1
|
Boska RL, Bishop TM, Capron DW, Paxton Willing MM, Ashrafioun L. Difficulties with emotion regulation within PTSD clusters and moral injury subtypes. MILITARY PSYCHOLOGY 2024:1-9. [PMID: 38421375 DOI: 10.1080/08995605.2024.2322904] [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: 06/28/2023] [Accepted: 02/12/2024] [Indexed: 03/02/2024]
Abstract
Treatment and research centered on trauma-related mental health issues have largely focused on posttraumatic stress disorder (PTSD); however, moral injury is another important mental health concern requiring attention. There is a paucity of research examining how PTSD and moral injury affect emotion regulation. The current investigation examined how PTSD clusters and moral injury subtypes were uniquely associated with difficulties with emotion regulation. Participants consisted of 253 previously deployed military personnel who were recruited online. To be included in the study, participants had to verify that they had served in the U.S. Military, had been deployed as part of their military service, and endorsed elevated levels of symptoms associated with PTSD and/or moral injury. A hierarchical linear regression was conducted to examine the association between PTSD symptom clusters, moral injury subtypes, and difficulties with emotion regulation. Results indicated that alterations in arousal and reactivity was the only PTSD symptom cluster associated with difficulties with emotion regulation. Self-transgressions was the only facet of moral injury significantly associated with difficulties with emotion regulation. This is the first study to examine the association between emotion dysregulation, PTSD symptom clusters, and moral injury in previously deployed U.S. Military.
Collapse
Affiliation(s)
- Rachel L Boska
- The War Related Illness and Injury Study Center, The VA New Jersey Healthcare System, East Orange, New Jersey
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, Canandaigua, New York
| | - Todd M Bishop
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, Canandaigua, New York
- Department of Psychiatry, University of Rochester School of Medicine & Dentistry, Rochester, New York
| | - Daniel W Capron
- Department of Psychology, Louisiana State University, Baton Rouge, Louisiana
| | - Maegan M Paxton Willing
- Center for Deployment Psychology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland
| | - Lisham Ashrafioun
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, Canandaigua, New York
- Department of Psychiatry, University of Rochester School of Medicine & Dentistry, Rochester, New York
| |
Collapse
|
2
|
Békés V, Szabó D, Lévay EE, Salgó E, Unoka Z. Moral Injury and Shame Mediate the Relationship Between Childhood Trauma and Borderline Personality Disorder, PTSD, and Complex PTSD Symptoms in Psychiatric Inpatients. J Pers Disord 2023; 37:406-423. [PMID: 37721777 DOI: 10.1521/pedi.2023.37.4.406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Moral injury (MI) has received increased research attention in the past decades. However, despite its detrimental mental health consequences, MI has not been studied in psychiatric patients. We aimed to establish the relationship between childhood trauma, MI, and borderline personality disorder (BPD), posttraumatic stress disorder (PTSD), and disturbances in self-organization symptoms (DSO), a core diagnostic criterion of complex PTSD besides PTSD symptoms, and shame as a moral emotion in an inpatient psychiatric sample (N = 240). We found that the impact of childhood trauma on present BPD, PTSD, and DSO symptoms was mediated by MI and shame; the models accounted for up to 31% of variance in symptomatology. To our knowledge, this study is the first to investigate MI in a psychiatric sample, and our results highlight the importance of considering MI as a critical factor of patient experiences in relation to childhood trauma that potentially contributes to the development of psychiatric symptoms.
Collapse
Affiliation(s)
- Vera Békés
- From Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York, USA
| | - Dominik Szabó
- Doctoral School of Mental Health Sciences, Semmelweis University, Budapest, Hungary
| | - Erika Evelyn Lévay
- Doctoral School of Mental Health Sciences, Semmelweis University, Budapest, Hungary
| | - Ella Salgó
- Doctoral School of Mental Health Sciences, Semmelweis University, Budapest, Hungary
| | - Zsolt Unoka
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Serfioti D, Murphy D, Greenberg N, Williamson V. Effectiveness of treatments for symptoms of post-trauma related guilt, shame and anger in military and civilian populations: a systematic review. BMJ Mil Health 2022:e002155. [PMID: 36442888 DOI: 10.1136/military-2022-002155] [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: 05/12/2022] [Accepted: 11/08/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Individuals who have been exposed to a traumatic event can develop profound feelings of guilt, shame and anger. Yet, studies of treatments for post-traumatic stress disorder (PTSD) have largely investigated changes in PTSD symptoms relating to a sense of ongoing fear or threat and the effectiveness of such treatments for post-trauma related guilt, shame or anger symptom reduction is comparatively not well understood. METHODS This review systematically examined the effectiveness of existing treatment approaches for three symptoms associated with exposure to traumatic events: guilt, shame and anger. Studies included had to be published after 2010 with a sample size of n=50 or greater to ensure stable treatment outcome estimates. RESULTS 15 studies were included, consisting of both civilian and (ex-) military population samples exposed to a wide range of traumatic events (eg, combat-related, sexual abuse). Findings indicated a moderate strength of evidence that both cognitive-based and exposure-based treatments are similarly effective in reducing symptoms. Cognitive-based treatments were found to effectively reduce post-trauma related guilt and anger, while exposure-based treatments appeared effective for post-trauma related guilt, shame and anger. CONCLUSIONS The findings suggest the importance of confronting and discussing the traumatic event during therapy, rather than using less directive treatments (eg, supportive counselling).Nonetheless, while these results are promising, firm conclusions regarding the comparative effectiveness and long-term impact of these treatments could not be drawn due to insufficient evidence. Further empirical research is needed to examine populations exposed to traumatic events and investigate which treatment approaches (or combination thereof) are more effective in the long-term.
