Partnership building for scale-up in the Veteran Sponsorship Initiative: Strategies for harnessing collaboration to accelerate impact in suicide prevention.

OBJECTIVE: To evaluate the implementation and trust-building strategies associated with successful partnership formation in scale-up of the Veteran Sponsorship Initiative (VSI), an evidence-based suicide prevention intervention enhancing connection to U.S. Department of Veterans Affairs (VA) and other resources during the military-to-civilian transition period. DATA SOURCES AND STUDY SETTING: Scaling VSI nationally required establishing partnerships across VA, the U.S. Department of Defense (DoD), and diverse public and private Veteran-serving organizations. We assessed partnerships formalized with a signed memorandum during pre- and early implementation periods (October 2020-October 2022). To capture implementation activities, we conducted 39 periodic reflections with implementation team members over the same period. STUDY DESIGN: We conducted a qualitative case study evaluating the number of formalized VSI partnerships alongside directed qualitative content analysis of periodic reflections data using Atlas.ti 22.0. DATA COLLECTION/EXTRACTION METHODS: We first independently coded reflections for implementation strategies, following the Expert Recommendations for Implementing Change (ERIC) taxonomy, and for trust-building strategies, following the Theoretical Model for Trusting Relationships and Implementation; a second round of inductive coding explored emergent themes associated with partnership formation. PRINCIPAL FINDINGS: During this period, VSI established 12 active partnerships with public and non-profit agencies. The VSI team reported using 35 ERIC implementation strategies, including building a coalition and developing educational and procedural documents, and trust-building strategies including demonstrating competence and credibility, frequent interactions, and responsiveness. Cultural competence in navigating DoD and VA and accepting and persisting through conflict also appeared to support scale-up. CONCLUSIONS: VSI's partnership-formation efforts leveraged a variety of implementation strategies, particularly around strengthening stakeholder interrelationships and refining procedures for coordination and communication. VSI implementation activities were further characterized by an intentional focus on trust-building over time. VSI's rapid scale-up highlights the value of partnership formation for achieving coordinated interventions to address complex problems.

A controlled trial of adaptive disclosure-enhanced to improve functioning and treat posttraumatic stress disorder.

OBJECTIVE: This is a randomized controlled trial (NCT03056157) of an enhanced adaptive disclosure (AD) psychotherapy compared to present-centered therapy (PCT; each 12 sessions) in 174 veterans with posttraumatic stress disorder (PTSD) related to traumatic loss (TL) and moral injury (MI). AD employs different strategies for different trauma types. AD-Enhanced (AD-E) uses letter writing (e.g., to the deceased), loving-kindness meditation, and bolstered homework to facilitate improved functioning to repair TL and MI-related trauma. METHOD: The primary outcomes were the Sheehan Disability Scale (SDS), evaluated at baseline, throughout treatment, and at 3- and 6-month follow-ups (Brief Inventory of Psychosocial Functioning was also administered), the Clinician-Administered PTSD Scale (CAPS-5), the Dimensions of Anger Reactions, the Revised Conflict Tactics Scale, and the Quick Drinking Screen. RESULTS: There were statistically significant between-group differences on two outcomes: The intent-to-treat (ITT) mixed-model analysis of SDS scores indicated greater improvement from baseline to posttreatment in the AD-E group (d = 2.97) compared to the PCT group, d = 1.86; -2.36, 95% CI [-3.92, -0.77], t(1,510) = -2.92, p < .001, d = 0.15. Twenty-one percent more AD-E cases made clinically significant changes on the SDS than PCT cases. From baseline to posttreatment, AD-E was also more efficacious on the CAPS-5 (d = 0.39). These differential effects did not persist at follow-up intervals. CONCLUSION: This was the first psychotherapy of veterans with TL/MI-related PTSD to show superiority relative to PCT with respect to functioning and PTSD, although the differential effect sizes were small to medium and not maintained at follow-up. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Supporting servicemembers and veterans during their transition to civilian life using certified sponsors: A three-arm randomized controlled trial.

