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Adaptive Disclosure: An Open Trial of a Novel Exposure-Based Intervention for Service Members With Combat-Related Psychological Stress Injuries
Abstract
We evaluated the preliminary effectiveness of a novel intervention that was developed to address combat stress injuries in active-duty military personnel. Adaptive disclosure (AD) is relatively brief to accommodate the busy schedules of active-duty service members while training for future deployments. Further, AD takes into account unique aspects of the phenomenology of military service in war in order to address difficulties such as moral injury and traumatic loss that may not receive adequate and explicit attention by conventional treatments that primarily address fear-inducing life-threatening experiences and sequelae. In this program development and evaluation open trial, 44 marines received AD while in garrison. It was well tolerated and, despite the brief treatment duration, promoted significant reductions in PTSD, depression, negative posttraumatic appraisals, and was also associated with increases in posttraumatic growth.
... Victor Frankl (1959), the existential psychotherapist and survivor of Nazi death camps, described how meaning can turn the worst atrocity into either an honorable experience, or moral suffering. Indeed, the ability of veterans to find redemptive meaning in morally injurious events may be critical to moving forward from a moral injury (Currier et al., 2015;Ferrajao & Oliveira, 2015Gray et al., 2012). Likewise, parents and child welfare professionals experiencing moral injury describe the active search for redemptive meaning in morally injurious trauma and injustice as one important component in moving away from the psychological and spiritual pain of moral injury (Haight et al., 2017). ...
... Available research indicates that the ability to find redemptive meaning in traumatic events and moral transgressions is critical for healing and moving forward from a moral injury in adults (Currier, Holland, Drescher, et al., 2015;Ferrajao & Oliveira, 2015;Gray et al., 2012). Adaptive disclosure, an intervention for military trauma, loss, and moral injury, incorporates meaning making as an essential change agent (Litz et al., 2016). ...
... Consistent with the existing literature (Barth et al., 2020;Currier et al., 2015;Ferrajao & Oliveira, 2015;Gray et al., 2012;Litz et al., 2016), many participants reporting moral injury in childhood and adolescence described a re-orientation of their narratives through meaning making. Most participants (25, 89 %), even those reporting concurrent moral injury, told narratives that included some themes that may re-orient narratives away from themes of anomie, guilt, shame, distrust and rage associated with moral injuries. ...
... Based on the results of the larger literature identifying both barriers and facilitators of trauma disclosure, items for the proposed measure were specifically written to capture dimensions of positive and negative disclosure expectancies. Resources used to maximize coverage of hypothesized positive and negative dimensions included research targeting barriers/facilitators/ expectancies of disclosure (e.g., Ahrens et al., 2007;Kellogg & Huston, 1995;Roesler & Wind, 1994); relevant conceptual reviews (e.g., Ullman, 1999Ullman, , 2003Ullman, , 2011; existing measures of disclosure-related constructs (e.g., Mueller et al., 2000;Ullman, 2000); and the authors' experience assessing and treating trauma-related psychopathology (e.g., Gray et al., 2012;Hassija & Gray, 2012;Litz et al., 2017). Scale items and response codes were developed by the second author. ...
... The majority of participants (73%) were in the 20 to 29 year age range. A detailed description of the sample and recruitment procedures is provided by Gray et al. (2012). ...
... Assessments used in the current analyses were collected at Session 1 and at Session 6 of AD. Complete details are provided by Gray et al. (2012). ...
Although the disclosure of traumatic experiences is believed to influence trajectories of post-trauma recovery, less is known about individual differences that affect survivors' motivation to share. The current project describes the development and evaluation of the Disclosure Expectancy Scale (DExS), a novel instrument intended to assess survivors' expectations about the potential risks and benefits of disclosure. Items targeting both positive and negative expectancies were generated based on existing research and the authors' clinical experience with various survivor populations. Preliminary analyses in trauma-exposed undergraduates (N = 359) offer support for hypothesized positive and negative expectancy dimensions with evidence for the convergent and discriminant validity of scores. Subsequent evaluation in active-duty, help-seeking military personnel (N = 35) provides further evidence of validity based on correlations with relevant clinical measures. A final regression demonstrating unique effects of initial disclosure expectancies on post-traumatic stress disorder (PTSD) severity following trauma-focused treatment highlights the predictive validity of DExS scores.
... Several themes emerged across these definitions which are worth summarizing. First, nearly all conceptions of MI concern "ethics-that is, they reference a moral transgression or violation, using the language of "right" and "wrong" or ethical "beliefs" (i.e., Shay, 1994;Litz et al., 2009;Drescher et al., 2011;Brock and Lettini, 2012;Gray et al., 2012;Stein et al., 2012;Nash and Litz, 2013;Jinkerson, 2016). For example, Brock and Lettini (2012) claim that MI is "a deep sense of transgression including feelings of shame, grief, meaninglessness, and remorse from having violated core moral belief " (p. ...
... xiv). Second, following Shay (1994), most definitions utilize the language of betrayal-either interpersonal betrayal or ideological betrayal (i.e., Shay, 1994Shay, , 2002Shay, , 2011Shay, , 2014Litz et al., 2009;Drescher et al., 2011;Brock and Lettini, 2012;Gray et al., 2012;Stein et al., 2012;Nash and Litz, 2013;Jinkerson, 2016). Intimately tied to this theme of betrayal is the notion of orientation-the source of the betrayal. ...
... For example, Shay (1994), Nash and Litz (2013), and Farnsworth et al. (2017) all discuss the inability to reconcile, process, or be virtuous in the wake of MI. Spiritual wounds or existential suffering is mentioned in four of the twelve definitions, bringing to light the connection between MI and the loss of purpose, hope, and meaning (i.e., Gray et al., 2012;Nash and Litz, 2013;Jinkerson, 2016;Farnsworth et al., 2017). A minority of definitions associated MI with the experience of specific emotions such as guilt, shame, and anger (i.e., Brock and Lettini, 2012;Gray et al., 2012;Jinkerson, 2016;Farnsworth et al., 2017). ...
In this article, we engage with a theory of management advanced by MacIntyrean scholars of business ethics and organization studies to develop an account of “chronic moral injury” in the workplace. In contrast to what we call “acute moral injury,” which focuses on grave, traumatic events, chronic moral injury results from poor institutional form—when an individual desiring excellence must function within a vicious institution that impedes the acquisition of virtues and marginalizes practices. In other words, chronic moral injury occurs when practitioners who pursue excellence in their practice work within corrupt or malformed organizations. To demonstrate this point, we recount the events associated with the rise and fall of the biotech company, Theranos. This case study advances an empirical contribution to MacIntyrean studies by demonstrating how chronic moral injury can happen under such conditions and what the negative consequences may entail for workers.
... First, the studies will show the therapeutic effect of the wheel. Transcripts from individual and group sessions were coded according to adaptive psychological functions and skills referenced in the MI treatment literature (e.g., Farnsworth et al., 2017;Gray et al., 2012;Pernicano et al., 2022). These therapeutic processes and competencies are presented in Table 3 and indicate the utility of the Moral Injury Experience Wheel to: ...
... Just as use of the wheel has shown potential to complement the impact of ACT, it may also assist MI recovery programs that rely on moral repair processes. The function, "Facilitates Accurate Appraisal," is critical to the cognitive work of interventions like Adaptive Disclosure and Pastoral Narrative Disclosure, for example (Carey & Hodgson, 2018;Gray et al., 2012;. These programs aim to help patients process memories of moral transgression in ways that lead to moral repair-a method defined as the integration of a moral violation into a functional belief system (Litz et al., 2009). ...
... These programs aim to help patients process memories of moral transgression in ways that lead to moral repair-a method defined as the integration of a moral violation into a functional belief system (Litz et al., 2009). In clinical practice, maladaptive interpretations are examined in the presence of unconditional support for themes of globality/specificity, stability/instability, and internality/externality in order to more fully and accurately shape appraisals (Gray et al., 2012). To the point: a precise appraisal is needed to successfully assign blame-only then, after the perpetrator has been identified, is forgiveness able to function as a corrective process. ...
This paper introduces an infographic tool called The Moral Injury Experience Wheel, designed to help users accurately label moral emotions and conceptualize the mechanisms of moral injury (MI). Feeling wheels have been used by therapists and clinical chaplains to increase emotional literacy since the 1980s. The literature on the skill of emotion differentiation shows a causal relationship between identifying emotions with specificity and emotional and behavioral regulation. Emerging research in moral psychology indicates that differentiating moral emotions with precision is related to similar regulatory effects. Based on this evidence, it is proposed that increasing moral emotional awareness through use of an instrument that visually depicts moral emotions and their causal links to MI will enhance appraisal and flexible thinking skills recognized to reduce the persistent dissonance and maladaptive coping related to MI. Design of the wheel is empirically grounded in MI definitional and scale studies. Iterative evaluative feedback from Veterans with features of MI offers initial qualitative evidence of validity. Two case studies will show utility of the wheel in clinical settings and present preliminary evidence of efficacy.
... The efficacy of AD has been tested in several clinical contexts. The first clinical trial of AD was an open, uncontrolled trial investigating whether AD is associated with symptom improvement for PTSD and related symptomatology (e.g., depression) in 44 previously deployed active-duty Marines and Navy Corps personnel who reported symptoms consistent with a DSM-IV PTSD diagnosis [31]. This trial followed the original AD manual, which was used to train the study therapists (i.e., two licensed clinical psychologists and two postdoctoral fellows), who all had extensive experience treating military populations. ...
... There were large effect sizes for PTSD, depression, and posttraumatic cognitions (Cohen's d = 0.79, 0.71, and 0.64, respectively) and a small-to-medium effect size for posttraumatic growth (Cohen's d = 0.33). Seventy-five percent of SMs who were initially referred to AD completed treatment, and SMs considered AD an overall positive experience, with the highest mean satisfaction item rating being for recommending AD to other Marines [31]. ...
... Although the AD open trial demonstrated that AD is tolerable for SMs, able to be implemented in garrison, and associated with large effects for decreasing relevant symptoms, the lack of a comparator arm precludes conclusions regarding treatment efficacy [31]. To evaluate AD's efficacy, a noninferiority trial was conducted [32•] in which AD was compared to Cognitive Processing Therapy -Cognitive Only (CPT-C) to examine change in PTSD symptoms and related outcomes (i.e., depression, functioning) in 122 active-duty Marines and Sailors with a DSM-IV PTSD diagnosis (the trial began prior to the DSM-5). ...
Purpose of Review
Modern evidence-based practice (EBP) primarily consists of the blanket application of treatment packages to purportedly treat behavioral health syndromes regardless of patient characteristics or context, which may be why current EBPs for posttraumatic stress disorder (PTSD) are less effective for treating veterans and military service members (SMs) than for civilians. Adaptive Disclosure is designed to operate within the culture and ethos of the military, and developments since the publication of the original manual reflect further effort to meet the needs of this population. This review presents to providers the rationale and evidence for the original AD manual, as well as an overview of the more recent developments and directions of the literature.
Recent Findings
The original AD manual has demonstrated efficacy in two clinical trials and noninferiority when compared to another EBP for PTSD. Additional treatment elements and enhancements are based on a rehabilitative model for treatment, primarily targeting functional outcomes over symptom reduction and promoting shared decision-making.
Summary
AD and its recent enhancements target symptoms related to PTSD, moral injury, and traumatic loss, but more importantly, they target the functional concerns of veterans and SMs within the military cultural context. Current research is focused on maximizing treatment flexibility to provide clinicians and patients with an adaptable and evidence-based framework for treatment.
... The research has been led by mental health-related disciplines (e.g., psychology, psychiatry) as well as spiritual and religious disciplines (e.g., chaplaincy), all of which have played important roles in conceptualizing and developing approaches to address MI. Standard interventions for PTSD, such as Prolonged Exposure (PE), may be helpful for addressing some of the psychological distress associated with exposure to PMIEs (e.g., Paul et al., 2014;Wachen et al., 2016); nevertheless, new intervention approaches directly targeting the specific causes and consequences of MI may also benefit some patients (e.g., Gray et al., 2012;Maguen et al., 2017). There is evidence that spiritually integrated psychotherapies, as well as chaplain facilitated pastoral care approaches, may be effective adjuncts or alternatives for addressing MI (e.g., Carey & Hodgson, 2018;Cenkner et al., 2021). ...
