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Kaufman CC, McHugh RK, Drury M, Merrill JG, Rosmarin DH. Spirituality/Religion Among First Responders With and Without Posttraumatic Stress Disorder and Alcohol Misuse. J Dual Diagn 2024; 20:291-302. [PMID: 38560884 DOI: 10.1080/15504263.2024.2330619] [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: 04/04/2024]
Abstract
Objective: To examine the co-occurrence of alcohol misuse and posttraumatic stress disorder (PTSD) and potential sources of coping (e.g., spirituality/religion) and clinically relevant variables among first responders (e.g., firefighters, law enforcement corrections officers, paramedics). Method: We assessed rates of independent and co-occurring alcohol misuse and PTSD among a national online sample of 320 first responders as well as the prevalence and salience of S/R, guilt, shame, moral injury, aspects of S/R, and treatment interest. Results: In our sample, 46.88% (n = 150) met criteria for comorbid alcohol misuse and probable PTSD and individuals with these comorbid conditions reported significantly greater negative religious coping, moral injury, and shame than all other diagnostic groups (i.e., independent alcohol misuse, independent PTSD, and neither). Correlations also revealed significant relationships between alcohol misuse and PTSD symptomatology with positive and negative religious coping, moral injury, shame, guilt, interest in treatment, and interest in spiritually integrated treatment. Conclusions: Findings highlight the high rates of independent and co-occurring alcohol misuse and PTSD among first responders as well as the salience of S/R in this population.
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Affiliation(s)
- Caroline C Kaufman
- Department of Psychiatry, Harvard Medical School, Belmont, Massachusetts, USA
- Spirituality and Mental Health Program, McLean Hospital, Belmont, Massachusetts, USA
| | - R Kathryn McHugh
- Department of Psychiatry, Harvard Medical School, Belmont, Massachusetts, USA
- McLean Hospital Stress, Anxiety, and Substance Use Laboratory, Belmont, Massachusetts, USA
| | - Mia Drury
- Spirituality and Mental Health Program, McLean Hospital, Belmont, Massachusetts, USA
| | - Julia G Merrill
- Department of Geriatrics, McLean Hospital, Belmont, Massachusetts, USA
| | - David H Rosmarin
- Department of Psychiatry, Harvard Medical School, Belmont, Massachusetts, USA
- Spirituality and Mental Health Program, McLean Hospital, Belmont, Massachusetts, USA
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Griffin BJ, Norman SB, Weber MC, Hinkson KD, Jendro AM, Pyne JM, Worthington EL, Maguen S. Properties of the modified self-forgiveness dual-process scale in populations at risk for moral injury. Stress Health 2024; 40:e3413. [PMID: 38730552 DOI: 10.1002/smi.3413] [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: 08/23/2023] [Revised: 03/11/2024] [Accepted: 04/13/2024] [Indexed: 05/13/2024]
Abstract
Despite theory suggesting that self-forgiveness facilitates recovery from moral injury, no measure of self-forgiveness has been validated with individuals exposed to potentially morally injurious events (PMIEs). Military veterans, healthcare workers, and first responders who reported PMIE exposure (n = 924) completed the Self-Forgiveness Dual-Process Scale, which assesses two dimensions of the self-forgiveness process. The first dimension, value affirmation, refers to appraising personal responsibility and being willing to make amends for one's involvement in a PMIE. The second dimension, esteem restoration, refers to accepting oneself as valuable and capable of growth despite one's failures and imperfections. Exploratory and Confirmatory Factor Analyses replicated the original scale's two-factor structure in 10 items modified to apply to the diverse contexts in which PMIEs occur. Next, we found that the factor structure, item loadings, and item intercepts were fully or partially invariant across professions, genders, races, ages, and religious affiliations in a series of Multi-Group Confirmatory Factor Analyses. Finally, diverging patterns of associations between value affirmation and esteem restoration with moral distress, posttraumatic stress, depression, insomnia, functional impairment, and posttraumatic growth provide evidence of convergent and discriminant validity between the subscales. The modified self-forgiveness dual process scale is the first measure of self-forgiveness to be validated with individuals exposed to a PMIE. Researchers and clinicians can use the scale to examine how self-forgiveness (or difficulties with forgiving oneself) relates to moral injury.