Transitioning servicemembers and veterans (TSMVs) face difficulties throughout their reintegration to civilian life, including challenges with employment, poor social connection, and elevated risk for suicide. To meet the needs of this high-risk population, national initiatives have leveraged community-based interventions. Authors conducted a three-arm randomized controlled trial (n = 200) to evaluate two community-based interventions. The first, Team Red, White, and Blue (RWB), connects TSMVs to their community through physical/social activities. The second, Expiration Term of Service Sponsorship Program (ETS-SP) provides one-on-one certified sponsors to TSMVs who provide support during the reintegration process. TSMVs were assessed at baseline, 3, 6, and 12 months. The primary hypothesis was not supported as reintegration difficulties and social support were not significantly different for participants randomly assigned to the two community-based interventions (Arm-2/RWB and Arm-3/RWB + ETS-SP), when the data from the separate arms were collapsed and combined, compared to the waitlist. The results did support the secondary hypothesis as Arm-3/RWB + ETS-SP had less reintegration difficulties over 12 months and initially had more social support compared to Arm-2/RWB, which suggest that augmenting interventions with sponsors outperforms participation in community-based interventions alone. Overall, the results show some limitations of the studied community-based interventions, as implemented and researched within this study. The authors identified factors that may have contributed to the null findings for the primary hypothesis, which can be addressed in future studies, such as addressing the unique needs of TSMVs, enrolling TSMVs into interventions prior to military discharge, measuring and improving participation levels, and providing stepped-care interventions based on risk levels. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Leveraging available metadata in VA PTSD clinics and generating benchmarks for clinically significant change.

OBJECTIVE: Measurement-based care is designed to track symptom levels during treatment and leverage clinically significant change benchmarks to improve quality and outcomes. Though the Veterans Health Administration promotes monitoring progress within posttraumatic stress disorder (PTSD) clinical teams, actionability of data is diminished by a lack of population-based benchmarks for clinically significant change. We reported the state of repeated measurement within PTSD clinical teams, generated benchmarks, and examined outcomes based on these benchmarks. METHOD: PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition data were culled from the Corporate Data Warehouse from the pre-COVID-19 year for Veterans who received at least eight sessions in 14 weeks (episode of care [EOC] cohort) and those who received sporadic care (modal cohort). We used the Jacobson and Truax (1991) approach to generate clinically significant change benchmarks at clinic, regional, and national levels and calculated the frequency of cases that deteriorated, were unchanged, improved, or probably recovered, using our generated benchmarks and benchmarks from a recent study, for both cohorts. RESULTS: Both the number of repeated measurements and the cases who had multisession care in the Corporate Data Warehouse were very low. Clinically significant change benchmarks were similar across locality levels. The modal cohort had worse outcomes than the EOC cohort. CONCLUSIONS: National benchmarks for clinically significant change could improve the actionability of assessment data for measurement-based care. Benchmarks created using data from Veterans who received multisession care had better outcomes than those receiving sporadic care. Measurement-based care in PTSD clinical teams is hampered by low rates of repeated assessments of outcome. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium.

