Perceptions of Military Experience Among Veterans Reporting Lifetime Warzone Moral Injury.

ABSTRACT: Exposures to potentially morally injurious events (PMIEs) and possible moral injury are risk factors for a range of difficulties impacting individual functioning. Although exposure to PMIEs is a somewhat common product of war, qualitative methods to understand Veterans' experiences of moral injury and Veterans Affairs treatment are limited. To better characterize Veterans' experiences, 14 male warzone Veterans who reported moral injury post-warzone deployment and completed posttraumatic stress disorder treatment in the past year were asked to describe their military service as part of a qualitative study. Through thematic analysis, we found two moral injury-consistent themes and four subthemes. The first theme was "military experiences were associated with morally questioning one's self" with subthemes of "moral shift" and "depersonalization." The second theme was "military experiences were associated with morally questioning others" with subthemes of "disillusionment" and "resignation." Based on these findings, we conclude with a discussion of treatment implications for moral injury.

Is and Ought: Descriptive and Prescriptive Cognitions in Military-Related Moral Injury.

Debate exists regarding the most appropriate way to address moral injuries that stem from involvement in war and other military conflicts. In recent years, some researchers have suggested that existing treatments for trauma may be inadequate to address moral injury and have thus proposed novel interventions to help mitigate these concerns. In response, advocates of more traditional approaches have argued that standard trauma interventions are generally sufficient for moral injury, and investment in new interventions may be premature. This conceptual article draws from research findings and current theories of moral injury to demonstrate that there is merit on both sides of this debate, and further clarifying the types of cognitions involved in moral injury can guide effective treatment planning. In particular, the most recent diagnostic criteria for posttraumatic stress disorder is used to distinguish the objectively falsifiable descriptive cognitions often associated with trauma from the subjectively determined prescriptive cognitions that characterize moral injury. Scenarios from war zone deployments have been used to highlight the relevance of this distinction for moral injury, and a general treatment framework that shows how existing and novel interventions may complement one another is presented. Research suggestions for assessing descriptive and prescriptive cognitions in moral injury and empirically validating this treatment framework are discussed.

What Ought We to Do With "Thick Terms"? A Response to Frankfurt & Coady's "Bringing Philosophy to Bear on Moral Injury and Posttraumatic Stress Disorder Construct Validation".

