Moral Injury: An Integrative Review.

Individuals who are exposed to traumatic events that violate their moral values may experience severe distress and functional impairments known as "moral injuries." Over the last decade, moral injury has captured the attention of mental health care providers, spiritual and faith communities, media outlets, and the general public. Research about moral injury, especially among military personnel and veterans, has also proliferated. For this article, we reviewed scientific research about moral injury. We identified 116 relevant epidemiological and clinical studies. Epidemiological studies described a wide range of biological, psychological/behavioral, social, and religious/spiritual sequelae associated with exposure to potentially morally injurious events. Although a dearth of empirical clinical literature exists, some authors debated how moral injury might and might not respond to evidence-based treatments for posttraumatic stress disorder (PTSD) whereas others identified new treatment models to directly address moral repair. Limitations of the literature included variable definitions of potentially morally injurious events, the absence of a consensus definition and gold-standard measure of moral injury as an outcome, scant study of moral injury outside of military-related contexts, and clinical investigations limited by small sample sizes and unclear mechanisms of therapeutic effect. We conclude our review by summarizing lessons from the literature and offering recommendations for future research.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Daño Moral: Una revisión integrativa REVISION INTEGRATIVA DE LA INVESTIGACION EN DAÑO MORAL Las personas que están expuestas a eventos traumáticos que violan sus valores morales pueden experimentar una angustia grave y discapacidades funcionales conocidas como "daño moral". En la última década, el daño moral ha captado la atención de proveedores de servicios de salud mental, comunidades espirituales y religiosas, medios de comunicación y el público en general. La investigación sobre daño moral, especialmente entre el personal militar y los veteranos, también ha proliferado. Para este artículo, revisamos la investigación científica sobre el daño moral. Se identificaron 116 estudios epidemiológicos y clínicos relevantes. Los estudios epidemiológicos describieron una amplia gama de secuelas biológicas, psicológicas / conductuales, sociales y religiosas / espirituales asociadas con la exposición a eventos potencialmente dañinos moralmente. Aunque existe una escasez de literatura clínica empírica, algunos autores debatieron cómo el daño moral podría y no podría responder a los tratamientos basados ​​en la evidencia para el trastorno de estrés postraumático (TEPT), mientras que otros identificaron nuevos modelos de tratamiento para abordar directamente la reparación moral. Las limitaciones de la literatura incluyeron definiciones de variables de eventos potencialmente perjudiciales desde el punto de vista moral, la ausencia de una definición consensuada y una medida de gold-estándar de daño moral y sus consecuencias, escaso estudio de daño moral fuera de contextos relacionados con el ejército e investigaciones clínicas limitadas por muestra de tamaño pequeños y mecanismos poco claros del efecto terapéutico. Concluimos nuestra revisión resumiendo las lecciones de la literatura y ofreciendo recomendaciones para futuras investigaciones.

Impact of Killing in War: A Randomized, Controlled Pilot Trial.

OBJECTIVE: The purpose of this pilot study was to test the effectiveness of Impact of Killing (IOK), a novel, cognitive-behavioral treatment (CBT) aimed at reducing mental health symptoms and functional impairment. METHOD: Participants were 33 combat Veterans with a posttraumatic stress disorder (PTSD) diagnosis who had completed trauma-focused psychotherapy and reported distress regarding killing or feeling responsible for the deaths of others in war. Veterans were randomized to either IOK treatment or a 6-week waitlist condition, after which Veterans could receive IOK. IOK is a 6- to 8-session, weekly, individual, CBT, lasting 60-90 minutes, and focused on key themes, including physiology of killing responses, moral injury, self-forgiveness, spirituality, making amends, and improved functioning. RESULTS: We found that compared to controls (N = 16), the IOK group (N = 17) experienced a significant improvement in PTSD symptoms, general psychiatric symptoms, and quality of life functional measures. Veterans who received IOK reported that the treatment was acceptable and feasible. CONCLUSION: These results provide preliminary evidence that Veterans can benefit from a treatment focused on the impact of killing after initial trauma therapy.

Pretreatment stabilization increases completion of trauma-focused evidence-based psychotherapies.

OBJECTIVE: Veterans with posttraumatic stress disorder (PTSD) initiate and complete cognitive processing therapy (CPT) and prolonged exposure (PE) at low rates within Veterans Health Administration (VHA) despite substantial dissemination and training. This study investigated how trauma-informed, skills-based treatment ("stabilization") administered before CPT and PE was related to initiation and completion of trauma-focused evidence-based psychotherapies (TF-EBPs). METHOD: Data were extracted from the VHA electronic medical record to identify veterans who initiated outpatient treatment in the PTSD Clinical Team (PCT) at a Veterans Affairs Health Care System. Treatment initiation was defined as three or more PCT visits with no prior PCT care for at least 18 months (N = 341). Before initiation of TF-EBP, veterans received either no stabilization or received individual and/or group stabilization. RESULTS: Twenty-eight percent of veterans without stabilization (n = 115) initiated TF-EBP, compared with 34% of veterans who completed individual-only stabilization (n = 82), and 10% of veterans who completed group-only stabilization (n = 29, p = .050). Compared with those with no stabilization, individual stabilization was associated with significantly higher TF-EBP completion (93% vs. 50%, p < .001). CPT completion was also significantly higher for veterans who received individual-only stabilization (90% vs. 43%, p = .001). Results for PE followed the same relationship, but did not reach significance (100% vs. 67%, p = .090). CONCLUSIONS: Findings suggest that individual stabilization may improve delivery of TF-EBPs in VHA settings by increasing TF-EBP completion without reducing initiation, while pretreatment with group-only stabilization may reduce initiation of TF-EBPs. Results inform how models of care can improve TF-EBP retention and completion among veterans with PTSD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Seeking Safety Pilot Outcome Study at Walter Reed National Military Medical Center.