Potentially morally injurious events (PMIEs) entail acts of commission (e.g., cruelty, proscribed or prescribed violence) or omission (e.g., high stakes failure to protect others) and bearing witness (e.g., to grave inhumanity, to the gruesome aftermath of violence), or being the victim of others' acts of commission (e.g., high stakes trust violations) or omission (e.g., being the victim of grave individual or systemic failures to protect) that transgress deeply held beliefs and expectations about right and wrong. Although there is a proliferation of interest in moral injury (the outcome associated with exposure to PMIEs), there has been no operational definition of the putative syndrome and no standard assessment scheme or measure, which has hampered research and care in this area. We describe an international effort to define the syndrome of moral injury and develop and validate the Moral Injury Outcome Scale (MIOS) in three stages. To ensure content validity, in Stage I, we conducted interviews with service members, Veterans, and clinicians/Chaplains in each country, inquiring about the lasting impact of PMIEs. Qualitative analysis yielded six operational definitions of domains of impact of PMIEs and components within domains that establish the parameters of the moral injury syndrome. From the domain definitions, we derived an initial pool of scale items. Stage II entailed scale refinement using factor analytic methods, cross-national invariance testing, and internal consistency reliability analyses of an initial 34-item MIOS. A 14-item MIOS was invariant and reliable across countries and had two factors: Shame-Related (SR) and Trust-Violation-Related (TVR) Outcomes. In Stage III, MIOS total and subscale scores had strong convergent validity, and PMIE-endorsers had substantially higher MIOS scores vs. non-endorsers. We discuss and contextualize the results and describe research that is needed to substantiate these inaugural findings to further explore the validity of the MIOS and moral injury, in particular to examine discriminant and incremental validity.

Partnered implementation of the veteran sponsorship initiative: protocol for a randomized hybrid type 2 effectiveness-implementation trial.

BACKGROUND: The USA is undergoing a suicide epidemic for its youngest Veterans (18-to-34-years-old) as their suicide rate has almost doubled since 2001. Veterans are at the highest risk during their first-year post-discharge, thus creating a "deadly gap." In response, the nation has developed strategies that emphasize a preventive, universal, and public health approach and embrace the value of community interventions. The three-step theory of suicide suggests that community interventions that reduce reintegration difficulties and promote connectedness for Veterans as they transition to civilian life have the greatest likelihood of reducing suicide. Recent research shows that the effectiveness of community interventions can be enhanced when augmented by volunteer and certified sponsors (1-on-1) who actively engage with Veterans, as part of the Veteran Sponsorship Initiative (VSI). METHOD/DESIGN: The purpose of this randomized hybrid type 2 effectiveness-implementation trial is to evaluate the implementation of the VSI in six cities in Texas in collaboration with the US Departments of Defense, Labor and Veterans Affairs, Texas government, and local stakeholders. Texas is an optimal location for this large-scale implementation as it has the second largest population of these young Veterans and is home to the largest US military installation, Fort Hood. The first aim is to determine the effectiveness of the VSI, as evidenced by measures of reintegration difficulties, health/psychological distress, VA healthcare utilization, connectedness, and suicidal risk. The second aim is to determine the feasibility and potential utility of a stakeholder-engaged plan for implementing the VSI in Texas with the intent of future expansion in more states. The evaluators will use a stepped wedge design with a sequential roll-out to participating cities over time. Participants (n=630) will be enrolled on military installations six months prior to discharge. Implementation efforts will draw upon a bundled implementation strategy that includes strategies such as ongoing training, implementation facilitation, and audit and feedback. Formative and summative evaluations will be guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework and will include interviews with participants and periodic reflections with key stakeholders to longitudinally identify barriers and facilitators to implementation. DISCUSSION: This evaluation will have important implications for the national implementation of community interventions that address the epidemic of Veteran suicide. Aligned with the Evidence Act, it is the first large-scale implementation of an evidence-based practice that conducts a thorough assessment of TSMVs during the "deadly gap." TRIAL REGISTRATION: ClinicalTrials.gov ID number: NCT05224440 . Registered on 04 February 2022.

Exploring the longitudinal clustering of lifestyle behaviors, social determinants of health, and depression.

Lifestyle behaviors such as exercise, sleep, smoking, diet, and social interaction are associated with depression. This study aimed to model the complex relationships between lifestyle behaviors and depression and among the lifestyle behaviors. Data from three waves of the Midlife in the United States study were used, involving 6898 adults. Network models revealed associations between the lifestyle behaviors and depression, with smoker status being strongly associated with depression. Depression, smoker status, age, time, and exercise were some of the most central components of the networks. Future lifestyle intervention research might prioritize specific behaviors based on these associations and centrality indices.