Collapse
Affiliation(s)
- Danai Serfioti
- University of Derby, Derby, UK
- KCMHR, Institute of Psychiatry Psychology and Neuroscience Department of Basic and Clinical Neuroscience, London, UK
- Nottingham Trent University, Nottingham, UK
| | | | - N Greenberg
- Academic Department for Military Mental Health, King's College London, London, UK
| | - V Williamson
- KCMHR, Institute of Psychiatry Psychology and Neuroscience Department of Basic and Clinical Neuroscience, London, UK
- University of Oxford, Oxford, UK
| |
Collapse
|
5
|
Senecal G, Adorno RL, LaFleur R, McNamara KA. Autoethnographic Family Case Study: Combat Veteran PTSD and its Effects on Familial Dynamics, Parenting, and Marriage. JOURNAL OF VETERANS STUDIES 2022. [DOI: 10.21061/jvs.v8i3.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
|
6
|
A cognitive behavioural therapy (CBT) approach for working with strong feelings of guilt after traumatic events. COGNITIVE BEHAVIOUR THERAPIST 2021. [DOI: 10.1017/s1754470x21000192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
This article outlines a cognitive behavioural therapy (CBT) approach to treating feelings of guilt and aims to be a practical ‘how to’ guide for therapists. The therapeutic techniques were developed in the context of working with clients with a diagnosis of post-traumatic stress disorder (PTSD); however, the ideas can also be used when working with clients who do not meet a diagnosis of PTSD but have experienced trauma or adversity and feel guilty. The techniques in this article are therefore widely applicable: to veterans, refugees, survivors of abuse, the bereaved, and healthcare professionals affected by COVID-19, amongst others. We consider how to assess and formulate feelings of guilt and suggest multiple cognitive and imagery strategies which can be used to reduce feelings of guilt. When working with clients with a diagnosis of PTSD, it is important to establish whether the guilt was first experienced during the traumatic event (peri-traumatically) or after the traumatic event (post-traumatically). If the guilt is peri-traumatic, following cognitive work, this new information may then need to be integrated into the traumatic memory during reliving.
Key learning aims
(1)
To understand why feelings of guilt may arise following experiences of trauma or adversity.
(2)
To be able to assess and formulate feelings of guilt.
(3)
To be able to choose an appropriate cognitive technique, based on the reason for the feeling of guilt/responsibility, and work through this with a client.
(4)
To be able to use imagery techniques to support cognitive interventions with feelings of guilt.
Collapse
|
7
|
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]
|
8
|
Held P, Klassen BJ, Steigerwald VL, Smith DL, Bravo K, Rozek DC, Van Horn R, Zalta A. Do morally injurious experiences and index events negatively impact intensive PTSD treatment outcomes among combat veterans? Eur J Psychotraumatol 2021; 12:1877026. [PMID: 34025919 PMCID: PMC8128118 DOI: 10.1080/20008198.2021.1877026] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Background: It has been suggested that current frontline posttraumatic stress disorder (PTSD) treatments are not effective for the treatment of moral injury and that individuals who have experienced morally injurious events may respond differently to treatment than those who have not. However, these claims have yet to be empirically tested. Objective: This study evaluated the rates of morally injurious event exposure and morally injurious index trauma and their impact on PTSD (PCL-5) and depression symptom (PHQ-9) reductions during intensive PTSD treatment. Method: Data from 161 USA military combat service members and veterans (91.3% male; mean age = 39.94 years) who participated in a 3-week Cognitive Processing Therapy (CPT)-based intensive PTSD treatment programme (ITP) was utilized. Morally injurious event exposure was established via the Moral Injury Event Scale (MIES). Index traumas were also coded by the treating clinician. Linear mixed effects regression analyses were conducted to examine if differences in average effects or trends over the course of treatment existed between veterans with morally injurious event exposure or index trauma and those without. Results: Rates of morally injurious event exposure in this treatment sample were high (59.0%-75.2%). Morally injurious event exposure and the type of index trauma did not predict changes in symptom outcomes from the ITP and veterans reported large reductions in PTSD (d = 1.35-1.96) and depression symptoms (d = 0.95-1.24) from pre- to post-treatment. Non-inferiority analyses also demonstrated equivalence across those with and without morally injurious event exposure and index events. There were no significant gender differences. Conclusions: The present study suggests that PTSD and depression in military veterans with morally injurious event exposure histories may be successfully treated via a 3-week CPT-based ITP.