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Affiliation(s)
- Brandon J Griffin
- Central Arkansas VA Health Care System, Center for Mental Health Care & Outcomes Research, North Little Rock, Arkansas, USA
- University of Arkansas for Medical Sciences, Psychiatric Research Institute, Little Rock, Arkansas, USA
- University of Colorado-Colorado Springs, Lyda Hill Institute for Human Resilience, Colorado Springs, Colorado, USA
| | - Sonya B Norman
- National Center for PTSD, White River Junction, Vermont, USA
- University of California San Diego School of Medicine, San Diego, California, USA
| | - Marcela C Weber
- Central Arkansas VA Health Care System, Center for Mental Health Care & Outcomes Research, North Little Rock, Arkansas, USA
- University of Arkansas for Medical Sciences, Psychiatric Research Institute, Little Rock, Arkansas, USA
| | - Kent D Hinkson
- Central Arkansas VA Health Care System, Center for Mental Health Care & Outcomes Research, North Little Rock, Arkansas, USA
- University of Arkansas for Medical Sciences, Psychiatric Research Institute, Little Rock, Arkansas, USA
| | - Ashlyn M Jendro
- Central Arkansas VA Health Care System, Center for Mental Health Care & Outcomes Research, North Little Rock, Arkansas, USA
| | - Jeffrey M Pyne
- Central Arkansas VA Health Care System, Center for Mental Health Care & Outcomes Research, North Little Rock, Arkansas, USA
- University of Arkansas for Medical Sciences, Psychiatric Research Institute, Little Rock, Arkansas, USA
| | | | - Shira Maguen
- San Francisco VA Health Care System, San Francisco, California, USA
- University of California San Francisco School of Medicine, San Francisco, California, USA
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D’Alessandro-Lowe AM, Brown A, Sullo E, Pichtikova M, Karram M, Mirabelli J, McCabe RE, McKinnon MC, Ritchie K. Why Are Healthcare Providers Leaving Their Jobs? A Convergent Mixed-Methods Investigation of Turnover Intention among Canadian Healthcare Providers during the COVID-19 Pandemic. NURSING REPORTS 2024; 14:2030-2060. [PMID: 39189282 PMCID: PMC11348248 DOI: 10.3390/nursrep14030152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Revised: 08/16/2024] [Accepted: 08/19/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND Staffing shortages across the healthcare sector pose a threat to the continuity of the Canadian healthcare system in the post-COVID-19 pandemic era. We sought to understand factors associated with turnover intention as well as Canadian healthcare providers' (HCPs) perspectives and experiences with turnover intention as related to both organizational and professional turnover. METHOD A convergent questionnaire mixed-methods design was employed. Descriptive statistics and ordinal logistic regressions were used to analyze quantitative data and ascertain factors associated with turnover intention. Thematic analysis was used to analyze qualitative open-field textbox data and understand HCPs' perspectives and experiences with turnover intention. RESULTS Quantitative analyses revealed that 78.6% of HCPs surveyed (N = 398) reported at least a 25% turnover likelihood regarding their organization, with 67.5% reporting at least a 25% turnover likelihood regarding their profession. Whereas regression models revealed the significant impact of years worked, burnout, and organizational support on turnover likelihood for organizations, age, sex, burnout, and organizational support contributed to the likelihood of leaving a profession. Patterns of meaning drawn from participants' qualitative responses were organized according to the following four themes: (1) Content to stay, (2) Drowning and no one cares, (3) Moral stressors, and (4) Wrestling with the costs and benefits. CONCLUSIONS Many HCPs described weighing the costs and benefits of leaving their organization or profession during the COVID-19 pandemic. Although challenging working conditions, moral stressors, and burnout may play a significant role in HCPs' experiences of turnover intention, there is ample room to intervene with organizational support.
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Affiliation(s)
| | - Andrea Brown
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L8S 4L8, Canada (M.C.M.)
| | - Emily Sullo
- Department of Psychology, Neuroscience and Behaviour, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Mina Pichtikova
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L8S 4L8, Canada (M.C.M.)
- Department of Applied Psychology and Human Development, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Mauda Karram
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L8S 4L8, Canada (M.C.M.)
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - James Mirabelli
- Department of Psychology, Neuroscience and Behaviour, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Randi E. McCabe
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L8S 4L8, Canada (M.C.M.)