Resilience predicts posttraumatic cognitions after a trauma reminder task and subsequent positive emotion induction among veterans with PTSD.

[Correction Notice: An Erratum for this article was reported in Vol 14(S1) of Psychological Trauma: Theory, Research, Practice, and Policy (see record 2022-45004-002). In the article (https://doi.org/10.1037/tra0001143), the Supplemental materials link was missing from the title page. All versions of this article have been corrected.] Objective: Posttraumatic stress disorder (PTSD) is a common problem for veterans. Resilience, the tendency to bounce back from difficult circumstances, is negatively associated with posttraumatic cognitions (PTCs) among individuals with a history of trauma, and it may be important to understand responses to trauma reminders. METHOD: Using a quasi-experimental design, we examined the association between trait resilience and state PTCs in veterans with PTSD (n = 47, Mage = 48.60, 91.8% male) at two points: following a written trauma narrative exposure (Time 1 [T1]), and following a subsequent positive distraction task (i.e., brief, positive video; Time 2 [T2]). RESULTS: After controlling for PTSD symptom severity and combat exposure, resilience was negatively associated with PTCs at T1 (ΔR2 = .19) and T2 (ΔR2 = .13). However, resilience was a poor predictor of change in PTCs from T1 to T2. We also examined the relationship between resilience and subtypes of PTCs: resilience was associated with negative views of the self (T1, ΔR2 = .24) but not negative views of the world or self-blame (T1, ΔR2s ≤ .07); these results were consistent at T2. CONCLUSIONS: Thus, resilience may attenuate negative trauma-related cognitions after trauma recall; however, this study was not designed to test causal pathways. Future research could examine whether resilience-building exercises reduce negative PTCs after trauma reminders among veterans. Additional research is needed to generalize to other trauma-exposed populations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Social Interaction Within a Trauma-Exposed Population During the Early Phase of COVID-19.

The novel coronavirus (COVID-19) has led to significant stressors and shifts in social life, yet social interactions experienced by people with trauma exposure during the COVID pandemic is largely unknown. This study assessed frequency of interactions, social support given and received, and prosocial behavior using online survey methods (N=1049). We examined differences in experiences across three groups: no trauma exposure, trauma-exposed with low PTSD symptoms, and trauma-exposed with high PTSD symptoms. We also explored correlations between social interactions and PTSD symptom clusters. Results indicated significant differences across groups and the high PTSD group reported stronger associations between social interaction variables and symptom clusters, on average.

Distinguishing the Effects of Life Threat, Killing Enemy Combatants, and Unjust War Events in U.S. Service Members.

Although previous studies have identified behavioral health risks associated with combat exposure, it is unclear which types of combat events are associated with these risks, particularly regarding contrasts among the risks associated with life-threatening experiences, killing combatants, and exposure to unjust war events, such as killing a noncombatant or being unable to help civilian women and children. In the present study, we examined surveys from 402 soldiers following deployment (i.e., baseline) and again 13 months later (i.e., Year 1). Regression analyses were conducted across a range of behavioral health (e.g., posttraumatic stress disorder, depression, suicide ideation, anxiety, somatic, insomnia, aggression) and benefit-finding measures, each controlling for two combat event categories while assessing the predictive utility of a third. The results suggested that life-threatening events were associated with poor behavioral health at baseline, relative risk (RR) = 10.00, but not at Year 1, RR = 2.67. At both baseline and Year 1, killing enemy combatants was not associated with behavioral health, RRs = 1.67-3.33, but was positively associated with benefit-finding, RRs = 26.67-40.00. Exposure to unjust war events was associated with a transdiagnostic pattern of behavioral health symptoms at baseline, RR = 40.00, and Year 1, RR = 23.33. Overall, the results suggest unjust war event exposure is particularly injurious, above and beyond exposure to other combat-related events. Future research can build on these findings to develop clearer descriptions of the combat events that might place service members at risk for moral injury and inform the development of assessment and treatment options.