... In comparison to standard PE, the exposure components of Adaptive Disclosure focus on identifying distressing appraisals and cognitions rather than fear extinction, and standard cognitive restructuring exercises are largely replaced with experiential exercises (Litz et al., 2021). Adaptive Disclosure has been tested in a pilot open trial (Gray et al., 2012) and a non-inferiority RCT (Litz et al., 2021). In the preliminary open trial of 44 active-duty US military personnel, significant improvements were found for PTSD symptoms, depression symptoms, post-traumatic cognitions and post-traumatic growth (Gray et al., 2012). ...
... Adaptive Disclosure has been tested in a pilot open trial (Gray et al., 2012) and a non-inferiority RCT (Litz et al., 2021). In the preliminary open trial of 44 active-duty US military personnel, significant improvements were found for PTSD symptoms, depression symptoms, post-traumatic cognitions and post-traumatic growth (Gray et al., 2012). Results from the noninferiority RCT with 122 active-duty US military personnel, evidenced reductions in PTSD symptoms in the Adaptive Disclosure condition to be comparable to reductions from CPT-Cognitive Therapy version. ...
Article Open Access: https://doi.org/10.1007/s10943-022-01534-4 The aim of this research was to describe the evidence examining the approaches taken by mental health providers (MHPs) and chaplains to address symptoms related to moral injury (MI) or exposure to potentially morally injurious events (PMIEs). This research also considers the implications for a holistic approach to address symptoms related to MI that combines mental health and chaplaincy work. A scoping review of literature was conducted using Medline, PsycINFO, Embase, Central Register of Controlled Trials, Proquest, Philosphers Index, CINAHL, SocINDEX, Academic Search Complete, Web of Science and Scopus databases using search terms related to MI and chaplaincy approaches or psychological approaches to MI. The search identified 35 eligible studies: 26 quantitative studies and nine qualitative studies. Most quantitative studies ( n = 33) were conducted in military samples. The studies examined interventions delivered by chaplains ( n = 5), MHPs ( n = 23) and combined approaches ( n = 7). Most studies used symptoms of post-traumatic stress disorder (PTSD) and/or depression as primary outcomes. Various approaches to addressing MI have been reported in the literature, including MHP, chaplaincy and combined approaches, however, there is currently limited evidence to support the effectiveness of any approach. There is a need for high quality empirical studies assessing the effectiveness of interventions designed to address MI-related symptoms. Outcome measures should include the breadth of psychosocial and spiritual impacts of MI if we are to establish the benefits of MHP and chaplaincy approaches and the potential incremental value of combining both approaches into a holistic model of care.
... Regarding emotions and behavioral challenges arising from MI, the 12 studies identified the following features, in summation: intense guilt, shame, anger, remorse, spiritual conflict, demoralization, a loss of trust, hope, faith and meaning, as well as self-harming behaviors, difficulty forgiving oneself, social withdrawal, and an increased risk for suicide ideation and attempts (Shay, 1994(Shay, , 2002(Shay, , 2011(Shay, , 2014Litz et al., 2009;Drescher et al., 2011;Stein et al., 2012;Gray et al., 2012;Brock & Lettini, 2013;Jinkerson, 2016;Farnsworth et al., 2017). While all 12 definitions plainly recognize perpetrative action as a central causative factor, it is difficult to conceive that all these outcomes stem directly from acts of transgression (omission/commission) by self or others. ...
... In terms of treatment, the current model recommends "moral repair" (Gray et al., 2012;Litz et al., 2009). As the term suggests, relieving the acute dissonance that follows a moral violation requires an "amending," or mending, of a moral breach (Litz et al., 2009, p. 704). ...
... Thus, the Veteran considers reparations to right the wrong and restore moral equilibrium -though the customary $2,500 allotted for "compensation payments" seems absurd to him. An evidencebased MI protocol, called Adaptive Disclosure, recommends the following methods of moral repair: the giving and receiving of forgiveness, "imaginal dialogues" with moral authority figures, asking for reparations, and making amends (Gray et al, 2012;Litz et al., 2016). When the repair is perceived to be complete, equilibrium is restored within the belief system and dissonance is resolved. ...
An infographic model of moral injury (MI) is introduced in this conceptual paper that distinguishes the development of a worldview discrepancy-induced genus of MI, called complex moral injury (C-MI), from a standard expression of moral injury (S-MI), clearly delineated as perpetration-focused and a violation of moral belief in the contemporary view. It builds upon a previous essay that examined the potential of paradoxical circumstance (e.g., clashes of value, competing moral expectations, and moral paradox) to inflict MI among military personnel during wartime (Fleming in J Relig Health 60(5):3012–3033, 2021). Accordingly, it heeds Litz et al.’s recommendation to expand the research of MI beyond the effects of perpetration and investigate the impact of morally injurious events that shake one’s core moral beliefs about the world and self (Litz et al. in Clin Psychol Rev 29(8):695–706, 2009). A review of definitional, scale, and qualitative studies shows evidence of a nuanced and complex form of MI that presents as moral disorientation and is a response to a disruption and subsequent failure of foundational moral beliefs to adequately appraise ethical problems and inform moral identity. Interrelations between MI, assumptive world, and meaning theories suggest the mechanism of C-MI and potential therapies. Case studies from a Veterans Administration hospital in the United States and a walk through the diagram will help illustrate the model. Clinical implications of a definition that includes morally injurious events that shatter fundamental moral assumptions are discussed. The role of chaplains in facilitating acceptance and meaning-making processes is recommended for C-MI recovery. Acknowledging the model’s need for empirical support, a plausible scale is discussed for future research.
... While discussions continue regarding the parameters of what constitutes moral injury, consensus is building in support of developing care approaches that are specifically designed to address it (Artra, 2014;Borges et al., 2020;Drescher et al., 2011;Gray et al., 2012;Nieuwsma et al., 2015;Sreenivasan, Smee, & Weinberger, 2014). Although evidence-based PTSD treatments have demonstrated some efficacy for decreasing PTSD symptoms, 60-72% of veterans receiving Prolonged Exposure (PE) or Cognitive Processing Therapy (CPT) still meet criteria for PTSD following treatment (Haagen, Smid, Knipscheer, & Kleber, 2015;Steenkamp, Litz, Hoge, & Marmar, 2015). ...
... As of 2015, the options for Veterans Affairs (VA) providers seeking to care for moral injury were limited. Of the two intervention studies published at that time, one was designed for active duty military populations (Gray et al., 2012) and the other focused exclusively on killing-related trauma for combat veterans (Maguen & Burkman, 2013). Both interventions placed some emphasis on self-forgiveness, which seemed to be a promising direction for moral injury intervention. ...
... REAL is one of several interventions that are being developed, tested, and refined by frontline VA providers and researchers to address moral injury. Other examples include Building Spiritual Strength (Harris et al., 2018), Acceptance and Commitment Therapy for Moral Injury (Borges, 2019), Impact of Killing (Maguen et al., 2017), Adaptive Disclosure (Gray et al., 2012), and the collection of practices that comprise VA Integrative Mental Health's Dynamic Diffusion Network , of which REAL is one. Each of these treatments/ care practices makes a distinctive contribution to the collective knowledge regarding moral injury, and it would serve veterans well to promote collaboration among intervention developers in this emerging field. ...
Moral injury is a particular response to profoundly distressing life events that manifests in damage to basic human/relational capacities, such as trust, autonomy, initiative, competence, identity, and intimacy. This paper describes and presents preliminary outcomes of "Reclaiming Experiences And Loss," or "REAL," which is an innovative moral injury group therapy that was developed collaboratively by Veterans Affairs mental health and spiritual care providers. Clinical outcome measures collected pre- and post-group indicates that REAL is effective at reducing symptoms of post-traumatic stress disorder and depression. Additionally, a cohort case example demonstrates the impact of REAL as told through individual stories as well as the intersectionality and interactions that comprise a typical REAL cohort and are considered central to care. Implications for ongoing care and future research are discussed.
... acts of omission or betrayal). Another proposed treatment, Adaptive Disclosure (Gray et al., 2012) has also been developed to treat moral injury in US veterans which considers a wider range of PMIEs. Evidence suggests that Adaptive Disclosure can be effective for those who suffer from MI-related difficulties (Litz et al., 2017), but this treatment was developed for, and currently has only been delivered to small numbers of US military populations (Gray et al., 2012). ...
... Another proposed treatment, Adaptive Disclosure (Gray et al., 2012) has also been developed to treat moral injury in US veterans which considers a wider range of PMIEs. Evidence suggests that Adaptive Disclosure can be effective for those who suffer from MI-related difficulties (Litz et al., 2017), but this treatment was developed for, and currently has only been delivered to small numbers of US military populations (Gray et al., 2012). Studies have shown there are key differences in trauma exposure and resultant mental health difficulties between UK and US militaries (Castro & Hall, 2021;Fear et al., 2010;Malcolm et al., 2015;Sundin et al., 2014). ...
Background: Experiencing potentially morally injurious events (PMIEs) has been found to be significantly associated with poor mental health outcomes in military personnel/veterans. Currently, no manualised treatment for moral injury-related mental health difficulties for UK veterans exists. This article describes the design, methods and expected data collection of the Restore & Rebuild (R&R) protocol, which aims to develop procedures to treat moral injury related mental ill health informed by a codesign approach.
Methods: The study consists of three main stages. First, a systematic review will be conducted to understand the best treatments for the symptoms central to moral injury-related mental ill health (stage 1). Then the R&R manual will be co-designed with the support of UK veteran participants with lived experience of PMIEs as well as key stakeholders who have experience of supporting moral injury affected individuals (stage 2). The final stage of this study is to conduct a pilot study to explore the feasibility and acceptability of the R&R manual (stage 3).
Results: Qualitative data will be analysed using thematic analysis.
Conclusions: This study was approved by the King's College London's Research Ethics Committee (HR-20/21-20850). The findings will be disseminated in several ways, including publication in academic journals, a free training event and presentation at conferences. By providing information on veteran, stakeholder and clinician experiences, we anticipate that the findings will not only inform the development of an acceptable evidence-based approach for treating moral injury-related mental health problems, but they may also help to inform broader approaches to providing care to trauma exposed military veterans.
... 15 Some have raised the question of whether the less pronounced symptom response among military personnel observed during PTSD treatment may be due to exposure to mor ally injurious traumas and whether these individuals need a different treatment approach. 12,[16][17][18] The question of CPT's appropriateness for individ uals with moral injury likely stems from the fact that CPT often involves helping patients reduce erroneous self-blame for traumas in which they were harmed by someone else or that were unforeseeable or uncontrol lable. As a result, some have wondered whether CPT is appropriate for patients who hold responsibility for their traumatic event or did not act in situations in which harm could have been prevented. ...
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.
... Moral injury occurs when an individual either engages in or witnesses events that challenge deeply held values or spiritual beliefs (Jinkerson, 2016;Litz et al., 2009). Although not a formal diagnosis within the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), researchers and clinicians have proposed that moral injury is a syndrome characterized by intractable and irrational guilt or anger, selfloathing, loss of faith or loss of meaning/purpose in life, and is associated with suicidal ideation and attempts, depression, substance use, withdrawal from social relationships, and difficulty with occupational and family role functions (Bryan et al., 2014;Gray et al., 2012;Harris et al., 2012;Jinkerson, 2016;Kopacz et al., 2016;Maguen et al., 2012). ...
Chaplains are an integral part of mental health treatment within the Veterans Health Administration (VHA) and over the past decade, efforts have been made to integrate chaplain services into behavioral health treatment. One unique duty of chaplains is to conduct spiritual assessments, which are characterized as collaborative discussions with veterans to understand their overall religious and belief system, identify spiritual injuries, and how to integrate one's spiritual values into medical care. Although spiritual assessments in Veterans Affairs Medical Centers have evolved throughout the years to adopt a more structured approach, spiritual assessments can vary depending on site, clinical setting, and medical center. The present study sought to examine chaplains' perspectives on standardizing spiritual assessments and incorporating empirically validated measures into the assessments. Thematic analysis was conducted on two focus groups of chaplains from a large VHA medical center. Overall, chaplains appeared interested in standardizing spiritual assessments, with an expressed desire to maintain their current conversational format. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
... Examples include adaptive disclosure (Gray et al., 2012;Litz et al., 2017Litz et al., , 2021 and impact of killing (Maguen et al., 2017;Purcell et al., 2018), which are individual psychotherapies designed to be administered by mental health providers. BSS (Harris et al., 2011;Harris, Usset, et al., 2018;Usset et al., 2021) is a group program for moral injury that can be led by chaplains, mental health providers, or both. ...