Collapse
Affiliation(s)
- Philip Held
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Brian J Klassen
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Victoria L Steigerwald
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Dale L Smith
- Department of Behavioral Sciences, Olivet Nazarene University, Burbonnais, IL, USA
| | - Karyna Bravo
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | - David C Rozek
- UCF RESTORES and Department of Psychology, University of Central Florida, Orlando, FL, USA
| | - Rebecca Van Horn
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Alyson Zalta
- Department of Psychological Science, University of California, Irvine, CA, USA
| |
Collapse
|
9
|
Litz BT, Rusowicz-Orazem L, Doros G, Grunthal B, Gray M, Nash W, Lang AJ. Adaptive disclosure, a combat-specific PTSD treatment, versus cognitive-processing therapy, in deployed marines and sailors: A randomized controlled non-inferiority trial. Psychiatry Res 2021; 297:113761. [PMID: 33540206 DOI: 10.1016/j.psychres.2021.113761] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 01/23/2021] [Indexed: 11/18/2022]
Abstract
Adaptive Disclosure (AD) is a new emotion-focused psychotherapy for combat-related PTSD. As a second step in the evaluation process, we conducted a non-inferiority (NI) trial of AD, relative to Cognitive Processing Therapy - Cognitive Therapy version (CPT-C), an established first-line psychotherapy. Participants were 122 U.S. Marines and Sailors. The primary endpoint was PTSD symptom severity change from pre- to posttreatment, using the Clinician Administered PTSD Scale for DSM-IV. Secondary endpoints were depression (Patient Health Questionnaire-9; PHQ-9) and functioning (Veterans Rand Health Survey-12; VR-12). For cases with complete data, the mean difference in CAPS-IV change scores was 0.33 and the confidence interval (CI) did not include the predefined NI margin (95% CI =-10.10, 9.44). The mean difference in PHQ-9 change scores was -1.01 and the CI did not include the predefined margin (95% CI = -3.31, 1.28), as was the case for the VR-12 Physical Component and VR-12 Mental Component subscale scores (0.27; 95% CI = -4.50, 3.95, and -2.10; 95% CI = -7.03, 2.83, respectively). A series of intent-to-treat sensitivity analyses confirmed these results. The differential effect size for CAPS-IV was d = 0.01 (nonsignificant). As predicted, Adaptive Disclosure was found to be no less effective than a first-line psychotherapy.
Collapse
Affiliation(s)
- Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, United States; Department of Psychiatry, Boston University School of Medicine, Boston, MA, United States.
| | - Luke Rusowicz-Orazem
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, United States; Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Gheorghe Doros
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, United States; Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Breanna Grunthal
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, United States
| | - Matthew Gray
- Department of Psychology, University of Wyoming College of Arts and Sciences, Laramie, WY, United States
| | - William Nash
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Ariel J Lang
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, CA, United States; Department of Psychiatry, University of California San Diego, San Diego, CA, United States
| |
Collapse
|
10
|
D'Alessandro AM, Ritchie K, McCabe RE, Lanius RA, Heber A, Smith P, Malain A, Schielke H, O'Connor C, Hosseiny F, Rodrigues S, McKinnon MC. Healthcare Workers and COVID-19-Related Moral Injury: An Interpersonally-Focused Approach Informed by PTSD. Front Psychiatry 2021; 12:784523. [PMID: 35264983 PMCID: PMC8900218 DOI: 10.3389/fpsyt.2021.784523] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/29/2021] [Indexed: 12/02/2022] Open
Abstract
The COVID-19 pandemic has resulted in a still-unfolding series of novel, potentially traumatic moral and ethical challenges that place many healthcare workers at risk of developing moral injury. Moral injury is a type of psychological response that may arise when one transgresses or witnesses another transgress deeply held moral values, or when one feels that an individual or institution that has a duty to provide care has failed to do so. Despite knowledge of this widespread exposure, to date, empirical data are scarce as to how to prevent and, where necessary, treat COVID-19-related moral injury in healthcare workers. Given the relation between moral injury and post-traumatic stress disorder (PTSD), we point here to social and interpersonal factors as critical moderators of PTSD symptomology and consider how this knowledge may translate to interventions for COVID-19-related moral injury. Specifically, we first review alterations in social cognitive functioning observed among individuals with PTSD that may give rise to interpersonal difficulties. Drawing on Nietlisbach and Maercker's 2009 work on interpersonal factors relevant to survivors of trauma with PTSD, we then review the role of perceived social support, social acknowledgment and social exclusion in relation to potential areas of targeted intervention for COVID-19-related moral injury in healthcare workers. Finally, building on existing literature (e.g., Phoenix Australia-Centre for Posttraumatic Mental Health and the Canadian Centre of Excellence-PTSD, 2020) we conclude with individual and organizational considerations to bolster against the development of moral injury in healthcare workers during the pandemic.