Low Incidence of Death and Renal Failure in United States Military Service Members Hospitalized with Exertional Heat Stroke: A Retrospective Cohort Study.

INTRODUCTION: The goal of the current study was to characterize the rate and estimate associated mortality and morbidity of exertional heat stroke (EHS) in U.S. military service members. MATERIALS AND METHODS: The current study was a retrospective cohort medical chart review study of all active-duty U.S. military service members, hospitalized with EHS at any MTF in the world between January1, 2007 and July 1, 2014. Enrolled patients were identified by altered mental status and elevated temperatures associated with physical exercise. RESULTS: Out of 607 service members with an International Classification of Disease code indicating any type of heat injury, 48 service members met inclusion criteria for EHS. Core temperature was M = 105.8°F (41°C), standard deviation = 1.43, 90% were diagnosed with EHS prior to hospitalization, and 71% received prehospital cooling. Meantime to normothermia post-hospitalization was 56 minutes (standard deviation = 79.28). Acute kidney injury was diagnosed in 40% of patients although none developed hyperkalemia or required dialysis. Disseminated intravascular coagulation was rare (4%, n = 2) and overall observed mortality was very low (2%, n = 1). CONCLUSION: EHS is aggressively identified and treated in U.S. Military Treatment Facilities. Mortality and morbidity were strikingly low.

Pre- to Posttreatment Changes in Trauma-Cued Negative Emotion Mediate Improvement in Posttraumatic Stress Disorder, Depression, and Impulsivity.

Posttraumatic stress disorder (PTSD) is characterized by strong negative emotions, often in response to trauma cues or reminders. Subsequent emotion regulation strategies impact the maintenance of PTSD symptoms and other trauma-related outcomes (depression, substance use). This study aimed to examine a range of trauma-cued emotions to enhance our understanding of changes following treatment and their potential role in improving relevant outcomes. Participants included 67 veterans diagnosed with PTSD and a substance use disorder who completed a dual diagnosis residential program that used cognitive processing therapy. At pre- and posttreatment, we measured 8 negative emotions following a trauma recall and PTSD symptoms, depressive symptoms, and negative urgency (impulsivity following negative emotions) as treatment outcomes. We used t-tests to assess changes at posttreatment and a within-subjects mediational analysis to test whether changes in trauma-cued emotions mediated treatment outcomes. Participants reported moderate, significant decreases for 5 emotions at posttreatment: anger at self, disgust at self, fear, guilt, and sadness (d ≥ 0.50), whereas nonsignificant changes were found for anger at others, disgust at others, and shame. Mediation analyses indicated greater reductions in trauma-cued sadness had a significant indirect effect on improvement in PTSD symptoms, depressive symptoms, and negative urgency. Reductions in disgust at self and fear also demonstrated a significant indirect effect on depressive symptom improvement. In this dual diagnosis program, veterans reported a significant reduction in some, but not all, trauma-cued emotions, and improvements in only select emotions accounted for a significant portion of improvement in relevant treatment outcomes.

SOCIAL ENGAGEMENT EARLY IN THE U.S. COVID-19 CRISIS: EXPLORING SOCIAL SUPPORT AND PROSOCIAL BEHAVIOR BETWEEN THOSE WITH AND WITHOUT DEPRESSION OR ANXIETY IN AN ONLINE SAMPLE.

INTRODUCTION: Social distancing and sheltering-in-place mitigate the physical health risks of the novel coronavirus (COVID-19); however, there are concerns about the impact on mental health and social engagement. METHODS: We used data from a U.S.-based online survey (March 2020) to examine patterns of social support and prosocial behavior, explore differences between people with and without depression or anxiety, and explore correlates of social engagement in both groups, including symptom severity in the clinical group. RESULTS: The clinical group reported greater social engagement. In both groups, social engagement was positively associated with COVID-19-related worry and trait moral elevation; mindfulness was positively associated with all outcomes for the clinical group only. Social interaction frequency had little influence on outcomes. Depressive symptom severity was positively associated with all outcomes, whereas anxiety was negatively associated with prosocial behavior. DISCUSSION: These findings highlight how social engagement was experienced early in the U.S. COVID-19 crisis.