- St. Joseph’s Healthcare Hamilton, Hamilton, ON L8N 4A6, Canada
| | - Margaret C. McKinnon
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L8S 4L8, Canada (M.C.M.)
- St. Joseph’s Healthcare Hamilton, Hamilton, ON L8N 4A6, Canada
- Homewood Research Institute, Guelph, ON N1E 6K9, Canada
| | - Kim Ritchie
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L8S 4L8, Canada (M.C.M.)
- Trent/Fleming School of Nursing, Trent University, Peterborough, ON K9L 0G2, Canada
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Maguen S, Griffin BJ, Pietrzak RH, McLean CP, Hamblen JL, Norman SB. Using the Moral Injury and Distress Scale to identify clinically meaningful moral injury. J Trauma Stress 2024; 37:685-696. [PMID: 38655683 DOI: 10.1002/jts.23050] [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: 11/19/2023] [Revised: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 04/26/2024]
Abstract
Despite the proliferation of moral injury studies, a remaining gap is distinguishing moral injury from normative distress following exposure to potentially morally injurious events (PMIEs). Our goal was to leverage mental health and functional measures to identify clinically meaningful and functionally impairing moral injury using the Moral Injury and Distress Scale (MIDS). Participants who endorsed PMIE exposure (N = 645) were drawn from a population-based sample of military veterans, health care workers, and first responders. Using signal detection methods, we identified the optimally efficient MIDS score for detecting clinically significant posttraumatic stress and depressive symptom severity, trauma-related guilt, and functional impairment. The most efficient cut scores across outcomes converged between 24 and 27. We recommend a cut score of 27 given that roughly 70% of participants who screened positive on the MIDS at this threshold reported clinically significant mental health symptoms, and approximately 50% reported severe trauma-related guilt and/or functional impairment. Overall, 10.2% of respondents exposed to a PMIE screened positive for moral injury at this threshold, particularly those who identified as a member of a minoritized racial or ethnic group (17.9%) relative to those who identified as White, non-Hispanic (8.0%), aOR = 2.52, 95% CI [1.45, 4.42]. This is the first known study to establish a cut score indicative of clinically meaningful and impairing moral injury. Such scores may enhance clinicians' abilities to conduct measurement-based moral injury care by enabling them to identify individuals at risk of negative outcomes and better understand risk and protective factors for moral injury.
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Affiliation(s)
- Shira Maguen
- Mental Health Services, San Francisco VA Health Care System, San Francisco, California, USA
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Brandon J Griffin
- Center for Mental Health Care and Outcomes Research, Central Arkansas VA, Little Rock, Arkansas, USA
- Psychiatric Research Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Robert H Pietrzak
- Clinical Neurosciences Division, National Center for PTSD, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, West Haven, Connecticut, USA
| | - Carmen P McLean
- Dissemination and Training Division, National Center for PTSD, Menlo Park, California, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Jessica L Hamblen
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Executive Division, National Center for PTSD, White River Junction, Vermont, USA
| | - Sonya B Norman
- Executive Division, National Center for PTSD, White River Junction, Vermont, USA
- Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, California, USA
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McDaniel JT, Redner R, Haun JN, McCowen P, Higgins ST. Moral injury among women military veterans and demand for cigarettes: A behavioral economic investigation using a hypothetical purchase task. Prev Med 2024:108036. [PMID: 38852890 DOI: 10.1016/j.ypmed.2024.108036] [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: 03/11/2024] [Revised: 05/20/2024] [Accepted: 06/06/2024] [Indexed: 06/11/2024]
Abstract
OBJECTIVES Unlike the United States general population, veteran women - as opposed to veteran men - have greater smoking prevalence; yet, little is known regarding factors that influence smoking in veteran women. The purpose of this study was to begin examining the relationship between a psychological concept known as moral injury and demand for cigarettes among veteran women. METHODS Veteran women who smoke (n = 44) were recruited for this cross-sectional study from Amazon MTurk, Reddit, and a veteran-serving non-profit organization in June-July 2023. Consenting participants received $2 for completing the cigarette purchase task (CPT), Fagerstrom Test for Nicotine Dependence (FTND), and the military version of the Moral Injury Symptom Scale (MISS-M-SF). We examined five CPT demand indices and calculated a modified exponential demand model stratified by moral injury severity status (i.e., probable vs. unlikely). RESULTS Probable morally injured women exhibited significantly higher relative reinforcing value (RRV) for smoking than unlikely morally injured women (F1, 920 = 9.16, p = 0.003). Average cigarette consumption at $0 (i.e., Q0) was 48.56% higher (M = 22.24 vs. M = 13.55) in probable compared to unlikely morally injured women (p = 0.04, Hedge's g = 0.74). FTND scores were significantly correlated with Pmax (i.e., demand elasticity point) and Omax (i.e., maximum expenditure) values in both populations (rs = 0.42-0.68, ps < 0.05). CONCLUSIONS We provide preliminary evidence of the relatively high RRV of smoking in morally injured veteran women. Continued research is needed to refine the characterization of this relationship.