Studies of moral injury among non-military samples are scarce despite repeated calls to examine the prevalence and outcomes of moral injury among civilian frontline workers. The purpose of this study was to describe the prevalence of moral injury and to examine its association with psychosocial functioning among health care workers during the COVID-19 pandemic. We surveyed health care workers (N = 480), assessing exposure to potentially morally injurious events (PMIEs) and psychosocial functioning. Data were analyzed using latent class analysis (LCA) to explore patterns of PMIE exposure (i.e., classes) and corresponding psychosocial functioning. The minimal exposure class, who denied PMIE exposure, accounted for 22% of health care workers. The moral injury-other class included those who had witnessed PMIEs for which others were responsible and felt betrayed (26%). The moral injury-self class comprised those who felt they transgressed their own values in addition to witnessing others’ transgressions and feeling betrayed (11%). The betrayal-only class included those who felt betrayed by government and community members but otherwise denied PMIE exposure (41%). Those assigned to the moral injury-self class were the most impaired on a psychosocial functioning composite, followed by those assigned to the moral injury-other and betrayal only classes, and finally the minimal exposure class. Moral injury is prevalent and impairing for health care workers, which establishes a need for interventions with health care workers in organized care settings.
... New treatments, developed specifically to address warrior ethos and the mental health sequelae associated with morally injurious experiences within military populations, represent promising innovations for moral injury treatment. Adaptive disclosure, conceptualized to facilitate meaning-making following morally injurious experiences and traumatic loss, demonstrated efficacy in a pilot study [66] and randomized controlled trial [67] and has been implemented in active duty and veteran treatment settings. The Impact of Killing (IOK) was created in an iterative process in consultation with veterans, to address guilt, shame, functional impairment, self-handicapping behaviors, and spiritual distress among veterans at high risk for mental health outcomes due to killing in war [68]. ...
Background
Military service puts service members at risk for moral injury. Moral injury is an array of symptoms (e.g., guilt, shame, anger) that develop from events that violate or transgress one's moral code.
Objective
We describe adaption of in-person mindfulness training program, Mindfulness to Manage Chronic Pain (MMCP), to address symptoms of moral injury to be delivered live via the web. We discuss how we will assess benchmarks (i.e., recruitment, credibility and acceptability, completion rates, and adherence) of the Mindfulness to Manage Moral Injury (MMMI) program.
Methods
Aim 1: To develop and then adapt the MMCP program based on feedback from experts and veterans who took part in Study 1. Aim 2: To develop an equally intensive facilitator-led online Educational Support (ES) program to serve as a comparison intervention and conduct a run-through of each program with 20 veterans (10 MMMI; 10 ES). Aim 3: To conduct a small-scale randomized controlled trial (N = 42 veterans; 21 MMMI; 21 ES) in which we will collect pre-post-test and weekly benchmark data for both refined intervention arms.
Results
Study 1 and 2 are completed. Data collection for Study 3 will be completed in 2022.
Conclusion
MMMI is designed to provide a live facilitated mindfulness program to address symptoms of moral injury. If Study 3 demonstrates good benchmarks, with additional large-scale testing, MMMI may be a promising treatment that can reach veterans who may not seek traditional VAMC care and/or who prefer a web-based program.
... Unlike perceived supervisor support, which is a result of previous experiences, to a certain extent, self-disclosure is a process of communication in which one naturally engages intentionally, with the purpose of sharing information about themselves and meaningful life events [34]. Previous studies suggest that self-disclosure leads to decreased loneliness [104,105], aiding people to perceive their contexts as empathic, helpful, and affirmative [106]. Thus, in opposition to perceived supervisor support, which describes a previous mode of relating, self-disclosure could have helped nurses experience social support after being exposed to PMIEs, and thus exert a reparatory influence. ...
The COVID-19 pandemic was a fertile ground for nurses’ exposure to self- and other-Potentially Morally Injurious Events (PMIEs). Our study explored the effects of nurses’ memories of self- and other-PMIEs on occupational wellbeing and turnover intentions. Using an experimental design on a convenience sample of 634 Romanian nurses, we tested a conceptual model with PLS-SEM, finding adequate explanatory and predictive power. Memories of self- and other-PMIEs were uniquely associated with work engagement, burnout, and turnover intentions, compared to a control group. These relationships were mediated by the three basic psychological needs. Relatedness was more thwarted for memories of other-PMIEs, while competence and autonomy were more thwarted for memories of self-PMIEs. Perceived supervisor support weakened the indirect effect between type of PMIE and turnover intentions, through autonomy satisfaction, but not through burnout. Self-disclosure weakened the indirect effect between type of PMIE and turnover intentions, through autonomy satisfaction, and both burnout and work engagement. Our findings emphasize the need for different strategies in addressing the negative long-term effects of nurses’ exposure to self- and other-PMIEs, according to the basic psychological need satisfaction and type of wellbeing indicator.
... Case studies were found of ACT-MI (15), BEPP for Moral Trauma (BEPP-MT) (23), Cognitive Therapy (CT) (24,25) and PE (24,26). Pilot studies were found of AD (27) and Impact of Killing (IoK) (28)(29)(30). We excluded interventions intended primarily for delivery by chaplains or clergy, including Building Spiritual Strength (BSS) (31) and the Mental Health Clinician and Community Clergy Collaboration (32). ...
Background
Military members and police officers often operate in high stakes situations and under high levels of physical and psychological stress. Consequently, they may be confronted with morally injurious experiences and develop moral injury. Most treatments for moral injury are cognitive-behavioral, face-to-face treatments, which may be supported by online interventions. Online interventions have shown promise in the treatment of trauma-related psychopathology, but few such interventions for moral injury yet exist.
Objective
To develop and conduct a preliminary evaluation of an online treatment module for moral injury in treatment-seeking military veterans and police officers, to be used in conjunction with regular face-to-face treatment.
Method
An online module was developed based on the moral injury literature, using elements from seven existing treatments. A preliminary evaluation was conducted using both quantitative and qualitative methods, and focusing on perceived feasibility, acceptability and engagement of the module, as well as potential benefits and harms. The concept module was evaluated by 15 assessors, including patient representatives, multidisciplinary caregivers and experts.
Results
The module was rated favorably, with mean evaluation scores ranging from 7.9 to 8.8 on a 10-point scale. Several suggestions for improvement were made, especially concerning privacy issues, safety instructions, patient-therapist collaborations, and role plays, and the module was adapted accordingly.
Conclusion
Using input from literature, patient representatives and experts, we developed an online treatment module for moral injury in military veterans and police officers, to be used in conjunction with face-to-face therapy. Acceptability and feasibility will be further examined in a future pilot study.
... Moral injury, the harmful psychological consequences that may result from a person's perception that their actions or inaction have violated their principles or morals (Litz et al., 2009), has symptoms that are similar to those of PTSD, but, rather than a basis in fear, moral injury is based in shame, guilt, and social isolation (Griffin et al., 2019). Experiences of moral injury can lead to feelings of intense anxiety, anger, shame, and guilt, perpetuating in the individual a belief that they are worthless and immoral (Gray et al., 2012). Although most research on moral injury has examined its impact on military veterans, moral injury has been studied in law enforcement personnel, educators, and healthcare providers, among others (Griffin et al., 2019), and researchers have suggested that moral injury may result from the experience of causing accidental death (Gray, 2021;Steinmetz & Gray, 2015). ...
Background. Posttraumatic growth (PTG)—positive changes that people may experience in the aftermath of highly distressing experiences—has been observed in survivors of a variety of events but has not been previously studied among people who have caused accidental death or injury (PCADIs). In addition, questions remain about the role, in PTG, of changes in the assumptive world and the relationships between PTG and distress, personality, and social support. Methods. Participants (N = 528), included PCADIs (n = 44) and a non-trauma comparison group (n = 484), who completed the Primals Inventory and measures of personality, anxiety, and depression. PCADIs (n = 43) also completed measures of PTG, PTG behavioral changes, social support and life satisfaction. Results. Modest levels of PTG commensurate with survivors of other relevant forms of distress were observed. Results demonstrated significant differences between primal world beliefs Good, Safe, Enticing, Just, Regenerative, Funny, and Improvable in PCADIs and non-trauma survivors as well as significant positive relationships between PTG and the primals Good, Safe, Alive, Just, Regenerative, Funny, and Improvable and between PTG and reported behavior changes related to PTG, but no significant relationships were found between PTG and distress, PTG and social support, or PTG and personality traits Extraversion, Openness to Experience, Conscientiousness, or Agreeableness (though a significant negative relationship was observed between PTG and Neuroticism). Conclusions. PCADIs may experience PTG that both influences and is influenced by primal world beliefs, but the hypothesized relationships between PTG and distress, personality, and social support were not observed. Additional studies with larger PCADI populations may find these relationships exist at a statistically significant level. And future research should aim to develop interventions addressing the distress and growth potential of this population.
... In an open trial of AD among 44 active-duty Marines with PTSD, significant reductions of PTSD symptoms and maladaptive posttraumatic cognitions were observed, as was a significant increase in a measure of posttraumatic growth (Gray et al., 2012). Specifically, AD has led to a decrease in both 'negative believes about the self' and 'negative believes about the world' (Gray et al., 2012, p. 413), both indicative of the rupture of one's moral code, either through transgression or betrayal. ...
Background: During a deployment, soldiers must make seemingly impossible decisions, including having to engage with child soldiers. Such moral conflicts may continue to affect service members and veterans in the aftermath of a deployment, sometimes leading to severe moral distress, anguish, and personal crises. Service providers have increasingly argued that as a diagnosis, Post-Traumatic Stress Disorder (PTSD) cannot account for these deeply personal and painful moral conflicts. In light of this, the concept of moral injury has been introduced to better capture the profound forms of guilt and shame that may be experienced by service members and veterans.
Objective: This paper addresses encounters with children and child soldiers during military deployments, as well as the risk for moral injury during and following these encounters, and their implications. This exploratory paper brings together existing literature on the topic to introduce, illustrate, and offer potential and promising interventions.
Results: Given the potential moral conflicts that may ensue, military personnel who encounter child soldiers during a military deployment may be at risk for moral injury during and following these encounters. The introduction of the concept of moral injury provides a way for these largely unnamed personal and painful moral conflicts and violations to be recognized, addressed, and with appropriate care, remedied. Although there is limited research into their effectiveness at treating moral injury, individual and group-based interventions have been identified as potentially beneficial.
Conclusion: As encounters with children during deployments are likely to continue, systematic research, training, healing interventions and prevention strategies are vital to support and protect children in conflict settings, as well as to ensure the mental health and well-being of service members and veterans.
HIGHLIGHTS
• Profound moral conflicts may affect service members and veterans in the aftermath of a military deployment, sometimes leading to severe moral distress, anguish, and personal crises. The concept of moral injury has been introduced to better capture the profound forms of guilt and shame that may be experienced by service members and veterans.
• Encountering children and child soldiers during a military deployment, may present unique challenges, stress, and moral crises leading to potentially moral injurious events. In particular, transgression-based events which result from an individual perpetrating or engaging in acts that contravene his or her deeply held moral beliefs and expectations such as harming children, and betrayal-based events, which results from witnessing or falling victim to the perceived moral transgressions of others, may lead to lasting psychological, biological, spiritual, behavioural and social impairments.
• Interventions applied in both an individual-based context such as Cognitive Processing Therapy, Impact of Killing, Adaptive Disclosure, and a group-based context such as Acceptance and Commitment Therapy and Resilience Strength Training, have been identified as potentially beneficial to addressing moral injury. However, more research is required to ascertain appropriate and effective intervention and healing strategies.
... While moral injury is not yet characterized as a diagnostic syndrome in the DSM, the mental health community is moving toward a syndromal model of conceptualizing moral injury (1,6). Syndromal models of moral injury include conceptualization that classifies experiences like guilt and shame as symptoms causal to psychopathology (3)(4)(5), a focus on creating measures to identify signs and symptoms, establishing cut points for these measures indicating the presence or absence of moral injury, and targeting the reduction of these symptoms in treatment (7)(8)(9)(10). Syndromal approaches to conceptualization focus on understanding the topography of a psychological disorder and its boundary conditions. ...
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.
... things that the individual has done or failed to do themselves and forgiveness of the other for events involving betrayal or moral transgression on the part of someone else. [36][37][38] The importance of opportunities for corrective experience that challenge negative and global attributions and opportunities for reparation has also been emphasised, 39 as has acceptance of experience and commitment to value-based behaviour. 40 Further research is needed before recommendations can be made with confidence about the preferred approach, but in the mean time practitioners should be guided by the current evidence showing promise for prolonged exposure, cognitive processing therapy, impact of killing, adaptive disclosure, and acceptance and commitment therapy. ...