Bringing Philosophy to Bear on Moral Injury and Posttraumatic Stress Disorder Construct Validation: Commentary on Farnsworth (2019).

Farnsworth (2019) proposed that posttraumatic stress disorder (PTSD) and moral injury (MI) can be differentiated using DSM-5 PTSD's Criteria D. It was suggested that PTSD cognitions are descriptions about what the world is like whose accuracy can be targeted by cognitive therapies, whereas MI cognitions are prescriptions about what the world should be like, which cannot be assessed for truth or falsehood and so are unsuitable for cognitive therapies. We believe that this appeal to the is/ought distinction distorts the therapeutic challenge, and misconceptualizes moral thinking as manifested only in thin terms such as "ought/should." In practical usage, it is unlikely that when people express cognitions they are only describing the world and not evaluating it as well. In this commentary, we will critique the prescriptivist view of trauma, suggest the importance of "thick terms," and reconsider the purported differences between MI and PTSD. MI might be meaningfully different from PTSD, but it is premature to differentiate these constructs based on DSM-5's Criteria D. A trauma theory that accounts for the interwoven descriptive and evaluative, cognitive as well as affective, elements of traumatic experiences will clarify both the PTSD diagnosis and MI model and improve treatment development and clinical care.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Aportando la filosofía sobre el daño moral y la validación de construcciones de TEPT: Comentario sobre Farnsworth (2019) COMENTARIO SOBRE FARNSWORTH (2019) Farnsworth (2019) propuso que el Trastorno de Estrés Postraumático (TEPT) y el daño moral (DM) se pueden diferenciar utilizando los Criterios D del TEPT del DSM-5. Se sugiere que las cogniciones del TEPT son descripciones sobre cómo es el mundo cuya precisión puede ser abordada por las terapias cognitivas, mientras que las cogniciones de DM son prescripciones sobre cómo debería ser el mundo, que no pueden ser evaluadas por la verdad o la falsedad y, por lo tanto, no son adecuadas para las terapias cognitivas. Creemos que esta apelación a la distinción es/debería distorsiona el desafío terapéutico, y malinterpreta el pensamiento moral como se manifiesta solo en términos ligeros como "debe / debería". En el uso práctico, es poco probable que cuando las personas expresan cogniciones solo sean describiendo el mundo y no evaluándolo también. En este comentario, criticaremos la visión prescriptivista del trauma, sugeriremos la importancia de los términos contundentes y reconsideraremos las supuestas diferencias entre el DM y el TEPT. El DM podría ser significativamente diferente del TEPT, pero es prematuro diferenciar estas construcciones basados en los Criterios D del DSM-5. Una teoría del trauma que considera los elementos entrelazados descriptivos y evaluativos, cognitivos y afectivos de las experiencias traumáticas aclararán tanto el diagnóstico de TEPT como el modelo de DM y mejorarán el desarrollo del tratamiento y la atención clínica.

Online expressive writing intervention for reintegration difficulties among veterans: Who is most likely to benefit?