Collapse
Affiliation(s)
| | - Kimberly Ritchie
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Randi E McCabe
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, ON, Canada.,Anxiety Treatment and Research Clinic, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Ruth A Lanius
- Department of Psychiatry, University of Western, London, ON, Canada.,Homewood Research Institute, Guelph, ON, Canada.,Imaging Division, Lawson Health Research Institute, London, ON, Canada.,Department of Neuroscience, Western University, London, ON, Canada
| | - Alexandra Heber
- Veterans Affairs Canada, Ottawa, ON, Canada.,Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada
| | - Patrick Smith
- Centre of Excellence on Post-Traumatic Stress Disorder, Ottawa, ON, Canada.,University of Ottawa Institute of Mental Health Research at the Royal, Ottawa, ON, Canada
| | - Ann Malain
- Homewood Health Centre, Guelph, ON, Canada
| | | | | | - Fardous Hosseiny
- Centre of Excellence on Post-Traumatic Stress Disorder, Ottawa, ON, Canada.,University of Ottawa Institute of Mental Health Research at the Royal, Ottawa, ON, Canada
| | - Sara Rodrigues
- Centre of Excellence on Post-Traumatic Stress Disorder, Ottawa, ON, Canada.,University of Ottawa Institute of Mental Health Research at the Royal, Ottawa, ON, Canada
| | - Margaret C McKinnon
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, ON, Canada.,Homewood Research Institute, Guelph, ON, Canada.,Mental Health and Addictions Program, St. Joseph's Healthcare, Hamilton, ON, Canada
| |
Collapse
|
11
|
Wiinikka-Lydon J. Mapping Moral Injury: Comparing Discourses of Moral Harm. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2020; 44:175-191. [PMID: 30877779 DOI: 10.1093/jmp/jhy042] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Moral injury is a term whose popularity has grown in psychology and psychiatry, as well as philosophy, over the last several years. This presents challenges, because these fields use the term in different ways and draw their understanding from different sources, creating the potential for contradiction. This, however, is also an opportunity. Comparison between behavioral sciences and philosophy can help enrich understandings of harms considered not just psychological but moral. To this end, I provide an overview of the more influential writing of moral injury, mapping them into three broad discourses: clinical, juridical-critical, and structural. This overview then leads to a discussion of how comparative engagement among these discourses promises to expand on current theories of moral harm. I argue that such a comparison will demonstrate that more emphasis on structural violence will strengthen current understandings of moral injury, often understood in a more narrow sense to be a result of more direct, physical violence, allowing us to view moral injury as a result of institutional and social violence and injustices.
Collapse
|
12
|
Livingston NA, Berke D, Scholl J, Ruben M, Shipherd JC. Addressing Diversity in PTSD Treatment: Clinical Considerations and Guidance for the Treatment of PTSD in LGBTQ Populations. ACTA ACUST UNITED AC 2020; 7:53-69. [PMID: 32421099 PMCID: PMC7223966 DOI: 10.1007/s40501-020-00204-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose of review Trauma exposure is widespread but is especially common among lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals. LGBTQ individuals also experience higher rates of discrimination, victimization, and minority stress which can complicate posttraumatic stress disorder (PTSD) treatment but also represent independent intervention targets. In this review, we highlight existing evidence-based practices, current limitations, and provide recommendations for care in the absence of established guidelines for treatment PTSD among LGBTQ patients. Recent findings Trauma-focused therapies (e.g., CPT, PE) and medications (e.g., SSRIs, SNRIs) have shown benefit for people with PTSD. However, evaluations of these interventions have failed to examine the role of LGBTQ identities in recovery from trauma, and existing PTSD treatments do not account for ongoing threat to safety or the pervasive minority stress experienced by LGBTQ patients. In addition, many LGBTQ patients report negative experiences with healthcare, necessitating increased education and cultural awareness on the part of clinicians to provide patient-centered care and, potentially, corrective mental health treatment experiences. Summary Providers should routinely assess trauma exposure, PTSD, and minority stress among LGBTQ patients. We provide assessment and screening recommendations, outline current evidence-based treatments, and suggest strategies for integrating existing treatments to treat PTSD among LGBTQ patients.
