a single mediation model, we further demonstrated that other-directed moral injury mediated the association between sexual harassment experience and mental health symptoms. Given the percentage of women veterans who reported sexual harassment, these results suggest that additional training for military members, and particularly, military leaders, is necessary to begin to reduce sexual harassment. In addition, mental health providers who work with current and former military members should consider how other-directed moral injury may be associated with mental health symptoms among women veterans who have experienced sexual harassment while in the military.
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Affiliation(s)
| | - Sarah J Ehlke
- Oklahoma Tobacco Research Center, Oklahoma City, OK, USA
| | - Rachel L Davies
- Virginia Consortium Program in Clinical Psychology, Norfolk, VA, USA
| | | | - Jennifer Naylor
- Durham Veterans Affairs Medical Center, NC, USA
- Duke University Medical Center, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham, NC, USA
| | - Michelle L Kelley
- Virginia Consortium Program in Clinical Psychology, Norfolk, VA, USA
- Old Dominion University, Norfolk, VA, USA
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Burkman K, Gloria R, Mehlman H, Maguen S. Treatment for Moral Injury: Impact of Killing in War. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2022; 9:101-114. [PMID: 35572857 PMCID: PMC9078088 DOI: 10.1007/s40501-022-00262-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 11/27/2022]
Abstract
Purpose of Review Veterans who kill in war are at risk of developing negative mental health problems including moral injury, PTSD, spiritual distress, and impairments in functioning. Impact of Killing (IOK) is a novel, cognitive-behaviorally based treatment designed to address the symptoms associated with killing that focuses on self-forgiveness and moral repair through cultivation of self-compassion and perspective-taking exercises, such as letter writing, and active participation in values-driven behavior. Recent Findings In a pilot trial assessing IOK, participants demonstrated a reduction in multiple mental health symptoms and improvement in quality-of-life measures, and they reported IOK was acceptable and feasible. Furthermore, trauma therapists have reported that moral injury is relevant to their clinical work, expressed a desire for additional training on the impact of killing, and identified barriers that make addressing killing in clinical settings challenging. Data are currently being collected in a national multi-site trial to examine the efficacy of IOK, compared to a control condition. Summary IOK fills a critical treatment gap by directly addressing the guilt, shame, self-sabotaging behaviors, functional difficulties, impaired self-forgiveness, and moral/spiritual distress directly associated with killing in war. Typically provided following some initial trauma-processing treatment, IOK can be integrated in existing systems of trauma care, creating a pathway for a stepped model of treatment for moral injury.
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Affiliation(s)
- Kristine Burkman
- San Francisco VA Medical Center, 4150 Clement Street (116-E), San Francisco, CA 94121 USA.,University of California, San Francisco, CA USA
| | - Rebecca Gloria
- San Francisco VA Medical Center, 4150 Clement Street (116-E), San Francisco, CA 94121 USA
| | - Haley Mehlman
- San Francisco VA Medical Center, 4150 Clement Street (116-E), San Francisco, CA 94121 USA
| | - Shira Maguen
- San Francisco VA Medical Center, 4150 Clement Street (116-E), San Francisco, CA 94121 USA.,University of California, San Francisco, CA USA
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Norman S. Trauma-Informed Guilt Reduction Therapy: Overview of the Treatment and Research. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2022; 9:115-125. [PMID: 35531442 PMCID: PMC9068861 DOI: 10.1007/s40501-022-00261-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 12/16/2022]
Abstract
Purpose of Review The purpose of this review is to describe Trauma-Informed Guilt Reduction Therapy (TrIGR), the Non-Adaptive Guilt and Shame (NAGS) model that underlies TrIGR, and the research supporting the use of TrIGR to treat the guilt and shame components of moral injury. TriGR is a 6-session individual psychotherapy that helps clients consider their role in the traumatic event and find constructive ways to express important values, so that they no longer need to express values by suffering through guilt and shame. Recent Findings A recently completed randomized controlled trial of TrIGR versus supportive care therapy included 144 post-9/11 veterans. TriGR showed greater reductions in trauma-related guilt, PTSD symptoms, and depression symptoms. Participants in TrIGR had greater likelihood of losing their PTSD diagnosis and showing clinical meaningful change in PTSD and depression symptoms. Mean attendance was high; 5.3 out of 6 sessions. Summary TrIGR is efficacious in reducing guilt that is common to moral injury as well as PTSD and depression symptoms among combat veterans. The next steps in the program of research to develop and evaluate TrIGR are studies with diverse trauma types and populations as well as relative effectiveness studies comparing TrIGR to other evidence-based treatments for moral injury and PTSD.