OBJECTIVE: Some veterans may benefit from psychosocial interventions to facilitate reintegration and prevent chronic impairments following discharge from the service. In a randomized controlled trial, an online expressive writing intervention for Iraq and Afghanistan War veterans with reintegration difficulties reduced distress relative to control conditions, albeit with small between-group effect sizes (Sayer, Noorbaloochi et al., 2015). The aims of this study were to further explore changes in distress severity in the parent study's experimental group by identifying subgroups with similar trajectories and examining predictors of those trajectories. METHOD: We used latent class growth modeling to identify trajectories of change in distress among veterans randomized into expressive writing (N = 508). We also tested six predictors of trajectory membership: baseline probable PTSD, social support, combat exposure, sex, VA user status, and active-duty versus National Guard/Reserve status. The sample was mostly White, middle-aged, Army veterans deployed from active duty, all of whom reported reintegration difficulties. RESULTS: A four-class model, with the following classes, best fit the data: Low Baseline Distress-Moderate Decrease (60%; Cohen's d = -0.69), Moderate Baseline Distress-No Change (25%; Cohen's d = -0.16), Severe Baseline Distress-Small Increase (10%; Cohen's d = 0.23), and Severe Baseline Distress-Very Large Decrease (5%; Cohen's d = -4.80). Veterans without probable PTSD, with less combat exposure, and with higher social support were more likely to be in classes with decreasing distress. CONCLUSION: Analyses revealed several subgroups with unique patterns of change. Non-therapist-assisted expressive writing may be most suitable for veterans with less complex psychosocial problems. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Predictors of recovery from post-deployment posttraumatic stress disorder symptoms in war veterans: The contributions of psychological flexibility, mindfulness, and self-compassion.

Posttraumatic stress disorder (PTSD) is a major challenge among war veterans. This study assessed the contribution of several interrelated, modifiable psychosocial factors to changes in PTSD symptom severity among combat-deployed post-9/11 Veterans. Data were drawn from a longitudinal study of predictors of mental health and functional outcomes among U.S. Iraq and Afghanistan war Veterans (N = 117). This study assessed the unique contribution of psychological flexibility, mindfulness, and self-compassion to PTSD recovery, after accounting for established predictors of PTSD chronicity, including combat exposure, alcohol use problems, and traumatic brain injury. PTSD symptom severity was assessed using a clinician-administered interview, and PTSD recovery was defined as the change in symptom severity from lifetime worst severity, measured at baseline, to current severity at one-year follow-up. A mindful awareness latent factor comprised of all three variables measured at baseline predicted PTSD recovery beyond the other predictors of PTSD chronicity (f2 = 0.30, large effect). Each construct predicted PTSD recovery when tested individually. When tested simultaneously, self-compassion, but not mindfulness or psychological flexibility, predicted PTSD recovery. These findings suggest that mindful awareness of emotional distress predicts recovery from PTSD symptoms in war veterans, which supports the utility mindfulness-based interventions in promoting post-trauma recovery.

Mechanisms of Moral Injury Following Military Sexual Trauma and Combat in Post-9/11 U.S. War Veterans.

Objective: Moral injury may result from perpetration-based and betrayal-based acts that violate deeply held norms; however, researchers and clinicians have little guidance about the moral injury syndrome's specific developmental pathways following morally injurious events. The present study's objective was to examine the direct and indirect pathways proposed in a frequently cited model of moral injury (1) in relation to two types of military-related traumas [experiencing military sexual trauma (MST) and combat exposure]. Methods: Secondary analyses were conducted within a sample of post-9/11 veterans at a Southwestern Veterans Health Care System (N = 310) across two time-points. Structural equation modeling tested the direct and indirect pathways from MST and combat to a PTSD-depression factor via betrayal, perpetration, guilt, and shame. Results: Betrayal accounted for the association between MST and PTSD-depression (ß = 0.10, p < 0.01, 95% CI = 0.01 - 0.11) and perpetration accounted for the association between combat and PTSD-depression (ß = 0.07, p < 0.05, 95% CI = 0.02 - 0.14). The indirect path from combat to shame to PTSD-depression was significant (ß = 0.16, p < 0.01, 95% CI = 0.07 - 0.28) but the path through guilt was not. The specific indirect paths through perpetration or betrayal to shame or guilt were non-significant. Conclusions: Betrayal and perpetration are associated with PTSD-depression following MST and combat. Results suggest multiple pathways of moral injury development following different military traumas and morally injurious events. Implications for moral injury conceptualization and treatment are discussed.