We respond to the commentary by Frankfurt and Coady (this issue) regarding the descriptive-prescriptive framework for partially distinguishing between posttraumatic stress disorder (PTSD) and moral injury (Farnsworth, 2019). In their commentary, Frankfurt & Coady raise concerns about the application of R. M. Hare's (2014) philosophical approach of prescriptivism to military-related moral injury (MI) and the potential philosophical and ethical implications that may follow. In this response, we clarify that Farnsworth's descriptive-prescriptive framework is not tied to or aligned with Hare's prescriptivism and, as a result, many of Frankfurt and Coady's critiques become tangential to Farnsworth's original argument. We go on to clarify that Farnsworth's descriptive-prescriptive framework does not deny the utility of all cognitive therapies for moral injury, nor does it attempt to fully separate descriptive and prescriptive cognitions from one another, as was asserted by Frankfurt and Coady. We also provide a counterargument to Frankfurt and Coady's ethical concerns regarding the potential of Farnsworth's framework to enable militarism and instead assert its value for increasing peace and understanding. Finally, we address the relevance of "thick terms" for MI, highlighting their potential strengths and clinical weaknesses. We conclude by joining with Frankfurt and Coady in expressing our hopes for future research on the association between PTSD and MI. We argue that future research must go beyond defining content-level boundaries between the two constructs and instead grapple with the processes that give rise to them and the philosophical, empirical, and professional questions that they imply.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) ¿Qué debemos hacer con "términos contundentes"? Respuesta a la (s) autor (es) 'Aportando a la filosofía sobre el daño moral y TEPT' QUÉ PODEMOS HACER Respondemos al comentario de Frankfurt y Cody (de este número) sobre el marco descriptivo y prescriptivo para distinguir, parcialmente, entre el trastorno de estrés postraumático (TEPT) y el daño moral (Farnsworth, 2019). En su comentario, Frankfurt y Cody plantean inquietudes sobre la aplicación del enfoque filosófico del prescriptivismo de R. M. Hare (2014) al daño moral (DM) relacionado con el ejército y las posibles implicaciones filosóficas y éticas que pueden surgir. En esta respuesta, aclaramos que el marco descriptivo-prescriptivo de Farnsworth no está ligado ni alineado con el prescriptivismo de Hare y, como resultado, muchas de las críticas de Frankfurt y Cody se vuelven tangenciales al artículo original de Farnsworth. Continuamos para aclarar que el marco descriptivo-prescriptivo de Farnsworth no niega la utilidad de todas las terapias cognitivas para el daño moral, ni intenta separar las cogniciones descriptivas y prescriptivas por completo, como afirmaron Frankfurt y Cody. También proporcionamos un argumento en contra de las preocupaciones éticas de Frankfurt y Cody sobre el potencial del marco de Farnsworth para permitir el militarismo y, en cambio, afirmar su valor para aumentar la paz y la comprensión. Finalmente, abordamos la relevancia de los "términos contundentes" para el DM, destacando sus potenciales fortalezas y debilidades clínicas. Concluimos uniéndonos a Frankfurt y Cody para expresar nuestras esperanzas de futuras investigaciones sobre la asociación entre TEPT y DM. Argumentamos que la investigación futura debe ir más allá de definir límites a nivel de contenido entre las dos construcciones y, en su lugar, lidiar con los procesos que las originan y las preguntas filosóficas, empíricas y profesionales que implican.

Moving Moral Injury Into the Future With Functional Contextualism: A Response to Nash's "Unpacking Two Models for Understanding Moral Injury" (2019).

In his commentary on the Journal of Traumatic Stress special issue on moral injury (Vol. 32, Issue 3), Nash (2019) critiques both Farnsworth's (2019) descriptive-prescriptive framework for differentiating posttraumatic stress disorder (PTSD) from moral injury and Farnsworth, Drescher, Evans, and Walser's (2017) functional contextual definition of moral injury and related concepts. To make his arguments, Nash contrasts these two frameworks with the Navy and Marine Corps Combat Operational Stress Control (COSC) model wherein moral stressors are presumed to cause literal damage to intrapsychic structures. Unfortunately, in drawing his comparisons, Nash makes several misstatements that we feel are important to clarify. We respond to Nash's commentary by first identifying the proper sources for the critiqued frameworks and correctly locate Farnsworth et al.'s functional contextual definition of moral injury within the domain of third-wave cognitive behavioral therapies. We go on to compare and contrast the respective origins of the COSC and functional contextual models, noting important differences in their intended purposes. Next, we defend our model against Nash's critiques by highlighting how a functional contextual approach to moral injury (a) links with evolutionary science, (b) captures multiple levels of analysis, (c) is parsimonious, (d) serves diverse populations, (e) directly informs interventions, (f) promotes moral humility, and (g) decreases stigma while preserving client autonomy. In our conclusion, we recognize the value of the COSC model for its intended purposes while also encouraging deep and respectful dialogue among researchers and clinicians regarding the proposed benefits of the functional contextual model of moral injury.

Temporal Associations Between Moral Injury and Posttraumatic Stress Disorder Symptom Clusters in Military Veterans.