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Affiliation(s)
- Sonya Norman
- Executive Division, National Center for PTSD, White River Junction, VT USA
- Department of Psychiatry, San Diego School of Medicine, University of California, San Diego, CA USA
- VA Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Drive, MC 116B, CA 92161 San Diego, USA
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Hodgson TJ, Carey LB, Koenig HG. Moral Injury, Betrayal and Retribution: Australian Veterans and the Role of Chaplains. JOURNAL OF RELIGION AND HEALTH 2022; 61:993-1021. [PMID: 35175506 DOI: 10.1007/s10943-022-01507-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/15/2022] [Indexed: 05/11/2023]
Abstract
This paper presents additional qualitative results from Phase 1 of a larger study examining potentially morally injurious events/experiences (PMIE) and/or moral injury (MI) among Australian veterans (Hodgson et al. in J Relig Health 60(5):3061-3089, 2021). It makes specific reference to (1) betrayal and (2) retribution experienced or perpetrated by Australian military veterans during military conflicts and peacekeeping missions. During two veteran seminars conducted in Adelaide, South Australia, a total of 50 veterans were recruited, 10 of whom were willing to be interviewed and audio-recorded about their deployment experiences. Narrative data analysis of veteran transcripts indicated that all participants had engaged in or were exposed to a PMIE/MI of one kind or another, and all had experienced betrayal and/or witnessed or perpetrated retribution. Given the ethical, moral and spiritual issues involved, the role of chaplains in addressing moral injury for the benefit of veterans through the use of 'Pastoral Narrative Disclosure' (PND) is suggested-with a specific focus upon 'restoration' and 'ritual'. Additional research is recommended with regard to acts of betrayal and retribution among veterans, as well as the further development of PND to address PMIE/MI.
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Affiliation(s)
- Timothy J Hodgson
- School of Historical and Philosophical Inquiry, University of Queensland, St. Lucia Campus, Brisbane, QLD, Australia.
| | - Lindsay B Carey
- School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
- Centre for Spirituality, Theology and Health, Duke University, Durham, NC, USA
| | - Harold G Koenig
- Centre for Spirituality, Theology and Health, Duke University, Durham, NC, USA
- Duke University Medical Centre, Duke University, Durham, NC, USA
- Department of Medicine, King Abdulaziz University, Jidda, Saudi Arabia
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Jones KA, Freijah I, Carey L, Carleton RN, Devenish-Meares P, Dell L, Rodrigues S, Madden K, Johnson L, Hosseiny F, Phelps AJ. Moral Injury, Chaplaincy and Mental Health Provider Approaches to Treatment: A Scoping Review. JOURNAL OF RELIGION AND HEALTH 2022; 61:1051-1094. [PMID: 35290554 PMCID: PMC8922078 DOI: 10.1007/s10943-022-01534-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 06/14/2023]
Abstract
The aim of this research was to describe the evidence examining the approaches taken by mental health providers (MHPs) and chaplains to address symptoms related to moral injury (MI) or exposure to potentially morally injurious events (PMIEs). This research also considers the implications for a holistic approach to address symptoms related to MI that combines mental health and chaplaincy work. A scoping review of literature was conducted using Medline, PsycINFO, Embase, Central Register of Controlled Trials, Proquest, Philosphers Index, CINAHL, SocINDEX, Academic Search Complete, Web of Science and Scopus databases using search terms related to MI and chaplaincy approaches or psychological approaches to MI. The search identified 35 eligible studies: 26 quantitative studies and nine qualitative studies. Most quantitative studies (n = 33) were conducted in military samples. The studies examined interventions delivered by chaplains (n = 5), MHPs (n = 23) and combined approaches (n = 7). Most studies used symptoms of post-traumatic stress disorder (PTSD) and/or depression as primary outcomes. Various approaches to addressing MI have been reported in the literature, including MHP, chaplaincy and combined approaches, however, there is currently limited evidence to support the effectiveness of any approach. There is a need for high quality empirical studies assessing the effectiveness of interventions designed to address MI-related symptoms. Outcome measures should include the breadth of psychosocial and spiritual impacts of MI if we are to establish the benefits of MHP and chaplaincy approaches and the potential incremental value of combining both approaches into a holistic model of care.