Collapse
Affiliation(s)
- Nicholas A Livingston
- National Center for PTSD, Behavioral Science Division, Boston, MA USA.,2Department of Psychiatry, Boston University School of Medicine, Boston, MA USA.,3VA Boston Healthcare System, Boston, MA USA
| | - Danielle Berke
- 4Hunter College of the City University of New York, New York City, NY USA.,5The Graduate Center, City University of New York, New York City, NY USA
| | - James Scholl
- 2Department of Psychiatry, Boston University School of Medicine, Boston, MA USA.,3VA Boston Healthcare System, Boston, MA USA
| | - Mollie Ruben
- 6Department of Psychology, University of Maine, Orono, ME USA
| | - Jillian C Shipherd
- National Center for PTSD, Behavioral Science Division, Boston, MA USA.,National Center for PTSD, Women's Health Sciences Division, Boston, MA USA.,8Lesbian, Gay, Bisexual, and Transgender (LGBT) Health Program, Veterans Health Administration, Washington, DC USA
| |
Collapse
|
13
|
Griffin BJ, Purcell N, Burkman K, Litz BT, Bryan CJ, Schmitz M, Villierme C, Walsh J, Maguen S. Moral Injury: An Integrative Review. J Trauma Stress 2019; 32:350-362. [PMID: 30688367 DOI: 10.1002/jts.22362] [Citation(s) in RCA: 257] [Impact Index Per Article: 51.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 07/13/2018] [Accepted: 07/14/2018] [Indexed: 12/18/2022]
Abstract
Individuals who are exposed to traumatic events that violate their moral values may experience severe distress and functional impairments known as "moral injuries." Over the last decade, moral injury has captured the attention of mental health care providers, spiritual and faith communities, media outlets, and the general public. Research about moral injury, especially among military personnel and veterans, has also proliferated. For this article, we reviewed scientific research about moral injury. We identified 116 relevant epidemiological and clinical studies. Epidemiological studies described a wide range of biological, psychological/behavioral, social, and religious/spiritual sequelae associated with exposure to potentially morally injurious events. Although a dearth of empirical clinical literature exists, some authors debated how moral injury might and might not respond to evidence-based treatments for posttraumatic stress disorder (PTSD) whereas others identified new treatment models to directly address moral repair. Limitations of the literature included variable definitions of potentially morally injurious events, the absence of a consensus definition and gold-standard measure of moral injury as an outcome, scant study of moral injury outside of military-related contexts, and clinical investigations limited by small sample sizes and unclear mechanisms of therapeutic effect. We conclude our review by summarizing lessons from the literature and offering recommendations for future research.
Collapse
Affiliation(s)
- Brandon J Griffin
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry, University of California-San Francisco, San Francisco, CA, USA
| | - Natalie Purcell
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Social and Behavioral Sciences, University of California-San Francisco, San Francisco, CA, USA
| | - Kristine Burkman
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry, University of California-San Francisco, San Francisco, CA, USA
| | - Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, USA.,Departments of Psychiatry and Psychology, Boston University, Boston, MA, USA
| | - Craig J Bryan
- National Center for Veterans Studies, The University of Utah, Salt Lake City, UT, USA.,Department of Psychology, The University of Utah, Salt Lake City, UT, USA
| | - Martha Schmitz
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry, University of California-San Francisco, San Francisco, CA, USA
| | - Claudia Villierme
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Jessica Walsh
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychology, Palo Alto University, Palo Alto, CA, USA
| | - Shira Maguen
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry, University of California-San Francisco, San Francisco, CA, USA
| |
Collapse
|
14
|
Koenig HG, Youssef NA, Pearce M. Assessment of Moral Injury in Veterans and Active Duty Military Personnel With PTSD: A Review. Front Psychiatry 2019; 10:443. [PMID: 31316405 PMCID: PMC6611155 DOI: 10.3389/fpsyt.2019.00443] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/04/2019] [Indexed: 11/17/2022] Open
Abstract
Background: Moral injury (MI) involves distress over having transgressed or violated core moral boundaries, accompanied by feelings of guilt, shame, self-condemnation, loss of trust, loss of meaning, and spiritual struggles. MI is often found in Veterans and Active Duty Military personnel with posttraumatic stress disorder (PTSD). MI is widespread among those with PTSD symptoms, adversely affects mental health, and may increase risk of suicide; however, MI is often ignored and neglected by mental health professionals who focus their attention on PTSD only. Methods: A review of the literature between 1980 and 2018 conducted in 2018 is presented here to identify scales used to assess MI. Databases used in this review were PsychInfo, PubMed (Medline), and Google Scholar. Search terms were "moral injury," "measuring," "screening," "Veterans," and "Active Duty Military." Inclusion criteria were quantitative measurement of MI and health outcomes, Veteran or Active Duty Military status, and peer-review publication. Excluded were literature reviews, dissertations, book chapters, case reports, and qualitative studies. Results: Of the 730 studies identified, most did not meet eligibility criteria, leaving 118 full text articles that were reviewed, of which 42 did not meet eligibility criteria. Of the remaining 76 studies, 34 were duplicates leaving 42 studies, most published in 2013 or later. Of 22 studies that assessed MI, five used scales assessing multiple dimensions, and 17 assessed only one or two aspects (e.g., guilt, shame, or forgiveness). The remaining 20 studies used one of the scales reported in the first 22. Of the five scales assessing multiple dimensions of MI, two assess both morally injurious events and symptoms and the remaining three assess symptoms only. All studies were cross-sectional, except three that tested interventions. Conclusions: MI in the military setting is widespread and associated with PTSD symptom severity, anxiety, depression, and risk of suicide in current or former military personnel. Numerous measures exist to assess various dimensions of MI, including five multidimensional scales, although future research is needed to identify cutoff scores and clinically significant change scores. Three multidimensional measures assess MI symptoms alone (not events) and may be useful for determining if treatments directed at MI may both reduce symptoms and impact other mental health outcomes including PTSD.