Moral injury is a relatively new, but increasingly studied, construct in the field of mental health, particularly in relation to current and ex-serving military personnel. Moral injury refers to the enduring psychosocial, spiritual or ethical harms that can result from exposure to high-stakes events that strongly clash with one's moral beliefs. There is a pressing need for further research to advance understanding of the nature of moral injury; its relationship to mental disorders such as posttraumatic stress disorder and depression; triggering events and underpinning mechanisms; and prevalence, prevention and treatment. In the meantime, military leaders have an immediate need for guidance on how moral injury should be addressed and, where possible, prevented. Such guidance should be theoretically sound, evidence-informed and ethically responsible. Further, the implementation of any practice change based on the guidance should contribute to the advancement of science through robust evaluation. This paper draws together current research on moral injury, best-practice approaches in the adjacent field of psychological resilience, and principles of effective implementation and evaluation. This research is combined with the military and veteran mental health expertise of the authors to provide guidance on the design, implementation and evaluation of moral injury interventions in the military. The paper discusses relevant training in military ethical practice, as well as the key roles leaders have in creating cohesive teams and having frank discussions about the moral and ethical challenges that military personnel face.
... Group-based treatments have been shown to be effective for addressing moral injury among military veterans. [45][46][47] Although research is still emerging, there is reason to be optimistic about also employing such an approach for moral injury in healthcare. [48][49][50] People are members of multiple moral communities, which means that different groups-including healthcare systems-can potentially aid in repair. ...
Moral injury results from the violation of deeply held moral commitments leading to emotional and existential distress. The phenomenon was initially described by psychologists and psychiatrists associated with the US Departments of Defense and Veterans Affairs but has since been applied more broadly. Although its application to healthcare preceded COVID-19, healthcare professionals have taken greater interest in moral injury since the pandemic’s advent. They have much to learn from combat veterans, who have substantial experience in identifying and addressing moral injury—particularly its social dimensions. Veterans recognise that complex social factors lead to moral injury, and therefore a community approach is necessary for healing. We argue that similar attention must be given in healthcare, where a team-oriented and multidimensional approach is essential both for ameliorating the suffering faced by health professionals and for addressing the underlying causes that give rise to moral injury.
... Practical interventions could include mindfulness training, brief interventions, and other minimally invasive treatments, but further research is required (66)(67)(68)(69). Adaptive disclosure (AD) is relatively recent intervention for active-duty service members (70). Noteworthy is that AD considers unique aspects of military service in war to address difficulties such as moral injury and traumatic loss that may not receive adequate attention by conventional treatments that primarily address fear-inducing experiences and their sequelae. ...
The impact of “moral injury” (MI) among deployed veterans, defined as actions in combat that violate a veteran's moral beliefs and result in psychological distress, has increasingly become a significant clinical concern separate from other trauma- and stressor-related disorders. MI involves severe distress over violations of core beliefs often followed by feelings of guilt and conflict and is common among veterans with PTSD. While the psychological impact of PTSD is well-documented among veterans, this has been done less so with respect to MI. We studied MI among 1,032 deployed veterans who were outpatients in a large non-profit multi-hospital system in central Pennsylvania. The study included active duty and Guard/Reserve members, as well as veterans who were not Department of Veterans Affairs (VA) service users. Our hypothesis was that, controlling for other risk factors, veterans with high MI would have current mental disorders. Our secondary hypothesis was that MI would be associated with other psychopathologies, including chronic pain, sleep disorders, fear of death, anomie, and use of alcohol/drugs to cope post deployment. Most veterans studied were deployed to Vietnam (64.1%), while others were deployed to post-Vietnam conflicts in Iraq and Afghanistan and elsewhere. Altogether, 95.1% of the veterans were male and their mean age was 61.6 years (SD = 11.8). Among the veterans, 24.4% had high combat exposure, 10.9% had PTSD, 19.8% had major depressive disorder, and 11.7% had a history of suicidal thoughts. Based on the Moral Injury Events Scale (MIES), 25.8% had high MI post deployment, defined as a score above the 75th percentile. Results show that high MI among veterans was associated with current global mental health severity and recent mental health service use, but not suicidal thoughts. In addition, as hypothesized, MI was also associated with pain, sleep disorders, fear of death, anomie, use of alcohol/drugs to cope post-deployment, and poor unit support/morale during deployment. Deployed veterans with MI are more likely to have current mental health disorders and other psychological problems years after deployment. Further research is advised related to the screening, assessment, treatment, and prevention of MI among veterans and others after trauma exposures.
... There are now several psychotherapeutic interventions for veterans with moral injury that have preliminary support and are undergoing more rigorous testing through randomized controlled trials (RCTs). These include Adaptive Disclosure (AD) (21), Impact of Killing (IOK) (22), Trauma-Informed Guilt Reduction Therapy (TrIGR) (23), Acceptance and Commitment Therapy for Moral Injury (ACT-MI) (24), Building Spiritual Strength (BSS) (25), and the Mental Health Clinician and Community Clergy Collaboration (MC3) (26). There is also some evidence that certain PTSD treatments can help with moral injury symptoms (e.g., Cognitive Processing Therapy) (27). ...
Healthcare workers face numerous occupational stressors, including some that may challenge personal and shared morals and values. This is particularly true during disasters and crises such as the COVID-19 pandemic, which require critical decisions to be made with little time and information often under personal distress and situational constraints. Consequently, healthcare workers are at risk for moral injuries characterized by stress-related and functional impacts. Although research on the evaluation and treatment of moral injury among military veterans burgeoned in the recent decade, addressing moral injury in healthcare workers and other civilians remains an important gap. In this perspective piece, we identify research gaps and make recommendations to advance future work on assessment, prevention, and treatment of moral injury in healthcare workers. We draw on empirical studies of moral injury in veterans, limited studies of moral injury in health professionals, and our clinical experiences with healthcare workers affected by moral injury.
... The emotional and psychological impact of moral distress can also over time increase the risk for burnout (Fumis et al., 2017). Traumatic incidents noted above, including operational and organizational stressors, can lead to not only trauma reactions that are fear-based or trauma reactions that are loss-based, but also to moral injury-based trauma reactions (Gray et al., 2012;Held et al., 2018;Litz et al., 2016). ...
The international need for innovation and reform in policing remains acute, but lacks a conceptual framework that could help guide it towards the goal of achieving public safety effectively, equitably, and with minimal collateral consequences. This article argues that policing and public health are natural conceptual partners in that both seek to reduce morbidity and mortality with broad interventions at the community level. That said, to overcome the problems that lead to recurring crises in policing—things which the medical profession would refer to as the iatrogenic harms of policing’s interventions—policing would be well-served to adopt many of the concepts and metrics of public health. One way to start this process would be to create an international center for policing and public health, which would combine research and practice in an iterative way that brings the two sectors into closer collaboration. The process could start with a series of executive sessions. Such an evolution would allow the civic leaders responsible for a community’s policing and public safety to demonstrate increased accountability by aligning measures of their success with evidence-informed endpoints that show how policing has decreased a community’s morbidity and mortality in meaningful ways, with minimized iatrogenic effects.KeywordsEvidence-based practiceAccountabilityMetricsPublic safetyInnovationPolice reform
... The emotional and psychological impact of moral distress can also over time increase the risk for burnout (Fumis et al., 2017). Traumatic incidents noted above, including operational and organizational stressors, can lead to not only trauma reactions that are fear-based or trauma reactions that are loss-based, but also to moral injury-based trauma reactions (Gray et al., 2012;Held et al., 2018;Litz et al., 2016). ...
Over the past four decades, there has been rapidly growing interest in revising and expanding training and education opportunities throughout the world for law enforcement officers. Research has demonstrated that stronger links between police departments and higher education institutions result in increased professionalism in policing. Throughout this period, societal expectations of law enforcement personnel have changed and expanded. This has been accompanied, regrettably, by too many examples of police brutality in the United States. Police officers are being called upon as the “first contact” for an increasing number of societal problems, and especially for citizens experiencing mental health issues. Another factor that has harmed police–community relationships is the trend towards the “militarization” of law enforcement in many nations. Strengthening the relationships between law enforcement and tertiary education faces many challenges, including mutual distrust and high costs. Two illustrations of innovative educational programs are provided and additional opportunities for collaboration and partnerships identified as pathways towards the goal of better education for police, expanded applied research and evidence-based policing.KeywordsLaw enforcementEducationTrainingTrustCollaborative opportunitiesMilitarization
... Acceptance & Commitment Therapy (ACT) (e.g., Hayes et al., 2011;Kopacz et al., 2016;Niewsma et al. 2015;Evans et al., 2020;Walser & Wharton, 2021;Farnsworth et al., 2017) Building Spiritual Strength (BSS) (Harris et al., 2011(Harris et al., , 2015(Harris et al., , 2018 Adaptive Disclosure (AD) (Gray et al., 2012Litz et al., 2016Litz et al., , 2021 Forgiveness Interview Protocol (IFP) (Buhagar, 2021) ...
Access article via: https://doi.org/10.1007/s10943-022-01507-7 This paper presents additional qualitative results from Phase 1 of a larger study examining potentially morally injurious events/experiences (PMIE) and/or moral injury (MI) among Australian veterans (Hodgson et al. in J Relig Health 60(5):3061–3089, 2021). It makes specific reference to (1) betrayal and (2) retribution experienced or perpetrated by Australian military veterans during military conflicts and peacekeeping missions. During two veteran seminars conducted in Adelaide, South Australia, a total of 50 veterans were recruited, 10 of whom were willing to be interviewed and audio-recorded about their deployment experiences. Narrative data analysis of veteran transcripts indicated that all participants had engaged in or were exposed to a PMIE/MI of one kind or another, and all had experienced betrayal and/or witnessed or perpetrated retribution. Given the ethical, moral and spiritual issues involved, the role of chaplains in addressing moral injury for the benefit of veterans through the use of ‘Pastoral Narrative Disclosure’ (PND) is suggested—with a specific focus upon ‘restoration’ and ‘ritual’. Additional research is recommended with regard to acts of betrayal and retribution among veterans, as well as the further development of PND to address PMIE/MI.
... It can result, for example, from the ethical and moral challenges of military service (Jinkerson, 2016). Distress associated with MI can include feelings of guilt, anger, grief, demoralization, hopelessness, and loss of purpose, and is associated with such behaviors as self-handicapping and poor self-care (Gray et al., 2012;Kopacz et al., 2016). There is substantial evidence that MI contributes to a longer, more severe course of mental health morbidity and increased suicide risk (Bryan, Bryan, Morrow, Etienne, & Ray-Sannerud, 2014;Harris et al., 2012;Maguen et al., 2012). ...
Some veterans experience symptoms of moral injury after being exposed to the ethical and moral challenges associated with military service. While it is well known that moral injury is associated with an increased risk for suicide as well as other mental health concerns, few tools exist to systematically screen for moral injury in chaplaincy settings. This preliminary study examines the psychometric properties as well as feasibility of applying two new moral injury screening tools that could be used with routine spiritual assessments, purposefully designed to assess for moral injury in chaplaincy settings at Department of Veterans Affairs (VA) Medical Centers. The results provide preliminary psychometric evidence to support the reliability and validity of these two new screening tools, which were shown to be feasible for use in VA chaplaincy settings.
... For example, Impact of Killing (IOK) is a treatment that targets perpetration-based moral injury by directly addressing the mental health IOK as well as self-forgiveness, self-compassion and the psychosocial and spiritual impact of moral injury (Maguen et al., 2017;Purcell, Griffin, Burkman, & Maguen, 2018). Other treatments that are focused on moral injury include Adaptive Disclosure, Trauma-Informed Guilt Reduction Therapy, Building Spiritual Strength, and Acceptance and Commitment Therapy for Moral Injury (Gray et al., 2012;Harris et al., 2011;Nieuwsma et al., 2015;Norman, Wilkins, Myers, & Allard, 2014). Each of these has either been tested in pilot randomized controlled trials (RCTs) or open trials, and all have larger RCTs underway. ...
Background
Our goal was to examine the association between moral injury, mental health, and suicide attempts during military service and after separation by gender in post-9/11 veterans.
Methods
A nationally representative sample of 14057 veterans completed a cross-sectional survey. To examine associations of exposure to potentially morally injurious events (PMIEs; witnessing, perpetrating, and betrayal) and suicidal self-directed violence, we estimated two series of multivariable logistic regressions stratified by gender, with peri- and post-military suicide attempt as the dependent variables.