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Affiliation(s)
- Justin T McDaniel
- School of Human Sciences, Southern Illinois University, 475 Clocktower Drive, Carbondale, IL 62901, USA.
| | - Ryan Redner
- School of Psychological and Behavioral Sciences, Southern Illinois University, 1125 Lincoln Drive, Carbondale, IL 62901, USA.
| | - Jolie N Haun
- James A. Haley Veterans' Hospital, Veterans Health Administration, 13000 Bruce B Downs Blvd., Tampa, FL 33612, USA.
| | - Patrick McCowen
- School of Human Sciences, Southern Illinois University, 475 Clocktower Drive, Carbondale, IL 62901, USA.
| | - Stephen T Higgins
- Departments of Psychiatry and Psychological Science, University of Vermont, 1 South Prospect Street, OH3, MS482, Burlington, VT 05401, USA.
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Heward C, Li W, Chun Tie Y, Waterworth P. A Scoping Review of Military Culture, Military Identity, and Mental Health Outcomes in Military Personnel. Mil Med 2024:usae276. [PMID: 38836843 DOI: 10.1093/milmed/usae276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/01/2024] [Accepted: 05/10/2024] [Indexed: 06/06/2024] Open
Abstract
INTRODUCTION The military is a unique cultural institution that significantly influences its members, contributing to the development and transformation of their identities. Despite growing interest in identity research in the military, challenges persist in the conceptualization of military identity, including understanding how it forms, assessing the influence of military culture on identity development, and evaluating the implications for mental health. The primary objective of this scoping review was to map the complexities of military culture's impact on military identity and its effects on mental health. MATERIALS AND METHODS A scoping review of the literature was conducted using the Joanna Briggs Institute Scoping Review Methodology. Studies were included if they described military culture, military identity, and mental health, resulting in 65 eligible studies. The extracted data were thematically analyzed to identify how military culture impacts military identity and mental health and well-being. RESULTS Multiple identities were evident within the military population, with 2 overarching identities, loyalty and military, overall conferring positive mental health outcomes. Where these identities were hidden or disrupted, poorer mental health outcomes were observed. CONCLUSIONS The scoping review conducted in this study challenges the notion of military identity as a singular concept promoting positive mental health outcomes. It highlights its multifaceted nature, revealing that individuals may face identity concealment and disruptions during periods of transition or adjustment, resulting in adverse mental health outcomes. To capture the complexity of military identity, the authors developed the Military Identity Model (MIM). Military leaders, policymakers, and health care professionals are encouraged to recognize the complex nature of military identity and its impact on mental health and well-being. We recommend using the Military Identity Model to explore military identity and adjustment-related difficulties.
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Affiliation(s)
- Carolyn Heward
- James Cook University, Townsville, Queensland 4811, Australia
| | - Wendy Li
- James Cook University, Townsville, Queensland 4811, Australia
| | - Ylona Chun Tie
- James Cook University, Townsville, Queensland 4811, Australia
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Walton TO, Graupensperger S, Walker DD, Kaysen D. Alcohol use disorder as a moderator of the relationship between posttraumatic stress disorder and suicidality among military personnel. ALCOHOL, CLINICAL & EXPERIMENTAL RESEARCH 2024; 48:1096-1106. [PMID: 38796793 DOI: 10.1111/acer.15313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 02/02/2024] [Accepted: 03/11/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Alcohol use disorder (AUD), posttraumatic stress disorder (PTSD), and suicide are substantial public health concerns among military service members, yet the nature of their relationships is not well understood. Here, we tested the hypothesis that AUD moderates the relationship between PTSD symptom severity and suicidal ideation. METHODS This secondary analysis uses data collected at baseline for a randomized clinical trial. The sample consists of 160 active-duty service members from three service branches (Army, Air Force, and Navy). All participants met diagnostic criteria for PTSD and were not engaged in evidence-based PTSD treatment at the time of enrollment. Zero-inflated Poisson generalized linear regression models were used to test the associations of PTSD and AUD symptom severity with the presence and severity of suicidal ideation. RESULTS Findings suggest that AUD symptom severity moderates (i.e., amplifies) the relationship between PTSD symptoms and severity of suicidal ideation among military personnel with untreated PTSD. Among service members with mild or absent AUD, we found no significant association between PTSD symptoms and the severity of suicidal ideation. However, when AUD severity was average (i.e., sample mean) or high (mean + 1SD), PTSD symptoms were significantly positively associated with the severity of suicidal ideation. CONCLUSIONS This study highlights the importance of assessing AUD and PTSD as a part of suicide risk evaluations of veterans. The results also provide strong support for the maintenance and further development in the military health system of treatment programs that simultaneously address AUD and PTSD comorbidity.