Post-traumatic stress disorder (PTSD) and substance use disorder are two of the most prominent psychiatric disorders among military service members. Seeking Safety (SS) is an evidence-based behavioral therapy model for this comorbidity. This article reports results of a study of SS conducted in a military setting. Our pilot trial addressed outcomes, feasibility, and satisfaction. SS was conducted as is to evaluate its impact without adaptation for military culture. The sample was 24 outpatient service members (from the Army, Navy, Air Force, and Marines) with 33% minority representation. Inclusion criteria were current PTSD and/or SUD. Ten clinicians participated in this study after receiving SS training. Results showed significant improvements on most outcomes, including substance use on the Brief Addiction Monitor; PTSD symptoms on the PTSD Checklist-Military Version (total and criterion D); and the Trauma Symptom Checklist-40 (sexual abuse trauma index and anxiety subscale); functioning on the Sheehan Disability Scale (total and family subscale); psychopathology on the Zung Depression Scale total; the Behavior and Symptom Identification Scale (BASIS)-24 (total and subscales depression functioning, emotional liability, and psychosis); and the Brief Symptom Inventory-18 (total and anxiety subscale); and coping on the Coping Self-Efficacy Scale (total). Satisfaction was strong. Discussion includes methodology limitations and next steps.

Seeking Safety plus Exposure Therapy: an outcome study on dual diagnosis men.

This study arose out of a prominent clinical need: effective treatment for comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) in civilian men. This dual diagnosis is estimated to occur in up to 38% of men in substance abuse treatment, and generally portends a more severe clinical course than SUD alone. Clinical issues include self-harm, suicidality, perpetration of violence against others, and HIV risk behaviors. This study appears to be the first outcome trial to address a sample of civilian men with PTSD and SUD using manualized psychosocial treatment. It evaluates a novel combination treatment, Seeking Safety plus Exposure Therapy-Revised. The former is a coping skills treatment designed for PTSD and SUD; the latter is an adaptation of Foa's exposure therapy, modified for PTSD and SUD. In this small sample (n = 5) outpatient pilot trial, patients with current PTSD and current SUD were offered 30 sessions over five months, with the option to select how much of each type of treatment they preferred. Outcome results showed significant improvements in drug use; family/social functioning; trauma symptoms; anxiety; dissociation; sexuality; hostility; overall functioning; meaningfulness; and feelings and thoughts related to safety. Trends indicating improvement on 11 other outcome variables were also found. Treatment attendance, satisfaction, and alliance were extremely high. The need for further evaluation using more rigorous methodology is discussed.

Cognitive behavioral therapy for insomnia in posttraumatic stress disorder: a randomized controlled trial.

STUDY OBJECTIVES: Examine whether cognitive behavioral therapy for insomnia (CBT-I) improves sleep in posttraumatic stress disorder (PTSD) as well as nightmares, nonsleep PTSD symptoms, depression symptoms, and psychosocial functioning. DESIGN: RANDOMIZED CONTROLLED TRIAL WITH TWO ARMS: CBT-I and monitor-only waitlist control. SETTING: Department of Veterans Affairs (VA) Medical Center. PARTICIPANTS: Forty-five adults (31 females: [mean age 37 y (22-59 y)] with PTSD meeting research diagnostic criteria for insomnia, randomly assigned to CBT-I (n = 29; 22 females) or monitor-only waitlist control (n = 16; nine females). INTERVENTIONS: Eight-session weekly individual CBT-I delivered by a licensed clinical psychologist or a board-certified psychiatrist. MEASUREMENTS AND RESULTS: Measures included continuous monitoring of sleep with diary and actigraphy; prepolysomnography and postpolysomnography and Clinician-Administered PTSD Scale (CAPS); and pre, mid, and post self-report questionnaires, with follow-up of CBT-I participants 6 mo later. CBT-I was superior to the waitlist control condition in all sleep diary outcomes and in polysomnography-measured total sleep time. Compared to waitlist participants, CBT-I participants reported improved subjective sleep (41% full remission versus 0%), disruptive nocturnal behaviors (based on the Pittsburgh Sleep Quality Index-Addendum), and overall work and interpersonal functioning. These effects were maintained at 6-mo follow-up. Both CBT-I and waitlist control participants reported reductions in PTSD symptoms and CAPS-measured nightmares. CONCLUSIONS: Cognitive behavioral therapy for insomnia (CBT-I) improved sleep in individuals with posttraumatic stress disorder, with durable gains at 6 mo. Overall psychosocial functioning improved following CBT-I. The initial evidence regarding CBT-I and nightmares is promising but further research is needed. Results suggest that a comprehensive approach to treatment of posttraumatic stress disorder should include behavioral sleep medicine. CLINICAL TRIAL INFORMATION: TRIAL NAME: Cognitive Behavioral Treatment Of Insomnia In Posttraumatic Stress Disorder. URL: http://clinicaltrials.gov/ct2/show/NCT00881647. REGISTRATION NUMBER: NCT00881647.

Treatment utilization by women with PTSD and substance dependence.

This study reports the treatment utilization of 77 women with post-traumatic stress disorder (PTSD) and substance dependence in three areas: lifetime utilization, past thirty days utilization, and perceived helpfulness/harmfulness of current treatments. Results indicated high lifetime treatment utilization overall, yet, for one subgroup, no treatment exposure at all. Most current treatments were focused on SA, in striking contrast to participants' preference: over 80% would choose either combined SA/PTSD treatment or PTSD-alone treatment. The most common treatments were individual therapy, medication, and hospitalization. Some treatments were perceived as harmful by some participants. The discussion addresses how to help patients obtain needed treatments.