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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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2
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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.
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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
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3
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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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4
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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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5
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Bonson A, Murphy D, Aldridge V, Greenberg N, Williamson V. Conceptualization of moral injury: A socio-cognitive perspective. JOURNAL OF MILITARY, VETERAN AND FAMILY HEALTH 2023. [DOI: 10.3138/jmvfh-2022-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
LAY SUMMARY This article looks at how moral injury (MI) may develop by considering what event features may be especially salient and cause MI and what experiences an individual may have after an event that might lead to the occurrence of a MI. It proposes that the beliefs someone has about themselves, others, and the world can be shaped by experiences in childhood and early life. Once an individual has experienced a potentially morally injurious event (PMIE) — for example, witnessing something that violates deeply held moral or ethical codes but being unable to stop it, doing something that violates these ethical codes, or experiencing a significant betrayal — they may try to make sense of it by changing the way they see the world, themselves, and others. This can lead to problems in the individual’s relationship with themselves and others, leading to feelings of shame and guilt and withdrawal from other people. More important, for an event to be a PMIE, it must significantly challenge strongly held moral beliefs and a sense of right and wrong.
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Affiliation(s)
- Amanda Bonson
- Research Department, Combat Stress, Leatherhead, Surrey, United Kingdom
| | - Dominic Murphy
- Research Department, Combat Stress, Leatherhead, Surrey, United Kingdom
| | - Vicky Aldridge
- Research Department, Combat Stress, Leatherhead, Surrey, United Kingdom
| | - Neil Greenberg
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Victoria Williamson
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
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6
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LoSavio ST, Holder N, Wells SY, Resick PA. Clinician Concerns About Cognitive Processing Therapy: A Review of the Evidence. COGNITIVE AND BEHAVIORAL PRACTICE 2022. [DOI: 10.1016/j.cbpra.2022.08.005] [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]
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7
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Wong PH. Moral Injury in Former Child Soldiers in Liberia. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2022; 15:847-856. [PMID: 35958708 PMCID: PMC9360290 DOI: 10.1007/s40653-021-00414-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/14/2021] [Indexed: 06/01/2023]
Abstract
Moral injury (MI) is a form of traumatic stress induced by perpetrating actions that transgress a person's beliefs and values. Existing research on MI has been mostly confined to military veterans, however there is reason to believe that the risk of MI among child soldiers is higher due to their age and history of abduction. This study examined the risk of MI in former child soldiers in Liberia and tested whether age and history of abduction moderate the relationship between perpetrating violence and MI based on a sample of 459 former child soldiers. Results from regression analysis confirmed that perpetrators had a higher risk of MI. However, while younger perpetrators were more vulnerable to MI, abduction history had no statistically significant moderation effect on the risk of MI. Further analysis also revealed that the moderation effects are primarily on anxiety, avoidance and negative feelings but not re-experiencing. These findings suggest that new tests and treatment models may be required for future disarmament, demobilization, rehabilitation and reintegration (DDRR) policy.
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Affiliation(s)
- Pui-Hang Wong
- Maastricht Graduate School of Governance, Maastricht University, Boschstraat 24, 6211 AX Maastricht, Netherlands
- United Nations University MERIT, Maastricht, Netherlands
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8
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9
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PTSD: equity in diagnostic practice. Lancet Psychiatry 2021; 8:1024-1026. [PMID: 34801116 DOI: 10.1016/s2215-0366(21)00366-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 08/22/2021] [Accepted: 08/23/2021] [Indexed: 11/22/2022]
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10
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Letter to the editor: Moral injury: A new (old) challenge for world psychiatry. J Psychiatr Res 2021; 143:599-601. [PMID: 33199050 DOI: 10.1016/j.jpsychires.2020.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 11/22/2022]
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11
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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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12
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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.
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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
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13
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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.
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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
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14
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Farnsworth JK. Is and Ought: Descriptive and Prescriptive Cognitions in Military-Related Moral Injury. J Trauma Stress 2019; 32:373-381. [PMID: 30667564 DOI: 10.1002/jts.22356] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/16/2018] [Accepted: 04/30/2018] [Indexed: 11/06/2022]
Abstract
Debate exists regarding the most appropriate way to address moral injuries that stem from involvement in war and other military conflicts. In recent years, some researchers have suggested that existing treatments for trauma may be inadequate to address moral injury and have thus proposed novel interventions to help mitigate these concerns. In response, advocates of more traditional approaches have argued that standard trauma interventions are generally sufficient for moral injury, and investment in new interventions may be premature. This conceptual article draws from research findings and current theories of moral injury to demonstrate that there is merit on both sides of this debate, and further clarifying the types of cognitions involved in moral injury can guide effective treatment planning. In particular, the most recent diagnostic criteria for posttraumatic stress disorder is used to distinguish the objectively falsifiable descriptive cognitions often associated with trauma from the subjectively determined prescriptive cognitions that characterize moral injury. Scenarios from war zone deployments have been used to highlight the relevance of this distinction for moral injury, and a general treatment framework that shows how existing and novel interventions may complement one another is presented. Research suggestions for assessing descriptive and prescriptive cognitions in moral injury and empirically validating this treatment framework are discussed.