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Affiliation(s)
- Thomas O Walton
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Scott Graupensperger
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Denise D Walker
- School of Social Work, University of Washington, Seattle, Washington, USA
| | - Debra Kaysen
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California, USA
- National Center for PTSD, VA Palo Alto Health Care System, Palo Alto, California, USA
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Kline AC, Harlé KM, Panza KE, Nichter B, Lyons R, Pitts M, Haller M, Allard CB, Capone C, Norman SB. Changes in guilt cognitions mediate the effect of trauma-informed guilt reduction therapy on PTSD and depression outcomes. J Clin Psychol 2024; 80:1147-1160. [PMID: 38340354 DOI: 10.1002/jclp.23659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/08/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE Trauma-informed guilt reduction therapy (TrIGR), a six-session cognitive behavioral therapy targeting trauma-related guilt and distress, reduces guilt and symptoms of posttraumatic stress disorder (PTSD) and depression, yet little is known regarding how and why TrIGR may be effective. METHOD This study examined treatment-related changes in avoidant coping and trauma-related guilt cognitions as possible mediators of treatment effects on PTSD and depression outcomes at 3- and 6-month follow-up. Data were from a randomized controlled trial for treatment of trauma-related guilt comparing TrIGR and supportive care therapy among 145 post-9/11 US veterans (Mage = 39.2 [8.1], 93.8% male). RESULTS At pretreatment, most (86%) met PTSD criteria. Intent to treat analyses using parallel mediation models indicated changes in guilt cognitions, but not avoidant coping, mediated the effect of TrIGR on reducing PTSD severity at 3-month (a × b = -0.15, p < 0.01, 95% CI: [-0.24 to -0.06], p = 0.001) and 6-month (a × b = -0.17, 95% CI: [-0.26 to -0.07], p = 0.001) follow-up. Similarly, changes in guilt cognitions, but not avoidant coping, mediated the effect of TrIGR on reducing depression severity at 3-month (a × b = -0.10, 95% CI: [-0.18 to -0.02], p = 0.02) and 6-month (a × b = -0.11, 95% CI: [-0.20 to -0.03], p = 0.01) follow-up. CONCLUSIONS Compared to guilt cognitions, changes in avoidant coping were less integral to downstream PTSD and depression symptom reduction. Guilt cognition change may be a salient active ingredient of PTSD and depression treatment for those with trauma-related guilt and a key therapy element to which providers should be attuned.