War zone veterans who experience posttraumatic stress disorder (PTSD) symptoms might struggle with co-occurring cognitive, emotional, and behavioral expressions of suffering that align with conceptual definitions of moral injury (MI). However, given that PTSD is a multidimensional condition, disentangling the apparent interplay with MI may inform clinical practice and research. This study incorporated a cross-lagged design to explore temporal associations between self- and other-directed outcomes related to MI and severity of DSM-5 PTSD symptom clusters while accounting for depressive symptoms. Drawing on the Expressions of Moral Injury Scale-Military Version in a community sample of 182 previously deployed veterans, MI-related outcomes were linked with severity of PTSD symptom clusters at two assessments spaced apart by 6 months, rs = .58-.62. Of possible models for conceptualizing the temporal nature of these associations, structural equation modeling analyses revealed a cross-lagged primary MI model best fit veterans' responses. Within this model, veterans' self-directed MI at Time 1 predicted greater PTSD symptoms at the 6-month follow-up. However, an equivalent cross-lagged path also emerged between Time 1 PTSD Cluster D symptoms and self-directed MI at Time 2, suggesting the value of a reciprocal MI model for this symptom domain. In contrast, other-directed outcomes of MI were not linked with PTSD in the presence of other variables. Overall, these findings support the prognostic value of assessing for MI-related outcomes among veterans who might be struggling with PTSD symptomatology, particularly with respect to self-directed problems associated with enduring moral distress.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Asociaciones temporales entre daño moral y grupos sintomáticos de TEPT en veteranos militares ASOCIACIONES TEMPORALES ENTRE DAÑO MORAL Y TEPT Los veteranos en zona de guerra que experimentan síntomas de trastorno de Estrés Postraumático (TEPT) pueden tener dificultades con las expresiones de sufrimiento cognitivas, emocionales y conductuales concomitantes que se alinean con las definiciones conceptuales de daño moral (DM). Sin embargo, dado que el TEPT es una condición multidimensional, desenredar la interacción aparente con el DM puede informar la práctica clínica y la investigación. Este estudio incorporo un diseño cruzado para explorar las asociaciones temporales entre los resultados auto-dirigidos y dirigidos por otros relacionados con el DM y la gravedad de los grupos sintomáticos de TEPT del DSM-5 mientras se toman en consideración los síntomas depresivos. Basándose en las Escala de Expresiones de Daño Moral - Versión Militar en una muestra comunitaria de 182 veteranos previamente desplazados, los resultados relacionados con DM estuvieron ligados con la severidad de los grupos sintomáticos de TEPT en las dos evaluaciones, espaciadas por 6 meses, rs = .58 -.62. De los posibles modelos para conceptualizar la naturaleza temporal de estas asociaciones, el análisis de modelos de ecuaciones estructurales revelo que un modelo de DM primario cruzado se adapta mejor a las respuestas de los veteranos. Dentro de este modelo, los veteranos con DM auto-dirigido en el momento 1 predijeron más síntomas de TEPT a los 6 meses de seguimiento. Sin embargo, tambien surgió un camino cruzado equivalente entre el tiempo 1 del grupo sintomático D de TEPT y DM auto-dirigido en el tiempo 2, sugiriendo el valor de un modelo de DM recíproco para este dominio de síntomas. En contraste, los resultados de DM dirigido a otros no estuvieron ligados con TEPT en la presencia de otras variables. En general, estos hallazgos apoyan el valor pronóstico de la evaluación de los resultados relacionados con DM entre veteranos que podrían estar luchando con sintomatología de TEPT, particularmente con respecto a los problemas auto-dirigidos asociados con sufrimiento moral duradero.

Development and evaluation of the Expressions of Moral Injury Scale-Military Version.

There is consensus that military personnel can encounter a far more diverse set of challenges than researchers and clinicians have historically appreciated. Moral injury (MI) represents an emerging construct to capture behavioural, social, and spiritual suffering that may transcend and overlap with mental health diagnoses (e.g., post-traumatic stress disorder and major depressive disorder). The Expressions of Moral Injury Scale-Military Version (EMIS-M) was developed to provide a reliable and valid means for assessing the warning signs of a MI in military populations. Drawing on independent samples of veterans who had served in a war-zone environment, factor analytic results revealed 2 distinct factors related to MI expressions directed at both self (9 items) and others (8 items). These subscales generated excellent internal consistency and temporal stability over a 6-month period. When compared to measures of post-traumatic stress disorder, major depressive disorder, and other theoretically relevant constructs (e.g., forgiveness, social support, moral emotions, and combat exposure), EMIS-M scores demonstrated strong convergent, divergent, and incremental validity. In addition, although structural equation modelling findings supported a possible general MI factor in Study 2, the patterns of associations for self- and other-directed expressions yielded evidence for differential validity with varying forms of forgiveness and combat exposure. As such, the EMIS-M provides a face valid, psychometrically validated tool for assessing expressions of apparent MI subtypes in research and clinical settings. Looking ahead, the EMIS-M will hopefully advance the scientific understanding of MI while supporting innovation for clinicians to tailor evidence-based treatments and/or develop novel approaches for addressing MI in their work.