Collapse
Affiliation(s)
- Harold G Koenig
- Duke University Medical Center, Durham, NC, United States.,King Abdulaziz University, Jeddah, Saudi Arabia.,Ningxia Medical University, Yinchuan, China
| | - Nagy A Youssef
- Medical College of Georgia, Augusta University, Charlie Norwood VA Medical Center, Augusta, GA, United States
| | - Michelle Pearce
- Department of Family and Community Medicine, Center for Integrative Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| |
Collapse
|
15
|
Toward an interdisciplinary conceptualization of moral injury: From unequivocal guilt and anger to moral conflict and disorientation. NEW IDEAS IN PSYCHOLOGY 2018. [DOI: 10.1016/j.newideapsych.2018.04.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
16
|
Nazarov A, Fikretoglu D, Liu A, Thompson M, Zamorski MA. Greater prevalence of post-traumatic stress disorder and depression in deployed Canadian Armed Forces personnel at risk for moral injury. Acta Psychiatr Scand 2018; 137:342-354. [PMID: 29504125 DOI: 10.1111/acps.12866] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND A link between moral injury (i.e., the psychological distress caused by perceived moral transgressions) and adverse mental health outcomes (AMHO) has been recently proposed. However, the prevalence of exposure to morally injurious events and the associated risk of experiencing AMHO remains understudied. METHOD The impact of exposure to potentially morally injurious experiences (PMIEs) was explored in relation to past-year PTSD and MDD, using the 2013 Canadian Armed Forces Mental Health Survey dataset of Afghanistan mission deployed regular force and reserve personnel. A series of logistic regressions were conducted, controlling for relevant sociodemographic, military, deployment, and trauma-related variables. RESULTS Over half of the deployed personnel endorsed at least one PMIE. Several demographic and military variables were associated with exposure to PMIEs. Those exposed to PMIEs demonstrated a greater likelihood of having past-year PTSD and MDD; feeling responsible for the death of Canadian or ally personnel demonstrated the strongest association with PTSD and MDD. Mental health training was not a moderator for PMIE exposure and AMHO. CONCLUSIONS Exposure to PMIEs during deployments is common and represents an independent risk factor for past-year PTSD and MDD. Improved training that targets moral-ethical dilemmas and treatment interventions that address moral injury expressions is warranted.
Collapse
Affiliation(s)
- A Nazarov
- Department of National Defence, Defence Research and Development Canada, Toronto, ON, Canada.,Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, ON, Canada
| | - D Fikretoglu
- Department of National Defence, Defence Research and Development Canada, Toronto, ON, Canada.,Douglas Mental Health University Institute, McGill University, Ottawa, ON, Canada
| | - A Liu
- Douglas Mental Health University Institute, McGill University, Ottawa, ON, Canada
| | - M Thompson
- Department of National Defence, Defence Research and Development Canada, Toronto, ON, Canada
| | - M A Zamorski
- Directorate of Mental Health, Canadian Forces Health Services Group, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
17
|
Beidel DC, Stout JW, Neer SM, Frueh BC, Lejuez C. An intensive outpatient treatment program for combat-related PTSD: Trauma Management Therapy. Bull Menninger Clin 2018; 81:107-122. [PMID: 28609148 DOI: 10.1521/bumc.2017.81.2.107] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
An estimated 18.5% of veterans returning from Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn are suffering from posttraumatic stress or posttraumatic stress disorder (PTSD). The number of veterans and service duty personnel requesting VA health care services is increasing, and the VA's ability to handle requests is dwindling. Thus, both the content of interventions and the format by which these services are delivered need to be reconceptualized. The authors present a multicomponent intervention program known as Trauma Management Therapy (TMT), a comprehensive, empirically supported treatment that can be delivered in an intensive, 3-week outpatient format. TMT combines individual exposure therapy with group social and emotional rehabilitation skills training to address specific aspects of the combat-related PTSD syndrome. The authors present the format of this novel intensive outpatient program, describe the components, and address implementation factors such as treatment compliance, dropout rates, and administrative considerations.