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Affiliation(s)
- Kimberley A Jones
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, VIC, 3053, Australia
| | - Isabella Freijah
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, VIC, 3053, Australia
| | - Lindsay Carey
- Department of Public Health, La Trobe University, Melbourne, Australia
| | | | - Peter Devenish-Meares
- Graduate School of Business, Queensland University of Technology, Brisbane, Australia
| | - Lisa Dell
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, VIC, 3053, Australia
| | - Sara Rodrigues
- Canadian Centre of Excellence on Post-Traumatic Stress Disorder (PTSD) and Related Mental Health Conditions, Ottawa, Canada
| | - Kelsey Madden
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, VIC, 3053, Australia
| | - Lucinda Johnson
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, VIC, 3053, Australia
| | - Fardous Hosseiny
- Department of Public Health, La Trobe University, Melbourne, Australia
| | - Andrea J Phelps
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, VIC, 3053, Australia.
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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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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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Smigelsky MA, Malott J, Parker R, Check C, Rappaport B, Ward S. Let's Get "REAL": A Collaborative Group Therapy for Moral Injury. J Health Care Chaplain 2022; 28:S42-S56. [PMID: 35112999 DOI: 10.1080/08854726.2022.2032978] [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
Moral injury is a particular response to profoundly distressing life events that manifests in damage to basic human/relational capacities, such as trust, autonomy, initiative, competence, identity, and intimacy. This paper describes and presents preliminary outcomes of "Reclaiming Experiences And Loss," or "REAL," which is an innovative moral injury group therapy that was developed collaboratively by Veterans Affairs mental health and spiritual care providers. Clinical outcome measures collected pre- and post-group indicates that REAL is effective at reducing symptoms of post-traumatic stress disorder and depression. Additionally, a cohort case example demonstrates the impact of REAL as told through individual stories as well as the intersectionality and interactions that comprise a typical REAL cohort and are considered central to care. Implications for ongoing care and future research are discussed.
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Affiliation(s)
- Melissa A Smigelsky
- Department of Veterans Affairs, Integrative Mental Health, Durham, North Carolina, USA
| | - Jesse Malott
- Christ Community Behavioral Health, Memphis, Tennessee, USA
| | - Ryan Parker
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Carter Check
- Eastern Oklahoma Veterans Affairs Health Care System, Muskogee, Oklahoma, USA
| | - Brad Rappaport
- Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Steffanie Ward
- Eastern Oklahoma Veterans Affairs Health Care System, Muskogee, Oklahoma, USA
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Thomas ED, Weiss NH, Forkus SR, Contractor AA. Examining the Interaction Between Potentially Morally Injurious Events and Religiosity in Relation to Alcohol Misuse Among Military Veterans. J Trauma Stress 2022; 35:314-320. [PMID: 33964030 PMCID: PMC8573051 DOI: 10.1002/jts.22682] [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: 05/12/2020] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 02/03/2023]
Abstract
Given the disproportionate rate of alcohol misuse among veterans and related outcomes as compared to the general population, the examination of predictors of alcohol misuse in this population is imperative. Potentially morally injurious events (PMIEs), defined as severe transgressions of a moral code, have been positively associated with alcohol misuse. Exposure to PMIEs may challenge one's religious beliefs, which may, in turn, influence the strength of the association between PMIEs and alcohol misuse among military veterans. The goal of the current study was to examine the potential moderating role of religiosity in the association between PMIEs and alcohol misuse (i.e., alcohol consumption, drinking behaviors, adverse reactions to drinking, and alcohol-related problems). Participants were 496 military veterans in the community (Mage = 37.80 years, SD = 11.42; 70.5% male). The results of moderation analyses indicated that overall religiosity, organizational religiosity, and intrinsic religiosity significantly moderated the association between PMIEs and alcohol misuse such that the positive relation between PMIEs and alcohol misuse was stronger at high versus low levels of religiosity, R2 s = .01. Our findings highlight the importance of considering the role of religiosity in relation to alcohol misuse as a moral injury outcome and the potential utility of tailoring treatments for military veterans who have experienced moral injury.