Results
PMIE exposure accounted for additional risk of suicide attempt during and after military service after controlling for demographic and military characteristics, current mental health status, and pre-military history of suicidal ideation and attempt. Men who endorsed PMIE exposure by perpetration were 50% more likely to attempt suicide during service and twice as likely to attempt suicide after separating from service. Men who endorsed betrayal were nearly twice as likely to attempt suicide during service; however, this association attenuated to non-significance after separation in the fully adjusted models. In contrast, women who endorsed betrayal were over 50% more likely to attempt suicide during service and after separation; PMIE exposure by perpetration did not significantly predict suicide attempts before or after service among women in the fully adjusted models.
Conclusions
Our findings indicate that suicide assessment and prevention programs should consider the impact of moral injury and attend to gender differences in this risk factor in order to provide the most comprehensive care.
... Therefore, a logical consequence of this understanding is the choice of the method of intent-analysis as the main one. Intent analysis is understood as a theoretical-experimental study of the communicant's intentions, which implies the unity of form and content (Gray et al., 2012;McGannon et al., 2017). ...
Since the twentieth century, information has become a particularly powerful tool of influence in all realms of human activities. The sender of the speech seeks to influence their recipients by all available means, both lingual and non-lingual. For this reason, we have placed special emphasis on psychological phenomena that help the speech author to succeed in court. One of such seminal psychological phenomena is transgression. Notwithstanding a thorough study of this issue, we have not come across any studies of courtroom discourse dealing with this phenomenon. While exploring the texts of the prosecutors` and defense attorneys` speeches we applied contextual and linguo-stylistic analyses as well as intent and discourse analysis methods.Based on such findings, transgression in courtroom discourse is used simultaneously to erase bounds, on the one hand, and to create hype and epatage, on the other. It is created with the help of lexical means mostly which can be either invective directly or become invective in the context.
... Namely, the etiology of moral injury is internalized while PTSD may be more external (Marx et al., 2010). Forgiveness of the situation may aid in decreasing fear, which is crucial in treatments for PTSD (Gray et al., 2012;Litz et al., 2016;Steenkamp et al., 2013). Understanding the different aspects of forgiveness that comprise moral injury and PTSD can assist in developing and understanding treatments for these disorders. ...
Objective:
Post-Traumatic Stress Disorder (PTSD) is a prominent mental health condition that affects military personnel. Moral injury is another mental health concern among military personnel that requires further investigation. Moral injury results when the individual is exposed to a situation or event that violates their moral code. Meanwhile, PTSD results when there is a substantial threat of harm. Although distorted cognitions are core components of PTSD symptomatology, there is no research of cognitions in moral injury. The current study examined how maladaptive cognitions (i.e., self-worth and judgment, threat of harm, forgiveness of the situation reliability, trustworthiness of others, forgiveness of others, forgiveness of self, and atonement) may be associated with either moral injury or PTSD.
Method:
Participants (N = 253) were recruited online and eligible for the study if they endorsed a previous deployment, answered military-specific questions, and reported clinical levels of distress on PTSD and Moral Injury self-report measures. An overwhelming majority of participants experienced foreign deployment(s; 90.1%).
Results:
Data indicated that moral injury was defined by atonement, self-worth and judgment, reliability and trustworthiness of others, and forgiveness of others while PTSD was defined by threat of harm and forgiveness of the situation. Forgiveness of self was not associated with moral injury nor PTSD.
Conclusion:
The results highlighted that moral injury and PTSD are associated with distinct maladaptive cognitions. The results of the current study can assist in treatment of moral injury and PTSD by identifying the maladaptive cognitions specific to moral injury that may be targets for change during treatment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... Taken together this suggests that individual differences in the ability to adaptively make sense of PMIEs could, in part, determine whether the event(s) have a protective or deleterious impact on moral injury-related mental disorders. We suggest that these findings have implications for counter-extremism efforts as well as clinical treatment, indicating the potential utility of cognitive restructuring and that targeting moral emotions may be especially helpful in improving individual wellbeing in cases of moral injury 78 . ...
This review aimed to explore individual-level factors involved in radicalization and the impact of moral injury on an individual’s beliefs and behaviors that are relevant to radicalization. The results indicate that both individuals who develop radical beliefs and those with moral injury are exposed to events which provoke similar adverse outcomes, including a loss of personal significance, suggesting that moral injury could be a useful way to understand the process of radicalization. Understanding the processes involved in moral injury may inform preventative programs, as well programs to promote disengagement from radical action in those who have already been radicalized.
... Conversely, it may also be important to assess for alcohol and drug use when veterans present with a history of exposure to morally distressing experiences. Research supporting various treatments for moral injury has been accumulating over the last few years, and treatments such as Trauma-Informed Guilt Reduction Therapy (Norman et al., 2014), Impact of Killing (Maguen et al., 2017), Adaptive Disclosure (Gray et al., 2012), Acceptance and Commitment Therapy for Moral Injury (Nieuwsma et al., 2015), and Building Spiritual Strength (Harris et al., 2011) may be considered. However, it is important to note that most of the treatment trials for these modalities have excluded individuals with SUDs or only included those with mild SUDs. ...
Background
Exposure to potentially morally injurious events (PMIEs) is associated with increased risk for substance use disorders (SUDs), although population-based studies remain limited. The goal of this study was to better understand the relationships between PMIE exposure and lifetime and past-year alcohol use disorder (AUD), drug use disorder (DUD), and SUD.
Methods
Data were analyzed from the 2019–2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 1321 combat veterans. Multivariable analyses examined associations between three types of PMIE exposure (perpetration, witnessing, and betrayal), and lifetime and past-year AUD, DUD, and SUD, adjusting for sociodemographic variables, combat exposure severity, prior trauma, and lifetime posttraumatic stress disorder and major depressive disorder.
Results
Perpetration was associated with increased odds of lifetime AUD (OR 1.15; 95% CI 1.01–1.31) and lifetime SUD (OR 1.18; 95% CI 1.03–1.35). Witnessing was associated with greater odds of past-year DUD (OR 1.20; 95% CI 1.04–1.38) and past-year SUD (OR 1.14; 95% CI 1.02–1.28). Betrayal was associated with past-year AUD (OR 1.20; 95% CI 1.03–1.39). A large proportion of the variance in past-year AUD was accounted for by betrayal (38.7%), while witnessing accounted for 25.8% of the variance in past-year DUD.
Conclusions
Exposure to PMIEs may be a stronger contributor to SUDs among veterans than previously known. These findings highlight the importance of targeted assessment and treatment of moral injury among veterans with SUDs, as well as attending to specific types of morally injurious experiences when conceptualizing and planning care.
The United States military is engaged in the longest war of its history. Post-Traumatic Stress Disorder (PTSD) will torment a significant number of warriors who have taken up arms during the Global War on Terror. Combat stress, spiritual wounds of moral injury, strained relationships, and suicidal ideations will afflict others. While the medical and mental health communities address a portion of these issues, they remain inadequately equipped to answer the questions that impact the soul of the warrior. Military members need chaplains, clergy members, and local churches to address the spiritual aspects of combat and engage them on paths to healing and wholeness. The following project develops and implements a three-part curriculum to prepare warriors for the challenges they will face upon their return from combat. It presents contemporary examples of veterans facing reintegration issues and encourages participants to share their own war stories. Participants in the intervention exhibited a 49 percent reduction in trauma-related symptoms, measured by the PTSD Checklist (PCL- 5), and a 55 percent increase in positive coping beliefs as measured by the Posttraumatic Growth Inventory (PTGI). Chaplains and clergy members can use the included curriculum and facilitator’s guide as a tool for engaging military members in the process of healing from the invisible wounds of war.
Ahlaki yaralanma (AY) belki insanlık tarihinin başlangıcından bu yana tecrübe edilen ancak bilimsel tarih bakımından çok yakın bir zamanda ortaya çıkan ve üzerinde yürütülen araştırmaların sayısının sınırlı olduğu ve ağırlıkla Batı kaynaklı çalışılan bir olgudur. Potansiyel ahlaki yaralayıcı olaylara, eylemlere ve tecrübelere (PAYO) maruz kalma sonucunda suçluluk, utanç, ihanet gibi semptomlarla ortaya çıkan davranışsal, duygusal, psikolojik, sosyal, ahlaki, varoluşsal, manevi ve dinî boyutları olan bir yapısı vardır. Travma sonrası stres bozukluğu (TSSB) ile ortak ve ayrıştıkları noktaları bulunmakla birlikte ondan farklı olan AY’nın henüz yerleşik bir tanısı yoktur. AY’nın yaygın olarak tecrübe edilebildiği alanlar ilk olarak tespit edildiği askerî kurumlardır. Askerî personelin yanı sıra doktorlar ve hemşireler gibi sağlık çalışanları, tıp öğrencileri, hâkimler, savcılar ve avukatlar gibi adli personel, itfaiye çalışanları gibi acil müdahale görevlileri, polisler, mülteciler, sığınmacılar, gazeteciler ve haberciler arasında da AY söz konusu olabilmektedir. Bu çalışmada nitel araştırma yöntemlerinden literatür taraması ile AY olgusu hakkında derinlemesine bilgi verilmesi amaçlanmakta ve bundan sonra konu üzerine yürütülecek araştırmalar için birtakım önerilerde bulunulmaktadır.
The U.S. Supreme Court’s 2022 ruling in Dobbs v Jackson Women's Health Organization held that the U.S. Constitution does not confer the right to an abortion, which set into motion an overhaul of reproductive health care services in certain states. Health care professionals are now operating within a rapidly changing landscape of clinical practice in which they may experience conflict between personal and professional morals (eg, bodily autonomy, patient advocacy), uncertainty regarding allowable practices, and fear of prosecution (eg, loss of medical license) related to reproductive health care services. The ethical dilemmas stemming from Dobbs create a context for exposure to potentially morally injurious events, moral distress, and moral injury (ie, functional impairment stemming from exposure to moral violations) among health care professionals. Considerations related to clinical intervention and approaches to policy are reviewed. Early identification of health care professionals' potentially morally injurious event exposure related to restricted reproductive services is critical for preventing and intervening on moral injury, with implications for improving functioning and retention within the medical field.
Objective:
Research on 'moral injury'-the psychological wound experienced by military personnel and other 'functionaries' whose moral values are violated-has proliferated in recent years. Many psychological researchers, including those in the UK, have subscribed to an increasingly individualised operationalisation of moral injury, with medicalised criteria that closely mirrors PTSD. This trend carries assumptions that have not been comprehensively verified by empirical research. This study aims to explore UK military veterans' experiences of, and challenges to, their moral values in relation to their deployment experiences, without prematurely foreclosing exploration of wider systemic influences.
Method:
Twelve UK military veterans who served in Afghanistan and/or Iraq were interviewed, and the data were analysed thematically and reflexively.
Results:
Three inter-related themes were generated: (1) 'you've been undermined', (2) 'how am I involved in this?' and (3) 'civilianised'.
Conclusions:
The analysis suggests that several assumptions privileged in moral injury research may be empirically contradicted, at least in relation to the experiences of UK military veterans. These assumptions include that moral injury is exclusively driven by individual, episodic acts of commission and omission, invariably leads to guilt and necessarily bifurcates into variants of either perpetration or betrayal. Instead, participants understood the moral violations they experienced as socially contingent. Rather than 'treating' moral injury as a disorder of thinking and feeling located within an individual, the socially contextualised understanding of moral injury indicated by this study's findings may prompt the development of psychological and social interventions that understand moral injury as the fallout of what occurs between people and within systems.
Covering both natural and man-made scenarios including war and terrorism, the Textbook of Disaster Psychiatry is a vital international reference for medical professionals, community leaders and disaster responders a decade after its initial publication. Spanning a decade of advances in disaster psychiatry, this new and updated second edition brings together the views of current international experts to offer a cutting-edge comprehensive review of the psychological, biological and social responses to disaster, in order to help prepare, react and aid effective recovery. Topics range from the epidemiology of disaster response, disaster ecology, the neurobiology of disaster exposure, to socio-cultural issues, early intervention and consultation-liaison care for injured victims. The role of non-governmental organizations, workplace policies and the implications for public health planning at both an individual and community level are also addressed.
Moral injury (MI) describes the intense feelings of shame, guilt, anger, and betrayal that individuals may experience after violating their own moral codes or witnessing the moral transgressions of others. While MI is not a diagnosable mental health disorder, it has been associated with elevated symptoms of depression and anxiety, suicidal ideation, and substance misuse. MI overlaps with some of the diagnostic properties of posttraumatic stress disorder (PTSD) but has been proposed as a distinct phenomenon. Originally identified in military contexts, moral injuries have also been observed in civilian populations. Healthcare workers (HCWs) are at risk of encountering potentially morally injurious events (PMIEs) in the workplace. During the COVID-19 crisis, HCWs forced to provide care with limited resources reported self-blame after losing patients and while fearful of infecting loved ones. As vaccine roll-out continues, it is essential that we encourage healing among the very population that serviced the ill in their time of need.