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Affiliation(s)
- Jacob K Farnsworth
- Veteran Affairs Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
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15
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Steinmetz SE, Gray MJ, Clapp JD. Development and Evaluation of the Perpetration-Induced Distress Scale for Measuring Shame and Guilt in Civilian Populations. J Trauma Stress 2019; 32:437-447. [PMID: 30892734 DOI: 10.1002/jts.22377] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 08/27/2018] [Accepted: 09/07/2018] [Indexed: 11/12/2022]
Abstract
Although the topic of moral injury (MI) has been garnering increasing attention in recent years within military populations, research has rarely applied the concept to civilian contexts. Extant literature on distinct acts of perpetration or transgressions suggests similar emotional, cognitive, and behavioral patterns of distress associated with appraisals of wrongdoing. However, the absence of a psychometrically sound measure to detect and quantify pathological levels of distress associated with perpetrating harm against others has hindered additional research from being conducted on the topic. The current research presents the Perpetration-Induced Distress Scale (PIDS) as a valid and reliable measurement of distress associated with MI within civilian contexts. Factor analytic techniques revealed a two-factor solution characterized by perpetration-induced distress related to maladaptive reactions to shame (seven items) and guilt/self-blame (seven items). The PIDS demonstrated favorable temporal stability over a 1-week period as well as excellent internal reliability. Further, the PIDS evidenced convergent validity with functional impairment, posttraumatic stress disorder, and existing scales of shame and guilt; associations were large (rs = 0.62-0.87). The development of the PIDS represents one of the first studies to measure MI within a civilian population and indicates evidence that additional research on the topic is warranted.
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Affiliation(s)
- Sarah E Steinmetz
- Department of Psychology, University of Wyoming, Laramie, Wyoming, USA
| | - Matt J Gray
- Department of Psychology, University of Wyoming, Laramie, Wyoming, USA
| | - Joshua D Clapp
- Department of Psychology, University of Wyoming, Laramie, Wyoming, USA
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16
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Frankfurt SB, DeBeer BB, Morissette SB, Kimbrel NA, La Bash H, Meyer EC. Mechanisms of Moral Injury Following Military Sexual Trauma and Combat in Post-9/11 U.S. War Veterans. Front Psychiatry 2018; 9:520. [PMID: 30450058 PMCID: PMC6225808 DOI: 10.3389/fpsyt.2018.00520] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/02/2018] [Indexed: 11/13/2022] Open
Abstract
Objective: Moral injury may result from perpetration-based and betrayal-based acts that violate deeply held norms; however, researchers and clinicians have little guidance about the moral injury syndrome's specific developmental pathways following morally injurious events. The present study's objective was to examine the direct and indirect pathways proposed in a frequently cited model of moral injury (1) in relation to two types of military-related traumas [experiencing military sexual trauma (MST) and combat exposure]. Methods: Secondary analyses were conducted within a sample of post-9/11 veterans at a Southwestern Veterans Health Care System (N = 310) across two time-points. Structural equation modeling tested the direct and indirect pathways from MST and combat to a PTSD-depression factor via betrayal, perpetration, guilt, and shame. Results: Betrayal accounted for the association between MST and PTSD-depression (β = 0.10, p < 0.01, 95% CI = 0.01 - 0.11) and perpetration accounted for the association between combat and PTSD-depression (β = 0.07, p < 0.05, 95% CI = 0.02 - 0.14). The indirect path from combat to shame to PTSD-depression was significant (β = 0.16, p < 0.01, 95% CI = 0.07 - 0.28) but the path through guilt was not. The specific indirect paths through perpetration or betrayal to shame or guilt were non-significant. Conclusions: Betrayal and perpetration are associated with PTSD-depression following MST and combat. Results suggest multiple pathways of moral injury development following different military traumas and morally injurious events. Implications for moral injury conceptualization and treatment are discussed.