The influence of mindfulness, self-compassion, psychological flexibility, and posttraumatic stress disorder on disability and quality of life over time in war veterans.

OBJECTIVES: Posttraumatic stress disorder (PTSD) strongly predicts greater disability and lower quality of life (QOL). Mindfulness-based and other third-wave behavior therapy interventions improve well-being by enhancing mindfulness, self-compassion, and psychological flexibility. We hypothesized that these mechanisms of therapeutic change would comprise a single latent factor that would predict disability and QOL after accounting for PTSD symptom severity. METHOD: Iraq and Afghanistan war veterans (N = 117) completed a study of predictors of successful reintegration. Principal axis factor analysis tested whether mindfulness, self-compassion, and psychological flexibility comprised a single latent factor. Hierarchical regression tested whether this factor predicted disability and QOL 1 year later. RESULTS: Mindfulness, self-compassion, and psychological flexibility comprised a single factor that predicted disability and QOL after accounting for PTSD symptom severity. PTSD symptoms remained a significant predictor of disability but not QOL. CONCLUSIONS: Targeting these mechanisms may help veterans achieve functional recovery, even in the presence of PTSD symptoms.

Indirect Relations Between Transgressive Acts and General Combat Exposure and Moral Injury.

INTRODUCTION: Moral injury describes the deleterious effects of acts of commission (e.g., killing noncombatants), omission (e.g., failing to prevent a massacre), or betrayal (i.e., by a trusted authority figure) during military service that transgress accepted behavioral boundaries and norms. Transgressive acts are proposed to lead to a guilt- and shame-based syndrome consisting of post-traumatic stress disorder (PTSD) symptoms, demoralization, self-handicapping, and self-injury. In this study, we tested a frequently cited model of moral injury and assessed the associations between potentially transgressive acts, moral injury outcomes, and guilt and fear. Additionally, we sought to clarify the relative contribution of transgressive and nontransgressive/general combat exposure to moral injury. On the basis of previous research and theory, we anticipated that the transgressive acts would be related to outcomes through guilt and that nontransgressive combat exposure would be related to outcomes through fear. MATERIALS AND METHODS: Secondary analysis was conducted on data from a sample of combat-exposed male veterans at a Midwestern Veterans Affairs (VA) medical center (N = 190) who participated in a larger parent study on postdeployment readjustment. Structural equation modeling was used to test the pathways from transgressive and nontransgressive combat exposure to PTSD symptoms and suicidality through combat-related guilt and combat-related fear. The institutional review boards of the Midwestern VA medical center and the university of the affiliated researchers approved the study. RESULTS: In total, 38% (n = 72) of the sample reported a potentially transgressive act as one of their three worst traumatic events. The most common potentially transgressive act was killing an enemy combatant (17%; n = 32). In structural equation modeling analyses. potentially transgressive acts were indirectly related to both suicidality (ß = 0.09, p < 0.01) and PTSD symptoms (ß = 0.06, p < 0.05) through guilt. General combat exposure was indirectly related to PTSD through fear, ß = 0.19, p < 0.01. Combat exposure was not directly or indirectly related to suicidality. CONCLUSION: Overall, these findings suggest that veterans with a history of potentially transgressive acts may present to the VA with a constellation of symptoms that are associated with combat-related guilt. Transgressive acts were identified using a qualitative approach, allowing a broader sampling of this domain. Results were limited by the use of self-report data and by gathering data from participants who were Veterans seeking compensation and pension evaluations for PTSD. The clinical implications suggest that focusing on fear-related outcomes and ignoring guilt- and shame-based reactions may lead to an incomplete case conceptualization. Clinicians working with veterans with moral injury are encouraged to prepare themselves for the discomfiting therapeutic experiences of bearing witness to and empathizing with clients' memories of their actions, which may include atrocities. Effective and empathic treatments that address the guilt and shame associated with transgressive acts are needed to adequately care for returning veterans.