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Affiliation(s)
- Alexander C Kline
- VA San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Katia M Harlé
- VA San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Kaitlyn E Panza
- VA San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | | | - Robert Lyons
- VA San Diego Healthcare System, San Diego, California, USA
| | - Michelle Pitts
- VA San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Moira Haller
- VA San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Carolyn B Allard
- VA San Diego Healthcare System, San Diego, California, USA
- California School of Professional Psychology, Alliant International University, San Diego, California, USA
| | - Christy Capone
- Providence VA Medical Center, Providence, Rhode Island, USA
- Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Sonya B Norman
- VA San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
- VA Center of Excellence for Stress and Mental Health, San Diego, California, USA
- National Center for Posttraumatic Stress Disorder, White River Junction, Vermont, USA
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Nichter B, Hill ML, Maguen S, Norman SB, Fischer IC, Pietrzak RH. Health and psychiatric impairment associated with moral injury, military sexual trauma, and their co-occurrence in U.S. combat veterans. J Psychosom Res 2024; 179:111617. [PMID: 38394711 DOI: 10.1016/j.jpsychores.2024.111617] [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: 08/16/2023] [Revised: 01/16/2024] [Accepted: 02/17/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Military sexual trauma (MST) and moral injury (MI) are associated with adverse psychiatric and health outcomes among military veterans. However, no known population-based studies have examined the incremental burden associated with the co-occurrence of these experiences relative to either alone. METHOD Cross-sectional data were analyzed from the National Health and Resilience in Veterans Study, a nationally representative sample of 1330 U.S. combat veterans. Veterans reported on history of exposure to MST and potentially morally injurious events (PMIEs). Analyses estimated the lifetime prevalence of MST only, PMIEs only, and co-occurring MST and PMIEs; and examined associations between MST/PMIEs status and psychiatric and physical health comorbidities, functioning, and suicidality. RESULTS The lifetime weighted prevalence of exposure to MST only, PMIEs only, and co-occurring MST and PMIEs were 2.7%, 32.3%, and 4.5%, respectively. Compared with all other groups, the co-occurring MST + PMIEs group reported greater severity of posttraumatic stress, depression, generalized anxiety, and insomnia symptoms. They also scored lower on measures of physical, mental, and psychosocial functioning, and reported a greater number of chronic medical conditions and somatic complaints. Veterans with co-occurring MST + PMIEs were more than twice as likely as those with MST only to report past-year suicidal ideation. CONCLUSIONS The co-occurrence of MST and MI is associated with a greater psychiatric and health burden among combat veterans than either experience alone. Results underscore the importance of assessing and treating MST and MI in this population. Findings underscore the importance for future work to parse overlap between morally salient aspects of MST and the concept of moral injury.
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Affiliation(s)
- Brandon Nichter
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America.
| | - Melanie L Hill
- Department of Psychiatry, University of California San Diego, La Jolla, CA, United States of America
| | - Shira Maguen
- San Francisco VA Health Care System, San Francisco, CA, United States of America; University of California - San Francisco, San Francisco, United States of America
| | - Sonya B Norman
- Department of Psychiatry, University of California San Diego, La Jolla, CA, United States of America; VA San Diego Healthcare System, San Diego, CA, USA; National Center for PTSD, White River Junction, VT, United States of America
| | - Ian C Fischer
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America; National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Robert H Pietrzak
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America; National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA; Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, United States of America
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Moral Injury in the Context of Substance Use Disorders: a Narrative Review. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2022; 9:321-330. [PMID: 36158584 PMCID: PMC9483387 DOI: 10.1007/s40501-022-00280-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 11/25/2022]
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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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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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Abstract
Background: Modern warfare in a civilian setting may expose combatants to severe moral challenges. Whereas most of these challenges are handled effectively, some potentially morally injurious events (PMIEs) may have deleterious psychological effects on the combatants, such as suicide ideation (SI). Self-disclosure, which includes sharing distressing thoughts and emotions, has been recognized as a protective factor against SI in the aftermath of stressful events. The current study is the first to examine the moderating role of self-disclosure in the relationship between PMIE exposure and SI among combat veterans. Method: A sample of 190 recently discharged Israeli combat veterans completed validated self-report questionnaires measuring combat exposure, PMIEs, depressive symptoms, SI, and self-disclosure in a cross-sectional design study. Results: PMIE dimensions and self-disclosure significantly contributed to current SI. Notably, the moderating model indicated that self-disclosure moderated the link between PMIE-Self and current SI, as PMIE-Self and current SI demonstrated a stronger association among veterans with low self-disclosure than among those with high self-disclosure. Limitations: Cross-sectional design of volunteers, the findings may not be directly generalizable to veterans' population. Conclusion: Self-disclosure, as a factor promoting a sense of belongingness, interpersonal bonding, and support, might diminish SI risk following PMIE exposure. Various mechanisms accounting for these associations are suggested, and the clinical implications of these interactions are discussed.
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Affiliation(s)
- Yossi Levi-Belz
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
| | - Sharon Shemesh
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel.,Department of Clinical Psychology, Ruppin Academic Center, Emek Hefer, Israel
| | - Gadi Zerach
- Department of Behavioral Sciences and Psychology, Ariel University, Ariel, Israel
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