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Affiliation(s)
- Emmanuel D. Thomas
- Department of Psychology, University of Rhode Island, Kingston, Rhode Island, USA
| | - Nicole H. Weiss
- Department of Psychology, University of Rhode Island, Kingston, Rhode Island, USA
| | - Shannon R. Forkus
- Department of Psychology, University of Rhode Island, Kingston, Rhode Island, USA
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Maguen S, Griffin BJ. Research Gaps and Recommendations to Guide Research on Assessment, Prevention, and Treatment of Moral Injury Among Healthcare Workers. Front Psychiatry 2022; 13:874729. [PMID: 35492723 PMCID: PMC9051037 DOI: 10.3389/fpsyt.2022.874729] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 03/21/2022] [Indexed: 11/30/2022] Open
Abstract
Healthcare workers face numerous occupational stressors, including some that may challenge personal and shared morals and values. This is particularly true during disasters and crises such as the COVID-19 pandemic, which require critical decisions to be made with little time and information often under personal distress and situational constraints. Consequently, healthcare workers are at risk for moral injuries characterized by stress-related and functional impacts. Although research on the evaluation and treatment of moral injury among military veterans burgeoned in the recent decade, addressing moral injury in healthcare workers and other civilians remains an important gap. In this perspective piece, we identify research gaps and make recommendations to advance future work on assessment, prevention, and treatment of moral injury in healthcare workers. We draw on empirical studies of moral injury in veterans, limited studies of moral injury in health professionals, and our clinical experiences with healthcare workers affected by moral injury.
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Affiliation(s)
- Shira Maguen
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States.,San Francisco VA Healthcare System, San Francisco, CA, United States
| | - Brandon J Griffin
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Central Arkansas VA Healthcare System, Little Rock, AR, United States
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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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Ter Heide FJJ, de Goede ML, van Dam S, Ekkers S. Development of an online supportive treatment module for moral injury in military veterans and police officers. Front Psychiatry 2022; 13:890858. [PMID: 36117648 PMCID: PMC9478510 DOI: 10.3389/fpsyt.2022.890858] [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] [Received: 03/06/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Military members and police officers often operate in high stakes situations and under high levels of physical and psychological stress. Consequently, they may be confronted with morally injurious experiences and develop moral injury. Most treatments for moral injury are cognitive-behavioral, face-to-face treatments, which may be supported by online interventions. Online interventions have shown promise in the treatment of trauma-related psychopathology, but few such interventions for moral injury yet exist. OBJECTIVE To develop and conduct a preliminary evaluation of an online treatment module for moral injury in treatment-seeking military veterans and police officers, to be used in conjunction with regular face-to-face treatment. METHOD An online module was developed based on the moral injury literature, using elements from seven existing treatments. A preliminary evaluation was conducted using both quantitative and qualitative methods, and focusing on perceived feasibility, acceptability and engagement of the module, as well as potential benefits and harms. The concept module was evaluated by 15 assessors, including patient representatives, multidisciplinary caregivers and experts. RESULTS The module was rated favorably, with mean evaluation scores ranging from 7.9 to 8.8 on a 10-point scale. Several suggestions for improvement were made, especially concerning privacy issues, safety instructions, patient-therapist collaborations, and role plays, and the module was adapted accordingly. CONCLUSION Using input from literature, patient representatives and experts, we developed an online treatment module for moral injury in military veterans and police officers, to be used in conjunction with face-to-face therapy. Acceptability and feasibility will be further examined in a future pilot study.