Collapse
Affiliation(s)
- Deborah C Beidel
- Department of Psychology, University of Central Florida, Orlando, Florida
| | - Jeremy W Stout
- Department of Psychology, University of Central Florida, Orlando, Florida
| | - Sandra M Neer
- Department of Psychology, University of Central Florida, Orlando, Florida
| | | | - Carl Lejuez
- Department of Psychology, University of Kansas, Lawrence, Kansas
| |
Collapse
|
18
|
Zerach G, Levi-Belz Y. Moral injury process and its psychological consequences among Israeli combat veterans. J Clin Psychol 2018. [PMID: 29528102 DOI: 10.1002/jclp.22598] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES We aim to examine the link between exposure to potentially morally injurious events (PMIEs) and posttraumatic stress disorder symptoms (PTSS). We also aim to explore the mediating roles of depressive attributions, trauma-related guilt and shame, and self-disgust in the relationship between PMIEs and PTSS among combat veterans. METHOD A volunteers' sample of 191 Israeli combat veterans responded to self-report questionnaires in a cross-sectional design study. RESULTS More than one-fifth of the sample reported experiencing PMIEs but only betrayal based experience was related to PTSS. Importantly, betrayal based experience was associated with depressive attributions which increased the level of trauma-related distressing guilt, intrinsic shame and self-disgust, which in turn were associated with high levels of PTSS. CONCLUSIONS PMIEs, and especially betrayal based experiences, are related to PTSS among Israeli veterans. Depressive attributions, trauma-related distressing guilt, intrinsic shame, and self-disgust might serve as possible mechanisms for the links between PMIEs and PTSS.
Collapse
|
19
|
Trachik B, Bowers C, Neer SM, Nguyen V, Frueh BC, Beidel DC. Combat-related guilt and the mechanisms of exposure therapy. Behav Res Ther 2018; 102:68-77. [DOI: 10.1016/j.brat.2017.11.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 11/13/2017] [Accepted: 11/24/2017] [Indexed: 10/18/2022]
|
20
|
Phelps AJ, Steel Z, Metcalf O, Alkemade N, Kerr K, O'Donnell M, Nursey J, Cooper J, Howard A, Armstrong R, Forbes D. Key patterns and predictors of response to treatment for military veterans with post-traumatic stress disorder: a growth mixture modelling approach. Psychol Med 2018; 48:95-103. [PMID: 29140225 DOI: 10.1017/s0033291717001404] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND To determine the patterns and predictors of treatment response trajectories for veterans with post-traumatic stress disorder (PTSD). METHODS Conditional latent growth mixture modelling was used to identify classes and predictors of class membership. In total, 2686 veterans treated for PTSD between 2002 and 2015 across 14 hospitals in Australia completed the PTSD Checklist at intake, discharge, and 3 and 9 months follow-up. Predictor variables included co-morbid mental health problems, relationship functioning, employment and compensation status. RESULTS Five distinct classes were found: those with the most severe PTSD at intake separated into a relatively large class (32.5%) with small change, and a small class (3%) with a large change. Those with slightly less severe PTSD separated into one class comprising 49.9% of the total sample with large change effects, and a second class comprising 7.9% with extremely large treatment effects. The final class (6.7%) with least severe PTSD at intake also showed a large treatment effect. Of the multiple predictor variables, depression and guilt were the only two found to predict differences in response trajectories. CONCLUSIONS These findings highlight the importance of assessing guilt and depression prior to treatment for PTSD, and for severe cases with co-morbid guilt and depression, considering an approach to trauma-focused therapy that specifically targets guilt and depression-related cognitions.