Moral injury was originally conceived as a socially‐inflicted wound of betrayal experienced by military veterans (Shay, 1994). However, moral injury has since been redefined by psychological researchers as an individualised, predominantly perpetration‐driven, and psychopathological phenomenon (e.g., Currier et al., 2015; Jinkerson, 2016). However, social scientific researchers (e.g., Hodgson & Carey, 2017; Molendijk, 2019; Wiinikka‐Lydon, 2017) have contested mainstream psychology's medicalisation and decontextualisation of moral injury. This theoretical review integrates insights from across these discourses, and brings them into dialogue with ideas from moral psychology, evolutionary science, and community psychology. The aim of this cross‐disciplinary review is to promote a more holistic understanding of moral injury that does justice to its individual and social dimensions. Drawing on these different theoretical strands, this paper proposes that moral injury can be best understood as a psychological wound to basic human needs for social belonging and cohesion. The implications of this integrative understanding of moral injury for applied psychologists and other societal actors are explored. While the relevance of moral injury to civilian populations such as health and social care professionals is clear (e.g., Dombo et al., 2013; French et al., 2021), this paper focuses on military veterans, whose experiences originally prompted the coinage of the term. Please refer to the Supplementary Material section to find this article's Community and Social Impact Statement.
Military personnel, police officers, firefighters, and other first responders must prepare for and respond to life-threatening crises on a daily basis. This lifestyle places stress on personnel, and particularly so on military personnel who may be isolated from support systems and other resources. The authors conducted a systematic review of studies of interventions designed to prevent, identify, and manage acute occupational stress among military, law enforcement, and first responders. The body of evidence consisted of 38 controlled trials, 35 cohort comparisons, and 42 case studies with no comparison group, reported in 136 publications. Interventions consisted of resilience training, stress inoculation with biofeedback, mindfulness, psychological first aid, front-line mental health centers, two- to seven-day restoration programs, debriefing (including critical incident stress debriefing), third-location decompression, postdeployment mental health screening, reintegration programs, and family-centered programs. Study limitations (risk of bias), directness, consistency, precision, and publication bias were considered in rating the quality of evidence for each outcome area. Overall, interventions had positive effects on return to duty, absenteeism, and distress. However, there was no significant impact on symptoms of psychological disorders such as PTSD, depression, and anxiety. Because of study limitations, inconsistency of results, indirectness, and possible publication bias, there was insufficient evidence to form conclusions about the effects of most specific intervention types, components, settings, or specific populations.
This chapter looks into detail at the various pathways to build workplace mental health by identifying organizational modifiable risk factors and identifying protective factors and strengths for prevention, growth, and resiliency. Discussion around common mental health conditions, prevention and continuum of care, and risk factors related to moral suffering, compassion fatigue, and burnout is highlighted along with protective factors, including, for instance, resiliency, self-compassion, compassion satisfaction, and psychological flexibility. Practical strategies for leaders are offered for better organizational culture, stigma reduction, and optimizing wellbeing. This chapter brings a unique twist to current debates around mental health and wellbeing, by having the testimonial from a veteran police officer who has been responded to a myriad of critical incidents and shares his narrative of experiences and insights as a veteran police officer. This chapter concludes with the importance of optimizing mental health education, prevention, and interventions to further healthy and more proactive organizational culture and workplace mental health.KeywordsMental healthTraumaRespondersStressInjury
The Moral Injury Group (MIG) at the Corporal Michael J. Crescenz (Philadelphia) VA Medical Center (CMCVAMC) is an example of collaborative care between chaplains and psychologists that engages religious, academic, and not-for-profit communities, as well as the media and other organizations external to the healthcare context. The intervention is primarily informed by a unique conceptualization: the moral injury (MI) of individual veterans is rooted in the unfair distribution of appropriate moral pain and best addressed through communal intervention that facilitates broader moral engagement and responsibility. MI is a public health issue that arises from the unfair distribution of appropriate moral pain and is sourced by the sedimentary layers of structural violence in US institutions related to war, and US war-culture. Preventing veteran suicide and promoting public health requires a larger social analysis and more broad-based, collective and collaborative understanding of, and response to, US war-culture, extending responsibility for MI care and prevention beyond individual veterans in health care institutions and clinical settings to US society.
This systematic review synthesizes the evidence on pretreatment patient characteristics and program features associated with treatment retention, response, and remission in military populations with posttraumatic stress disorder (PTSD).
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.
Moral-injury cognitions (beliefs regarding moral violations) represent a potential mechanism that may underlie the association between potentially morally injurious events (PMIEs) and psychological symptoms in refugees. We implemented a novel experimental paradigm (i.e., the simulation of a PMIE using mental imagery) to investigate the impact of moral-injury cognitions on psychological outcomes in 71 Arabic-speaking refugees. A latent class analysis of preexisting moral-injury beliefs yielded three classes characterized by (a) high moral-injury beliefs about violations by others (49.3%), (b) high moral-injury beliefs about violations by others and by oneself (25.5%), and (c) low moral-injury beliefs (25.5%). Investigation of group differences revealed that the moral-injury classes reported greater negative emotional responses following the simulated PMIE. Furthermore, the association between moral-injury classes and psychological outcomes was moderated by situation-specific blame appraisals of the simulated PMIE. These findings have important implications for psychological interventions for refugees.
Purpose of review
The scope of this article is to summarize (a) what is known about the relationships between spirituality and trauma outcomes and (b) outline options for spiritually integrated trauma care.
Recent findings
Research on relationships between spirituality and psychological trauma outcomes has advanced to the point that there is no doubt that interventions addressing spiritual distress can provide critically needed help to trauma survivors who want spiritually integrated care. There are now many options for providing spiritually integrated care for trauma, including both implicitly and explicitly spiritually integrated options, group and individual options, and options for chaplaincy and mental health providers.
Summary
This review focused on spiritually integrated interventions for posttraumatic stress disorder that have at least one randomized controlled trial in the peer-reviewed literature. Eight interventions with that level of evidence are described with a review of clinical recommendations for their use.
"Emotion in Psychotherapy" draws from the literature of both clinical and experimental psychology to provide a critical review of theory and research on the role of emotion in the process of change. Providing a general theoretical framework for understanding the impact of affect in therapy, this unique volume describes specific change events in which emotions enhance the achievement of therapeutic goals. Case examples and extensive transcripts vividly portray a variety of affective modes—such as completing emotional expression, accessing previously unacknowledged feelings, and restructuring emotions—and illustrate in clear, practical terms how certain processes apply to particular patient problems. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Relatively little research has been devoted to developing empirically-supported interventions for the secondary prevention of chronic post-traumatic stress disorder (i.e., for individuals who have developed PTSD symptoms but not the full PTSD disorder). One-session psychological debriefing has been routinely used as a primary preventive intervention for individuals exposed to trauma, but the appropriateness of this practice has been questioned. The authors describe an alternative, secondary prevention model of brief exposure-based treatment using three cases of military members seeking help at a forward-deployed medical clinic in Iraq for PTSD symptoms following combat-related traumas. Treatment involved repeated imaginal exposure and in vivo exposure conducted in four therapy sessions over a five-week period. Baseline measures on the PTSD Checklist were at a level that is considered to be in the range of PTSD. The results indicated that after four treatment sessions, PTSD symptoms were reduced by an average of 56%, and the final PTSD Checklist scores were within normal limits. The results suggest that prolonged exposure therapy may be a rapid individual treatment for the secondary prevention of combat-related PTSD.
Literature describing the phenomenology of the stress of combat suggests that war-zone experiences may lead to adverse psychological outcomes such as post-traumatic stress disorder not only because they expose persons to life threat and loss but also because they may contradict deeply held moral and ethical beliefs and expectations. We sought to develop and validate a measure of potentially morally injurious events as a necessary step toward studying moral injury as a possible adverse consequence of combat. We administered an 11-item, self-report Moral Injury Events Scale to active duty Marines 1 week and 3 months following war-zone deployment. Two items were eliminated because of low item-total correlations. The remaining 9 items were subjected to an exploratory factor analysis, which revealed two latent factors that we labeled perceived transgressions and perceived betrayals; these were confirmed via confirmatory factor analysis on an independent sample. The overall Moral Injury Events Scale and its two subscales had favorable internal validity, and comparisons between the 1-week and 3-month data suggested good temporal stability. Initial discriminant and concurrent validity were also established. Future research directions were discussed.
Context
The Primary Care Evaluation of Mental Disorders (PRIME-MD) was developed
as a screening instrument but its administration time has limited its clinical
usefulness.Objective
To determine if the self-administered PRIME-MD Patient Health Questionnaire
(PHQ) has validity and utility for diagnosing mental disorders in primary
care comparable to the original clinician-administered PRIME-MD.Design
Criterion standard study undertaken between May 1997 and November 1998.Setting
Eight primary care clinics in the United States.Participants
Of a total of 3000 adult patients (selected by site-specific methods
to avoid sampling bias) assessed by 62 primary care physicians (21 general
internal medicine, 41 family practice), 585 patients had an interview with
a mental health professional within 48 hours of completing the PHQ.Main Outcome Measures
Patient Health Questionnaire diagnoses compared with independent diagnoses
made by mental health professionals; functional status measures; disability
days; health care use; and treatment/referral decisions.Results
A total of 825 (28%) of the 3000 individuals and 170 (29%) of the 585
had a PHQ diagnosis. There was good agreement between PHQ diagnoses and those
of independent mental health professionals (for the diagnosis of any 1 or
more PHQ disorder, κ = 0.65; overall accuracy, 85%; sensitivity, 75%;
specificity, 90%), similar to the original PRIME-MD. Patients with PHQ diagnoses
had more functional impairment, disability days, and health care use than
did patients without PHQ diagnoses (for all group main effects, P<.001). The average time required of the physician to review the
PHQ was far less than to administer the original PRIME-MD (<3 minutes for
85% vs 16% of the cases). Although 80% of the physicians reported that routine
use of the PHQ would be useful, new management actions were initiated or planned
for only 117 (32%) of the 363 patients with 1 or more PHQ diagnoses not previously
recognized.Conclusion
Our study suggests that the PHQ has diagnostic validity comparable to
the original clinician-administered PRIME-MD, and is more efficient to use.
Figures in this Article
Mental disorders in primary care are common, disabling, costly, and
treatable.1- 5
However, they are frequently unrecognized and therefore not treated.2- 6
Although there have been many screening instruments developed,7- 8
PRIME-MD (Primary Care Evaluation of Mental Disorders)5
was the first instrument designed for use in primary care that actually diagnoses
specific disorders using diagnostic criteria from the Diagnostic
and Statistical Manual of Mental Disorders, Revised Third Edition9(DSM-III-R) and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition10(DSM-IV).
PRIME-MD is a 2-stage system in which the patient first completes a
26-item self-administered questionnaire that screens for 5 of the most common
groups of disorders in primary care: depressive, anxiety, alcohol, somatoform,
and eating disorders. In the original study,5
the average amount of time spent by the physician to administer the clinician
evaluation guide to patients who scored positively on the patient questionnaire
was 8.4 minutes. However, this is still a considerable amount of time in the
primary care setting, where most visits are 15 minutes or less.11
Therefore, although PRIME-MD has been widely used in clinical research,12- 28
its use in clinical settings has apparently been limited. This article describes
the development, validation, and utility of a fully self-administered version
of the original PRIME-MD, called the PRIME-MD Patient Health Questionnaire
(henceforth referred to as the PHQ).
DESCRIPTION OF PRIME-MD PHQ
ABSTRACT
|
DESCRIPTION OF PRIME-MD PHQ
|
STUDY PURPOSE
|
METHODS
|
RESULTS
|
COMMENT
|
REFERENCES
The 2 components of the original PRIME-MD, the patient questionnaire
and the clinician evaluation guide, were combined into a single, 3-page questionnaire
that can be entirely self-administered by the patient (it can also be read
to the patient, if necessary). The clinician scans the completed questionnaire,
verifies positive responses, and applies diagnostic algorithms that are abbreviated
at the bottom of each page. In this study, the data from the questionnaire
were entered into a computer program that applied the diagnostic algorithms
(written in SPSS 8.0 for Windows [SPSS Inc, Chicago, Ill]). The computer program
does not include the diagnosis of somatoform disorder, because this diagnosis
requires a clinical judgment regarding the adequacy of a biological explanation
for physical symptoms that the patient has noted.