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Khan AJ, Campbell-Sills L, Sun X, Kessler RC, Adler AB, Jain S, Ursano RJ, Stein MB. Association Between Responsibility for the Death of Others and Postdeployment Mental Health and Functioning in US Soldiers. JAMA Netw Open 2021; 4:e2130810. [PMID: 34724553 PMCID: PMC8561325 DOI: 10.1001/jamanetworkopen.2021.30810] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Rates of suicidal thoughts and behaviors (STBs) in US soldiers have increased sharply since the terrorist attacks on September 11, 2001, and postdeployment posttraumatic stress disorder (PTSD) remains a concern. Studies show that soldiers with greater combat exposure are at an increased risk for adverse mental health outcomes, but little research has been conducted on the specific exposure of responsibility for the death of others. OBJECTIVE To examine the association between responsibility for the death of others in combat and mental health outcomes among active-duty US Army personnel at 2 to 3 months and 8 to 9 months postdeployment. DESIGN, SETTING, AND PARTICIPANTS This cohort study obtained data from a prospective 4-wave survey study of 3 US Army brigade combat teams that deployed to Afghanistan in 2012. The sample was restricted to soldiers with data at all 4 waves (1-2 months predeployment, and 2-3 weeks, 2-3 months, and 8-9 months postdeployment). Data analysis was performed from December 12, 2020, to April 23, 2021. MAIN OUTCOMES AND MEASURES Primary outcomes were past-30-day PTSD, major depressive episode, STBs, and functional impairment at 2 to 3 vs 8 to 9 months postdeployment. Combat exposures were assessed using a combat stress scale. The association of responsibility for the death of others during combat was tested using separate multivariable logistic regression models per outcome adjusted for age, sex, race and ethnicity, marital status, brigade combat team, predeployment lifetime internalizing and externalizing disorders, and combat stress severity. RESULTS A total of 4645 US soldiers (mean [SD] age, 26.27 [6.07] years; 4358 men [94.0%]) were included in this study. After returning from Afghanistan, 22.8% of soldiers (n = 1057) reported responsibility for the death of others in combat. This responsibility was not associated with any outcome at 2 to 3 months postdeployment (PTSD odds ratio [OR]: 1.23 [95% CI, 0.93-1.63]; P = .14; STB OR: 1.19 [95% CI, 0.84-1.68]; P = .33; major depressive episode OR: 1.03 [95% CI, 0.73-1.45]; P = .87; and functional impairment OR: 1.12 [95% CI, 0.94-1.34]; P = .19). However, responsibility was associated with increased risk for PTSD (OR, 1.42; 95% CI, 1.09-1.86; P = .01) and STBs (OR, 1.55; 95% CI, 1.03-2.33; P = .04) at 8 to 9 months postdeployment. Responsibility was not associated with major depressive episode (OR, 1.30; 95% CI, 0.93-1.81; P = .13) or functional impairment (OR, 1.13; 95% CI, 0.94-1.36; P = .19). When examining enemy combatant death only, the pattern of results was unchanged for PTSD (OR, 1.44; 95 CI%, 1.10-1.90; P = .009) and attenuated for STBs (OR, 1.46; 95 CI%, 0.97- 2.20; P = .07). CONCLUSIONS AND RELEVANCE This cohort study found an association between being responsible for the death of others in combat and PTSD and STB at 8 to 9 months, but not 2 to 3 months, postdeployment in active-duty soldiers. The results suggest that delivering early intervention to those who report such responsibility may mitigate the subsequent occurrence of PTSD and STBs.