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Affiliation(s)
- Sheila B. Frankfurt
- VISN 17 Center of Excellence for Research on Returning War Veterans, United States Department of Veterans Affairs, Waco, TX, United States
- Central Texas Veterans Health Care System, Temple, TX, United States
- College of Medicine, Texas A&M University Health Science Center, College Station, TX, United States
| | - Bryann B. DeBeer
- VISN 17 Center of Excellence for Research on Returning War Veterans, United States Department of Veterans Affairs, Waco, TX, United States
- Central Texas Veterans Health Care System, Temple, TX, United States
- College of Medicine, Texas A&M University Health Science Center, College Station, TX, United States
| | | | - Nathan A. Kimbrel
- Durham VA Medical Center, Durham, NC, United States
- Mental Illness Research, Education and Clinical Centers MIRECC (VA), Durham, NC, United States
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, United States
| | - Heidi La Bash
- National Center for PTSD, VA Palo Alto Healthcare System, Palo Alto, CA, United States
| | - Eric C. Meyer
- VISN 17 Center of Excellence for Research on Returning War Veterans, United States Department of Veterans Affairs, Waco, TX, United States
- Central Texas Veterans Health Care System, Temple, TX, United States
- College of Medicine, Texas A&M University Health Science Center, College Station, TX, United States
- Department of Psychology and Neuroscience, Baylor University, Waco, TX, United States
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17
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Stayton LE, Dickstein BD, Chard KM. Impact of Self-Blame on Cognitive Processing Therapy: A Comparison of Treatment Outcomes. J Trauma Stress 2018; 31:419-426. [PMID: 29924426 DOI: 10.1002/jts.22289] [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] [Received: 06/15/2017] [Revised: 02/08/2018] [Accepted: 02/14/2018] [Indexed: 11/07/2022]
Abstract
Research suggests that cognitive processing therapy (CPT) may be a particularly well-suited intervention for trauma survivors who endorse self-blame; however, no study has examined the impact of self-blame on response to CPT. Accordingly, the current study compared response to CPT between two groups of veterans seeking residential treatment for posttraumatic stress disorder (PTSD). In one group, participants endorsed low self-blame at pretreatment (n = 133) and in the other group, participants endorsed high self-blame (n = 133). Results from multilevel modeling analysis suggest that both groups experienced significant reductions in PTSD symptoms as measured by the PTSD Checklist, B = -1.58, SE = 0.11; 95% CI [-1.78, -1.37]; t(1654) = -14.97, p < .001. After controlling for pretreatment symptom severity and additional covariates, there was no difference in treatment response between the low- and high-self-blame groups, Time × Self-blame interaction: B = 0.18, SE = 0.12; 95% CI = [-0.06, 0.42]; t(1646) = 1.49, p = .138. This suggests that CPT is an effective treatment for individuals exposed to trauma, regardless of level of self-blame.
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Affiliation(s)
- Laura E Stayton
- Cincinnati VA Medical Center, Trauma Recovery Center, Cincinnati, Ohio, USA
| | | | - Kathleen M Chard
- Cincinnati VA Medical Center, Trauma Recovery Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Psychiatry and Behavioral Neuroscience, Cincinnati, Ohio, USA
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18
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Abstract
DSM-5 substantially revised the PTSD criteria relating to exposure, redrawing symptom clusters and introducing additional symptom criteria, among them a newly defined criterion of persistent distorted blame of self or others. This commentary argues that there are fundamental problems with the current DSM-5 formulation of the blame criterion for PTSD. Most critically, there is conflation of self-blame and other-blame, which are two distinct phenomena, and there is heterogeneity in the research findings regarding the association between both kinds of blame and PTSD. Secondly, distortion of blame may be complex to determine. Finally, standard assessment tools fail to accurately represent the criteria as currently formulated. Despite the conceptual ambiguity in the diagnostic criteria and the lack of clarity regarding the assessment of this item in commonly-used measures, there is also evidence that blame is associated with other PTSD symptoms, is clinically relevant and may be an important intervention target in therapy. It is crucial, therefore, to clarify the blame criterion, differentiating aspects of self-blame and other-blame and, even more importantly, delineating the boundaries between normal and pathological blame.
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Affiliation(s)
- Talya Greene
- Department of Community Mental Health, University of Haifa, Haifa, Israel
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19
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Wachen JS, Dondanville KA, Resick PA. Correcting Misperceptions About Cognitive Processing Therapy to Treat Moral Injury: A Response to Gray and Colleagues (this issue). COGNITIVE AND BEHAVIORAL PRACTICE 2017. [DOI: 10.1016/j.cbpra.2017.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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