Case Conceptualizing in Acceptance and Commitment Therapy for Moral Injury: An Active and Ongoing Approach to Understanding and Intervening on Moral Injury.

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.

Cultivating psychological flexibility to address religious and spiritual suffering in moral injury.

In the current paper, we aim to expand the dialogue about applying psychological flexibility processes to moral injury-related spiritual suffering using Acceptance and Commitment Therapy (ACT). Psychological flexibility is the process of practicing present moment awareness and openness to experiences of emotions and thoughts, while also choosing to engage in actions that are consistent with one's values. This open, aware, and engaged approach to life fits well with spiritual endeavors. We provide a framework and a case example illustrating how spiritual care providers and Chaplains can use psychological flexibility processes to target spiritual suffering in the context of moral injury.

Fear of emotion as a moderator between PTSD and firefighter social interactions.

Despite high levels of exposure to stress, questions remain regarding how social interactions and beliefs about emotion interact to influence posttraumatic stress disorder (PTSD) in firefighters. United States urban firefighters (N = 225) completed the Interpersonal Support Evaluation List, the Unsupportive Social Interactions Inventory, the Affective Control Scale, and the Posttraumatic Stress Disorder Checklist. Each independent variable predicted PTSD beyond variance accounted for by demographic variables. Additionally, fear of emotion emerged as the strongest individual predictor of PTSD and a moderator of the relation between social interactions and PTSD symptoms. These findings emphasize the importance of beliefs about emotion both in how these beliefs might influence the expression of PTSD symptoms, and in how the social networks of trauma survivors might buffer distress.

A contextual behavioral approach for responding to moral dilemmas in the age of COVID-19.

Prior pandemics and current news stories suggest that a "second pandemic" of potentially devastating mental health consequences will follow the COVID-19 pandemic. Given the changing contextual demands associated with the pandemic for many people, the mental health consequences of COVID-19 are likely to include exposure to a range of moral dilemmas. Such dilemmas may set the stage for the development of moral distress and moral injury in a broad range of contexts from the ER to the grocery store. In the current paper we offer an approach to responding to moral dilemmas presented by COVID-19. We propose a contextual behavioral model of moral injury that is relevant to those experiencing moral pain associated with the COVID-19 pandemic. Based on this model, we offer two different approaches to intervening on COVID-19-related moral dilemmas. First, we propose the use of Acceptance and Commitment Therapy for Moral Injury (ACT-MI) among individuals suffering from moral injury. Second, to intervene on moral dilemmas at the level of the group, we propose the use of the Prosocial intervention. We offer case examples describing ACT-MI and Prosocial to highlight how these interventions might be applied to moral-dilemma-related concerns during the COVID-19 pandemic and discuss implications for future research.

A commentary on moral injury among health care providers during the COVID-19 pandemic.

Although little is known about moral injury in nonmilitary populations, the COVID-19 pandemic has made it clear that moral injury's relevance extends beyond the battlefield. Health care providers are experiencing potentially morally injurious events that may violate their moral code or values, yet almost no research has been conducted on moral injury among health care providers to date. The purpose of this commentary is to describe the relevance of moral injury to health care providers and to spark a dialogue that motivates future research, prevention, and intervention. (PsycInfo Database Record (c) 2020 APA, all rights reserved).