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Affiliation(s)
- Amanda J. Khan
- Department of Psychiatry, University of California San Diego, La Jolla
| | | | - Xiaoying Sun
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Amy B. Adler
- Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Sonia Jain
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla
| | - Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Murray B. Stein
- Department of Psychiatry, University of California San Diego, La Jolla
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla
- Psychiatry Service, Veterans Affairs San Diego Healthcare System, San Diego, California
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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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Pyne JM, Sullivan S, Abraham TH, Rabalais A, Jaques M, Griffin B. Mental Health Clinician Community Clergy Collaboration to Address Moral Injury Symptoms: A Feasibility Study. JOURNAL OF RELIGION AND HEALTH 2021; 60:3034-3051. [PMID: 33864575 DOI: 10.1007/s10943-021-01257-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 06/12/2023]
Abstract
Moral injury (MI) symptoms (guilt, shame, isolation) can be associated with military experiences. While a degree of overlap is recognized between MI and posttraumatic stress disorder (PTSD) symptoms, MI symptoms do not always respond to evidence-based treatments for PTSD. Mental Health Clinician Community Chaplain Collaboration (MC4) was delivered by community clergy to address MI symptoms through facilitation of forgiveness and community reintegration. Thirteen veterans participated and the results suggested that MC4 was generally feasible and acceptable. However, it is unlikely community clergy time could keep up with demand. Shifting intervention delivery to Department of Veterans Affairs (VA) chaplains will alleviate many barriers experienced in this feasibility study.
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Affiliation(s)
- Jeffrey M Pyne
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System (North Little Rock), 2200 Ft. Roots Drive, Bldg. 58, 152/NLR, North Little Rock, AR, 72114-1706, USA.
- South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, USA.
| | - Steve Sullivan
- Mental Health and Chaplaincy, Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham VA Medical Center, 508 Fulton Street, Durham, NC, USA
| | - Traci H Abraham
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System (North Little Rock), 2200 Ft. Roots Drive, Bldg. 58, 152/NLR, North Little Rock, AR, 72114-1706, USA
- South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, USA
| | - Aline Rabalais
- University of Texas Health Science Center at Houston, 7000 Fannin St #1200, Houston, TX, USA
| | - Michael Jaques
- Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, USA
| | - Brandon Griffin
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System (North Little Rock), 2200 Ft. Roots Drive, Bldg. 58, 152/NLR, North Little Rock, AR, 72114-1706, USA
- South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, USA
- Mental Health and Chaplaincy, Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham VA Medical Center, 508 Fulton Street, Durham, NC, USA
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Hodgson TJ, Carey LB, Koenig HG. Moral Injury, Australian Veterans and the Role of Chaplains: An Exploratory Qualitative Study. JOURNAL OF RELIGION AND HEALTH 2021; 60:3061-3089. [PMID: 34553273 DOI: 10.1007/s10943-021-01417-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/27/2021] [Indexed: 05/11/2023]
Abstract
Military personnel deployed to war zones or assigned to other morally challenging military duties are likely to be exposed to potentially morally injurious events (PMIE) that may inflict a moral injury (MI). This qualitative study formed 'Phase 1' of a larger study into PMIEs experienced by Australian veterans and the potential pastoral/spiritual care role of chaplains. Two seminars were conducted that involved 10 veterans being interviewed and audio recorded about their deployment experiences to evaluate whether there was any evidence among Australian veterans of a PMIE. Narrative data analysis indicated that all participants had been exposed to, or were involved in, a PMIE of one kind or another. Seven key themes were identified from the analyzed qualitative data: (i) immoral acts, (ii) death and injury, (iii) betrayal, (iv) ethical dilemmas, (v) disproportionate violence, (vi) retribution and (vii) religious/spiritual issues. Given this preliminary PMIE evidence identified, there is a need for further research, as well as the development of a suitable moral injury assessment scale appropriate for Australian veterans. Furthermore, given the ethical, moral, and spiritual issues involved, the implementation of a rehabilitation program suitable for Australian veterans which can be provided by chaplains is also suggested-namely 'Pastoral Narrative Disclosure.' It is argued that moral injury needs to be recognized, not just as an issue affecting individual personnel and their families, but is also a community health, organizational and government responsibility.