Collapse
Affiliation(s)
- A J Phelps
- Department of Psychiatry,Phoenix Australia - Centre for Posttraumatic Mental Health, University of Melbourne,Level 3, Alan Gilbert Building, 161 Barry St, Carlton,Australia
| | - Z Steel
- St John of God Richmond Hospital and School of Psychiatry, University of New South Wales,Sydney,Australia
| | - O Metcalf
- Department of Psychiatry,Phoenix Australia - Centre for Posttraumatic Mental Health, University of Melbourne,Level 3, Alan Gilbert Building, 161 Barry St, Carlton,Australia
| | - N Alkemade
- Department of Psychiatry,Phoenix Australia - Centre for Posttraumatic Mental Health, University of Melbourne,Level 3, Alan Gilbert Building, 161 Barry St, Carlton,Australia
| | - K Kerr
- Toowong Private Hospital,496 Milton Road, Toowong, Queensland,Australia
| | - M O'Donnell
- Department of Psychiatry,Phoenix Australia - Centre for Posttraumatic Mental Health, University of Melbourne,Level 3, Alan Gilbert Building, 161 Barry St, Carlton,Australia
| | - J Nursey
- Department of Psychiatry,Phoenix Australia - Centre for Posttraumatic Mental Health, University of Melbourne,Level 3, Alan Gilbert Building, 161 Barry St, Carlton,Australia
| | - J Cooper
- Department of Psychiatry,Phoenix Australia - Centre for Posttraumatic Mental Health, University of Melbourne,Level 3, Alan Gilbert Building, 161 Barry St, Carlton,Australia
| | - A Howard
- Department of Psychiatry,Phoenix Australia - Centre for Posttraumatic Mental Health, University of Melbourne,Level 3, Alan Gilbert Building, 161 Barry St, Carlton,Australia
| | - R Armstrong
- Department of Psychiatry,Phoenix Australia - Centre for Posttraumatic Mental Health, University of Melbourne,Level 3, Alan Gilbert Building, 161 Barry St, Carlton,Australia
| | - D Forbes
- Department of Psychiatry,Phoenix Australia - Centre for Posttraumatic Mental Health, University of Melbourne,Level 3, Alan Gilbert Building, 161 Barry St, Carlton,Australia
| |
Collapse
|
21
|
Frankfurt S, Frazier P. A Review of Research on Moral Injury in Combat Veterans. MILITARY PSYCHOLOGY 2017. [DOI: 10.1037/mil0000132] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
22
|
Held P, Klassen BJ, Brennan MB, Zalta AK. Using Prolonged Exposure and Cognitive Processing Therapy to Treat Veterans with Moral Injury-Based PTSD: Two Case Examples. COGNITIVE AND BEHAVIORAL PRACTICE 2017; 25:377-390. [PMID: 30147290 DOI: 10.1016/j.cbpra.2017.09.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Moral injury refers to acts of commission or omission that violate individuals' moral or ethical standards. Morally injurious events are often synonymous with psychological trauma, especially in combat situations; thus, morally injurious events are often implicated in the development of PTSD for military service members and veterans. Although Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) have been well-established as effective treatments for veterans who are struggling with posttraumatic stress disorder (PTSD), it has been suggested that these two evidence-based therapies may not be sufficient for treating veterans whose PTSD resulted from morally injurious events. The purpose of this manuscript is to detail how the underlying theories of PE and CPT can account for moral-injury based PTSD and to describe two case examples of veterans with PTSD stemming from morally injurious events who were successfully treated with PE and CPT. The manuscript concludes with a summary of challenges that clinicians may face when treating veterans with PTSD resulting from moral injury using either PE or CPT.
Collapse
Affiliation(s)
- Philip Held
- Department of Psychiatry, Rush University Medical Center
| | | | | | - Alyson K Zalta
- Department of Psychiatry, Rush University Medical Center
- Department of Behavioral Sciences, Rush University Medical Center
| |
Collapse
|
23
|
Itzhaky L, Avidor S, Solomon Z. Long-Term Guilt and Hostility Underlying Posttraumatic Stress Symptoms in War Combatants and Ex-Prisoners of War. JOURNAL OF LOSS & TRAUMA 2017. [DOI: 10.1080/15325024.2017.1284491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Liat Itzhaky
- I-Core Research Center for Mass Trauma, The Bob Shappell School of Social Work, Tel-Aviv University, Tel-Aviv, Israel
| | - Sharon Avidor
- I-Core Research Center for Mass Trauma, The Bob Shappell School of Social Work, Tel-Aviv University, Tel-Aviv, Israel
| | - Zahava Solomon
- I-Core Research Center for Mass Trauma, The Bob Shappell School of Social Work, Tel-Aviv University, Tel-Aviv, Israel
| |
Collapse
|
24
|
The Trauma Related Shame Inventory: Measuring Trauma-Related Shame Among Patients with PTSD. JOURNAL OF PSYCHOPATHOLOGY AND BEHAVIORAL ASSESSMENT 2014. [DOI: 10.1007/s10862-014-9422-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
25
|
Rauch SA, Smith E, Duax J, Tuerk P. A Data-Driven Perspective: Response to Commentaries by Maguen and Burkman (2013) and Steenkamp et al. (2013). COGNITIVE AND BEHAVIORAL PRACTICE 2013. [DOI: 10.1016/j.cbpra.2013.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|