A fourth page has been added to the PHQ that includes questions about
menstruation, pregnancy and childbirth, and recent psychosocial stressors.
This report covers only data from the diagnostic portion (first 3 pages) of
the PHQ. Users of the PHQ have the choice of using the entire 4-page instrument,
just the 3-page diagnostic portion, a 2-page version (Brief PHQ) that covers
mood and panic disorders and the nondiagnostic information described above,
or only the first page of the 2-page version (covering only mood and panic
disorders) (Figure 1).
Figure 1. First Page of Primary Care Evaluation
of Mental Disorders Brief Patient Health QuestionnaireGrahic Jump Location+View Large |
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Download Slide (.ppt)
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View in Article ContextCopyright held by Pfizer Inc, but may be photocopied ad libitum.
For office coding, see the end of the article.
The original PRIME-MD assessed 18 current mental disorders. By grouping
several specific mood, anxiety, and somatoform categories into larger rubrics,
the PHQ greatly simplifies the differential diagnosis by assessing only 8
disorders. Like the original PRIME-MD, these disorders are divided into threshold
disorders (corresponding to specific DSM-IV diagnoses,
such as major depressive disorder, panic disorder, other anxiety disorder,
and bulimia nervosa) and subthreshold disorders (in which the criteria for
disorders encompass fewer symptoms than are required for any specific DSM-IV diagnoses: other depressive disorder, probable alcohol
abuse or dependence, and somatoform and binge eating disorders).
One important modification was made in the response categories for depressive
and somatoform symptoms that, in the original PRIME-MD, were dichotomous (yes/no).
In the PHQ, response categories are expanded. Patients indicate for each of
the 9 depressive symptoms whether, during the previous 2 weeks, the symptom
has bothered them "not at all," "several days," "more than half the days,"
or "nearly every day." This change allows the PHQ to be not only a diagnostic
instrument but also to yield a measure of depression severity that can be
of aid in initial treatment decisions as well as in monitoring outcomes over
time. Patients indicate for each of the 13 physical symptoms whether, during
the previous month, they have been "not bothered," "bothered a little," or
"bothered a lot" by the symptom. Because physical symptoms are so common in
primary care, the original PRIME-MD dichotomous-response categories often
led patients to endorse physical symptoms that were not clinically significant.
An item was added to the end of the diagnostic portion of the PHQ asking
the patient if he or she had checked off any problems on the questionnaire:
"How difficult have these problems made it for you to do your work, take care
of things at home, or get along with other people?" As with the original PRIME-MD,
before making a final diagnosis, the clinician is expected to rule out physical
causes of depression, anxiety and physical symptoms, and, in the case of depression,
normal bereavement and history of a manic episode.
STUDY PURPOSE
ABSTRACT
|
DESCRIPTION OF PRIME-MD PHQ
|
STUDY PURPOSE
|
METHODS
|
RESULTS
|
COMMENT
|
REFERENCES
Our major purpose was to test the validity and utility of the PHQ in
a multisite sample of family practice and general internal medicine patients
by answering the following questions:
Are diagnoses made by the PHQ as accurate as diagnoses
made by the original PRIME-MD, using independent diagnoses made by mental
health professionals (MHPs) as the criterion standard?Are the frequencies of mental disorders found by
the PHQ comparable to those obtained in other primary care studies?Is the construct validity of the PHQ comparable
to the original PRIME-MD in terms of functional impairment and health care
use?Is the PHQ as effective as the original PRIME-MD
in increasing the recognition of mental disorders in primary care patients?How valuable do primary care physicians find the
diagnostic information in the PHQ?How comfortable are patients in answering the questions
on the PHQ, and how often do they believe that their answers will be helpful
to their physicians in understanding and treating their problems?
This chapter begins with an evaluation of recent research that has accumulated about traumatic grief (TG) symptomatology. More specifically, the available evidence is reviewed to determine whether it satisfies requirements for the establishment of TG as a distinct clinical entity. Following this review, the authors discuss some advantages and disadvantages of developing standardized criteria for TG. Given their belief that the advantages outweigh the disadvantages, they then describe the logic behind the consensus criteria for TG proposed by a panel of experts. Results of a preliminary test of the proposed criteria set for TG are reported, directions for their further refinement are discussed, and assessment tools for TG are presented. The authors conclude by proposing ways to distinguish between normal and TG reactions and by suggesting directions for future research. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This article describes the development and validation of a new measure of trauma-related thoughts and beliefs, the Posttraumatic Cognitions Inventory (PTCI), whose items were derived from clinical observations and current theories of post-trauma psychopathology. The PTCI was administered to 601 volunteers, 392 of whom had experienced a traumatic event and 170 of whom had moderate to severe posttraumatic stress disorder (PTSD). Principal-components analysis yielded 3 factors: Negative Cognitions About Self, Negative Cognitions About the World, and Self-Blame. The 3 factors showed excellent internal consistency and good test-retest reliability; correlated moderately to strongly with measures of PTSD severity, depression, and general anxiety; and discriminated well between traumatized individuals with and without PTSD. The PTCI compared favorably with other measures of trauma-related cognitions, especially in its superior ability to discriminate between traumatized individuals with and without PTSD. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The current combat operations in Iraq and Afghanistan have involved US military personnel in major ground combat and hazardous security duty. Studies are needed to systematically assess the mental health of members of the armed services who have participated in these operations and to inform policy with regard to the optimal delivery of mental health care to returning veterans.
We studied members of 4 US combat infantry units (3 Army units and a Marine Corps unit) using an anonymous survey that was administered to the subjects either before their deployment to Iraq (n=2530) or 3 to 4 months after their return from combat duty in Iraq or Afghanistan (n=3671). The outcomes included major depression, generalized anxiety, and posttraumatic stress disorder (PTSD), which were evaluated on the basis of standardized, self-administered screening instruments.
Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6% to 17.1%) than after duty in Afghanistan (11.2%) or before deployment to Iraq (9.3%); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23% to 40% sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care.
This study provides an initial look at the mental health of members of the Army and the Marine Corps who were involved in combat operations in Iraq and Afghanistan. Our findings indicate that among the study groups there was a significant risk of mental health problems and that the subjects reported important barriers to receiving mental health services, particularly the perception of stigma among those most in need of such care. The recent military operations in Iraq and Afghanistan, which have involved the first sustained ground combat undertaken by the United States since the war in Vietnam, raise important questions about the effect of the experience on the mental health of members of the military services who have been deployed there. Research conducted after other military conflicts has shown that deployment stressors and exposure to combat result in considerable risks of mental health problems, including posttraumatic stress disorder, major depression, substance abuse, impairment in social functioning and in the ability to work, and the increased use of healthcare services. One study that was conducted just before the military operations in Iraq and Afghanistan began found that at least 6% of all US military service members on active duty receive treatment for a mental disorder each year. Given the ongoing military operations in Iraq and Afghanistan, mental disorders are likely to remain an important healthcare concern among those serving there. Many gaps exist in the understanding of the full psychosocial effect of combat. The all-volunteer force deployed to Iraq and Afghanistan and the type of warfare conducted in these regions are very different from those involved in past wars, differences that highlight the need for studies of members of the armed services who are involved in the current operations. Most studies that have examined the effects of combat on mental health were conducted among veterans years after their military service had ended. A problem in the methods of such studies is the long recall period after exposure to combat. Very few studies have examined a broad range of mental health outcomes near to the time of subjects' deployment. Little of the existing research is useful in guiding policy with regard to how best to promote access to and the delivery of mental health care to members of the armed services. Although screening for mental health problems is now routine both before and after deployment and is encouraged in primary care settings, we are not aware of any studies that have assessed the use of mental health care, the perceived need for such care, and the perceived barriers to treatment among members of the military services before or after combat deployment. We studied the prevalence of mental health problems among members of the US armed services who were recruited from comparable combat units before or after their deployment to Iraq or Afghanistan. We identified the proportion of service members with mental health concerns who were not receiving care and the barriers they perceived to accessing and receiving such care.
Bereavement is a universal experience, and its association with excess morbidity and mortality is well established. Nevertheless, grief becomes a serious health concern for a relative few. For such individuals, intense grief persists, is distressing and disabling, and may meet criteria as a distinct mental disorder. At present, grief is not recognized as a mental disorder in the DSM-IV or ICD-10. The goal of this study was to determine the psychometric validity of criteria for prolonged grief disorder (PGD) to enhance the detection and potential treatment of bereaved individuals at heightened risk of persistent distress and dysfunction.
A total of 291 bereaved respondents were interviewed three times, grouped as 0-6, 6-12, and 12-24 mo post-loss. Item response theory (IRT) analyses derived the most informative, unbiased PGD symptoms. Combinatoric analyses identified the most sensitive and specific PGD algorithm that was then tested to evaluate its psychometric validity. Criteria require reactions to a significant loss that involve the experience of yearning (e.g., physical or emotional suffering as a result of the desired, but unfulfilled, reunion with the deceased) and at least five of the following nine symptoms experienced at least daily or to a disabling degree: feeling emotionally numb, stunned, or that life is meaningless; experiencing mistrust; bitterness over the loss; difficulty accepting the loss; identity confusion; avoidance of the reality of the loss; or difficulty moving on with life. Symptoms must be present at sufficiently high levels at least six mo from the death and be associated with functional impairment.
The criteria set for PGD appear able to identify bereaved persons at heightened risk for enduring distress and dysfunction. The results support the psychometric validity of the criteria for PGD that we propose for inclusion in DSM-V and ICD-11. Please see later in the article for Editors' Summary.
The therapeutic process involves many different types of affective phenomena. No single therapeutic perspective has been able to encompass within its own theoretical framework all the ways in which emotion plays a role in therapeutic change. A comprehensive, constructive theory of emotion helps transcend the differences in the therapeutic schools by viewing emotion as a complex synthesis of expressive motor, schematic, and conceptual information that provides organisms with information about their responses to situations that helps them orient adaptively in the environment. In addition to improved theory, increased precision in the assessment of affective functioning in therapy, as well as greater specification of different emotional change processes and means of facilitating these, will allow the role of emotion in change to be studied more effectively. A number of different change processes involving emotion are discussed, as well as principles of emotionally focused intervention that help access emotion and promote emotional restructuring.
We examined the psychometric properties of the PTSD Checklist (PCL), a self-report instrument designed to assess symptoms of posttraumatic stress disorder. Three hundred ninety-two participants recruited in a university setting completed the PCL in addition to several well-established self-report instruments designed to assess various forms of psychopathology (e.g., depression, general anxiety, PTSD). Ninety participants returned for readministration of selected measures. Findings provided support for psychometric properties of the PCL, including internal consistency, test-retest reliability, convergent validity, and discriminant validity. Additional strengths of the PCL are discussed.
In this paper, we contend that complicated grief (CG) constitutes a distinct psychopathological diagnostic entity and thus warrants a place in standardized psychiatric diagnostic taxonomies. CG is characterized by a unique pattern of symptoms following bereavement that are typically slow to resolve and can persist for years if left untreated. This paper will demonstrate that existing diagnoses are not sufficient, as the phenomenology, risk factors, clinical correlates, course, and outcomes for CG are distinct from those of posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and adjustment disorder (AD). It is argued that the establishment of CG as a diagnostic entity is essential because its symptoms are associated with enduring mental and physical health morbidity and require specifically designed clinical interventions. We conduct a critical review of all published evidence on this topic to date, demonstrating that the advantages of standardizing the diagnostic criteria of CG outweigh the disadvantages. In addition, recommendations for future lines of research are made. This paper concludes that CG must be established in the current nosology to address the needs of individuals who are significantly suffering and impaired by this disorder.
In 1988, the National Vietnam Veterans Readjustment Study (NVVRS) of a representative sample of 1200 veterans estimated that
30.9% had developed posttraumatic stress disorder (PTSD) during their lifetimes and that 15.2% were currently suffering from
PTSD. The study also found a strong dose-response relationship: As retrospective reports of combat exposure increased, PTSD
occurrence increased. Skeptics have argued that these results are inflated by recall bias and other flaws. We used military
records to construct a new exposure measure and to cross-check exposure reports in diagnoses of 260 NVVRS veterans. We found
little evidence of falsification, an even stronger dose-response relationship, and psychological costs that were lower than
previously estimated but still substantial. According to our fully adjusted PTSD rates, 18.7% of the veterans had developed
war-related PTSD during their lifetimes and 9.1% were currently suffering from PTSD 11 to 12 years after the war; current
PTSD was typically associated with moderate impairment.