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Affiliation(s)
- Timothy J Hodgson
- School of Historical and Philosophical Inquiry, University of Queensland, Brisbane, Australia
| | - Lindsay B Carey
- Palliative Care Unit, Department of Public Health, School of Psychology and Public Health, La Trobe University (Melbourne Campus), Bundoora, Melbourne, 3086, Australia.
| | - Harold G Koenig
- Departments of Psychiatry and Medicine, Duke University Health System , Duke University, Durham, NC, USA
- Division of Psychiatry, Department of Medicine , King Abdulaziz University, Jeddah, Saudi Arabia
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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: 46] [Impact Index Per Article: 15.3] [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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Knobloch LK, Owens JL, Gobin RL. Spiritual care for combat trauma: A qualitative evaluation of REBOOT Combat Recovery. MILITARY PSYCHOLOGY 2021. [DOI: 10.1080/08995605.2021.1962183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Leanne K. Knobloch
- Department of Communication, University of Illinois, Urbana-Champaign, Illinois, USA
| | | | - Robyn L. Gobin
- Department of Kinesiology and Community Health, University of Illinois, Urbana-Champaign, Illinois, USA
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Evans WR, Russell LH, Hall-Clark BN, Fina BA, Brown LA, Foa EB, Peterson AL, For the Consortium to Alleviate PTSD. Moral Injury and Moral Healing in Prolonged Exposure for Combat-Related PTSD: A Case Study. COGNITIVE AND BEHAVIORAL PRACTICE 2021. [DOI: 10.1016/j.cbpra.2020.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Zerach G, Levi-Belz Y, Griffin BJ, Maguen S. Patterns of exposure to potentially morally injurious events among Israeli combat veterans: A latent class analysis approach. J Anxiety Disord 2021; 79:102378. [PMID: 33647608 DOI: 10.1016/j.janxdis.2021.102378] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 01/07/2021] [Accepted: 02/22/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Following exposure to events that transgress moral beliefs and expectations rooted in cultural, organizational, and group-based ethical rules, veterans can experience psychological, social, and spiritual problems referred to as Moral Injury (MI). We examined patterns of exposure to potentially morally injurious events (PMIEs) among Israeli veterans as well as psychological and functional correlates of exposure. METHOD A sample of 381 Israeli veterans volunteered to complete a cross-sectional electronic survey between 2017-2018. Latent Class Analysis (LCA) was used to identify classes characterized by unique patterns of exposure to PMIEs and compare differences in psychological and functional problems. RESULTS Three subgroups were identified: Moral Injury (12.1 %), Betrayal-Only (20.8 %), and Minimal Exposure (67.1 %). Whereas those in the betrayal-only class reported more traditional posttraumatic symptoms and those in the moral injury class reported more moral injury symptoms (i.e., guilt-related cognitions), some psychological problems were shared by veterans assigned to the moral injury and betrayal-only classes (e.g., entrapment). Importantly, while both those in the betrayal-only and moral injury classes had lower forgiveness relative to those in the minimal exposure class, those in the betrayal-only class received more familial support than did those in the moral injury class. CONCLUSIONS The study's findings offer an overview of the complex associations between patterns of exposure to PMIEs and associated outcomes. Clinicians treating veterans coping with combat trauma should be aware of the unique and shared symptoms reported by those with moral injury and betrayal exposures.
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Affiliation(s)
- Gadi Zerach
- Dept. of Behavioral Sciences and Psychology, Ariel University, Ariel, Israel.
| | - Yossi Levi-Belz
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
| | - Brandon J Griffin
- University of Arkansas for Medical Sciences, Little Rock, AR, USA; Central Arkansas VA Health Care System, North Little Rock, AR, USA
| | - Shira Maguen
- University of California - San Francisco, San Francisco, CA, USA; San Francisco VA Health Care System, San Francisco, CA, USA
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