Sixty veterans (54 men, 6 women) with chronic military-related posttraumatic stress disorder (PTSD) participated in a wait-list controlled trial of cognitive processing therapy (CPT). The overall dropout rate was 16.6% (20% from CPT, 13% from waiting list). Random regression analyses of the intention-to-treat sample revealed significant improvements in PTSD and comorbid symptoms in the CPT condition compared with the wait-list condition. Forty percent of the intention-to-treat sample receiving CPT did not meet criteria for a PTSD diagnosis, and 50% had a reliable change in their PTSD symptoms at posttreatment assessment. There was no relationship between PTSD disability status and outcomes. This trial provides some of the most encouraging results of PTSD treatment for veterans with chronic PTSD and supports increased use of cognitive- behavioral treatments in this population.
The prevalence of posttraumatic stress disorder (PTSD) is elevated among women who have served in the military, but no prior study has evaluated treatment for PTSD in this population. Prior research suggests that cognitive behavioral therapy is a particularly effective treatment for PTSD.
To compare prolonged exposure, a type of cognitive behavioral therapy, with present-centered therapy, a supportive intervention, for the treatment of PTSD.
A randomized controlled trial of female veterans (n=277) and active-duty personnel (n=7) with PTSD recruited from 9 VA medical centers, 2 VA readjustment counseling centers, and 1 military hospital from August 2002 through October 2005.
Participants were randomly assigned to receive prolonged exposure (n = 141) or present-centered therapy (n = 143), delivered according to standard protocols in 10 weekly 90-minute sessions.
Posttraumatic stress disorder symptom severity was the primary outcome. Comorbid symptoms, functioning, and quality of life were secondary outcomes. Blinded assessors collected data before and after treatment and at 3- and 6-month follow-up.
Women who received prolonged exposure experienced greater reduction of PTSD symptoms relative to women who received present-centered therapy (effect size, 0.27; P = .03). The prolonged exposure group was more likely than the present-centered therapy group to no longer meet PTSD diagnostic criteria (41.0% vs 27.8%; odds ratio, 1.80; 95% confidence interval, 1.10-2.96; P = .01) and achieve total remission (15.2% vs 6.9%; odds ratio, 2.43; 95% confidence interval, 1.10-5.37; P = .01). Effects were consistent over time in longitudinal analyses, although in cross-sectional analyses most differences occurred immediately after treatment.
Prolonged exposure is an effective treatment for PTSD in female veterans and active-duty military personnel. It is feasible to implement prolonged exposure across a range of clinical settings.
clinicaltrials.gov Identifier: NCT00032617.
Although most military personnel returning from recent deployments will readjust successfully to life in the United States, a significant minority will exhibit PTSD or some other psychiatric disorder. Practitioners should routinely inquire about war-zone trauma and associated symptoms when conducting psychiatric assessments. Treatment should be initiated as soon as possible, not only to ameliorate PTSD symptoms but also to forestall the later development of comorbid psychiatric and/or medical disorders and to prevent interpersonal or vocational functional impairment. If evidence-based practices are utilized, complete remission can be achieved in 30%-50% of cases of PTSD, and partial improvement can be expected with most patients. We can all look forward to future break-throughs that will improve our capacity to help people with PTSD.
The development of the Posttraumatic Growth Inventory, an instrument for assessing positive outcomes reported by persons who have experienced traumatic events, is described. This 21-item scale includes factors of New Possibilities, Relating to Others, Personal Strength, Spiritual Change, and Appreciation of Life. Women tend to report more benefits than do men, and persons who have experienced traumatic events report more positive change than do persons who have not experienced extraordinary events. The Posttraumatic Growth Inventory is modestly related to optimism and extraversion. The scale appears to have utility in determining how successful individuals, coping with the aftermath of trauma, are in reconstructing or strengthening their perceptions of self, others, and the meaning of events.
The growing number of service members in need of mental health care requires that empirically based interventions be tailored to the unique demands and exigencies of this population. We discuss a 6-session intervention for combat-related PTSD designed to foster willingness to engage with and disclose difficult deployment memories through a combination of imaginal exposure and subsequent cognitive restructuring and meaning-making strategies. Core corrective elements of existing PTSD treatments are incorporated and expanded, including techniques designed to specifically address traumatic loss and moral conflict.
This study examined the mental health impact of reported direct and indirect killing among 2,797 U.S. soldiers returning from Operation Iraqi Freedom. Data were collected as part of a postdeployment screening program at a large Army medical facility. Overall, 40% of soldiers reported killing or being responsible for killing during their deployment. Even after controlling for combat exposure, killing was a significant predictor of posttraumatic disorder (PTSD) symptoms, alcohol abuse, anger, and relationship problems. Military personnel returning from modern deployments are at risk of adverse mental health conditions and related psychosocial functioning related to killing in war. Mental health assessment and treatment should address reactions to killing to optimize readjustment following deployment.
Throughout history, warriors have been confronted with moral and ethical challenges and modern unconventional and guerilla wars amplify these challenges. Potentially morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long-term, emotionally, psychologically, behaviorally, spiritually, and socially (what we label as moral injury). Although there has been some research on the consequences of unnecessary acts of violence in war zones, the lasting impact of morally injurious experience in war remains chiefly unaddressed. To stimulate a critical examination of moral injury, we review the available literature, define terms, and offer a working conceptual framework and a set of intervention strategies designed to repair moral injury.
The Alcohol Use Disorders Identification Test (AUDIT) has been developed from a six-country WHO collaborative project as a screening instrument for hazardous and harmful alcohol consumption. It is a 10-item questionnaire which covers the domains of alcohol consumption, drinking behaviour, and alcohol-related problems. Questions were selected from a 150-item assessment schedule (which was administered to 1888 persons attending representative primary health care facilities) on the basis of their representativeness for these conceptual domains and their perceived usefulness for intervention. Responses to each question are scored from 0 to 4, giving a maximum possible score of 40. Among those diagnosed as having hazardous or harmful alcohol use, 92% had an AUDIT score of 8 or more, and 94% of those with non-hazardous consumption had a score of less than 8. AUDIT provides a simple method of early detection of hazardous and harmful alcohol use in primary health care settings and is the first instrument of its type to be derived on the basis of a cross-national study.
The psychometric properties of the PTSD Checklist (PCL), a new, brief, self-report instrument, were determined on a population of 40 motor vehicle accident victims and sexual assault victims using diagnoses and scores from the CAPS (Clinician Administered PTSD Scale) as the criteria. For the PCL as a whole, the correlation with the CAPS was 0.929 and diagnostic efficiency was 0.900 versus CAPS. Examination of the individual items showed wide ranging values of individual item correlations ranging from 0.386 to 0.788, and with diagnostic efficiencies of 0.700 or better for symptoms. We support the value of the PCL as a brief screening instrument for PTSD.
The authors present a multidimensional meta-analysis of studies published between 1980 and 2003 on psychotherapy for PTSD.
Data on variables not previously meta-analyzed such as inclusion and exclusion criteria and rates, recovery and improvement rates, and follow-up data were examined.
Results suggest that psychotherapy for PTSD leads to a large initial improvement from baseline. More than half of patients who complete treatment with various forms of cognitive behavior therapy or eye movement desensitization and reprocessing improve. Reporting of metrics other than effect size provides a somewhat more nuanced account of outcome and generalizability.
The majority of patients treated with psychotherapy for PTSD in randomized trials recover or improve, rendering these approaches some of the most effective psychosocial treatments devised to date. Several caveats, however, are important in applying these findings to patients treated in the community. Exclusion criteria and failure to address polysymptomatic presentations render generalizability to the population of PTSD patients indeterminate. The majority of patients posttreatment continue to have substantial residual symptoms, and follow-up data beyond very brief intervals have been largely absent. Future research intended to generalize to patients in practice should avoid exclusion criteria other than those a sensible clinician would impose in practice (e.g., schizophrenia), should avoid wait-list and other relatively inert control conditions, and should follow patients through at least 2 years.
The US military has conducted population-level screening for mental health problems among all service members returning from deployment to Afghanistan, Iraq, and other locations. To date, no systematic analysis of this program has been conducted, and studies have not assessed the impact of these deployments on mental health care utilization after deployment.
To determine the relationship between combat deployment and mental health care use during the first year after return and to assess the lessons learned from the postdeployment mental health screening effort, particularly the correlation between the screening results, actual use of mental health services, and attrition from military service.
Population-based descriptive study of all Army soldiers and Marines who completed the routine postdeployment health assessment between May 1, 2003, and April 30, 2004, on return from deployment to Operation Enduring Freedom in Afghanistan (n = 16,318), Operation Iraqi Freedom (n = 222,620), and other locations (n = 64,967). Health care utilization and occupational outcomes were measured for 1 year after deployment or until leaving the service if this occurred sooner.
Screening positive for posttraumatic stress disorder, major depression, or other mental health problems; referral for a mental health reason; use of mental health care services after returning from deployment; and attrition from military service.
The prevalence of reporting a mental health problem was 19.1% among service members returning from Iraq compared with 11.3% after returning from Afghanistan and 8.5% after returning from other locations (P<.001). Mental health problems reported on the postdeployment assessment were significantly associated with combat experiences, mental health care referral and utilization, and attrition from military service. Thirty-five percent of Iraq war veterans accessed mental health services in the year after returning home; 12% per year were diagnosed with a mental health problem. More than 50% of those referred for a mental health reason were documented to receive follow-up care although less than 10% of all service members who received mental health treatment were referred through the screening program.
Combat duty in Iraq was associated with high utilization of mental health services and attrition from military service after deployment. The deployment mental health screening program provided another indicator of the mental health impact of deployment on a population level but had limited utility in predicting the level of mental health services that were needed after deployment. The high rate of using mental health services among Operation Iraqi Freedom veterans after deployment highlights challenges in ensuring that there are adequate resources to meet the mental health needs of returning veterans.
Mr. K, a 38-year-old National Guard sol- dier, was assessed in an outpatient psy- chiatric clinic several months after he re- turned home from a 12-month deployment to the Sunni Triangle in Iraq, where he had his first exposure to com- bat in his 10 years of National Guard duty. Before deployment, he worked suc- cessfully as an automobile salesman, was a happily married father with children ages 10 and 12 years, and was socially outgoing with a large circle of friends and active in civic and church activities. While in Iraq, he had extensive combat exposure. His platoon was heavily shelled and was ambushed on many occasions, often resulting in death or injury to his buddies. He was a passenger on patrols and convoys in which roadside bombs destroyed vehicles and wounded or killed people with whom he had become close. He was aware that he had killed a number of enemy combatants, and he feared that he may also have been re- sponsible for the deaths of civilian by- standers. He blamed himself for being unable to prevent the death of his best friend, who was shot by a sniper. When asked about the worst moment during his deployment, he readily stated that it occurred when he was unable to inter- cede, but only to watch helplessly, while a small group of Iraqi women and chil- dren were killed in the crossfire during a particularly bloody assault.
Group-based exposure therapy (GBET) was field-tested with 102 veterans with war-related posttraumatic stress disorder (PTSD). Nine to 11 patients attended 3 hours of group therapy per day twice weekly for 16-18 weeks. Stress management and a minimum of 60 hours of exposure was included (3 hours of within-group war-trauma presentations per patient, 30 hours of listening to recordings of patient's own war-trauma presentations and 27 hours of hearing other patients' war-trauma presentations). Analysis of assessments conducted by treating clinicians pre-, post- and 6-month posttreatment suggests that GBET produced clinically significant and lasting reductions in PTSD symptoms for most patients on both clinician symptoms ratings (6-month posttreatment effect size delta = 1.22) and self-report measures with only three dropouts.
The Posttraumatic Growth Inventory: Measuring the positive legacy of trauma
- R Tedeschi
- L Calhoun
Tedeschi, R., & Calhoun, L. (1996). The Posttraumatic Growth
Inventory: Measuring the positive legacy of trauma. Journal
of Traumatic Stress, 9, 455-472.
RECEIVED: January 26, 2011
ACCEPTED: September 8, 2011
Effective Treatments for PTSD: Practice Guidelines from the International Society of Traumatic Stress Studies
- E Foa
- T Keane
- M Friedman
- J Cohen
Foa, E., Keane, T., Friedman, M., & Cohen, J. (2009). Effective
Treatments for PTSD: Practice Guidelines from the International Society of Traumatic Stress Studies. New York:
Guilford Press.