A functional approach to defining and repairing moral injury: Evidence, change agents, clinical strategies, and lessons learned.

This is a conceptual overview of a premeeting institute (PMI) I presented at the 39th International Society for Traumatic Stress Studies (ISTSS) annual meeting in November 2023 entitled, "A Functional Approach to Repairing Moral Injury and Traumatic Loss in Context: Evidence, Change Agents, Clinical Strategies, and Lessons Learned." This paper was invited by the co-chairs of the Scientific Program Committee, Isaac Galatzer-Levy and Katharina Schultebraucks. I first describe the aims of the PMI and then summarize the foundational assumptions that led me to expand adaptive disclosure and create adaptive disclosure-enhanced (AD-E). The foundational assumptions are that (a) moral injury is a unique measurable potential clinical problem, (b) moral injury damages the sustaining building blocks to personal and collective humanity, and (c) repairing moral injury requires corrective humanizing and virtuous experiences and connections. I then provide an overview of AD-E and describe two new change agents- loving-kindness meditation and letter writing-that augment the original AD in service of promoting corrective experiences in the social world that are valued, valuing, and promote the experience of belonging.

Mechanisms of change in posttraumatic headache-related disability: A mediation model.

OBJECTIVE: To explore whether the association between change in headache management self-efficacy and posttraumatic headache-related disability is partially mediated by a change in anxiety symptom severity. BACKGROUND: Many cognitive-behavioral therapy treatments for headache emphasize stress management, which includes anxiety management strategies; however, little is currently known about mechanisms of change in posttraumatic headache-related disability. Increasing our understanding of mechanisms could lead to improvements in treatments for these debilitating headaches. METHODS: This study is a secondary analysis of veterans (N = 193) recruited to participate in a randomized clinical trial of cognitive-behavioral therapy, cognitive processing therapy, or treatment as usual for persistent posttraumatic headache. The direct relationship between headache management self-efficacy and headache-related disability, along with partial mediation through change in anxiety symptoms was tested. RESULTS: The mediated latent change direct, mediated, and total pathways were statistically significant. The path analysis supported a significant direct pathway between headache management self-efficacy and headache-related disability (b = -0.45, p < 0.001; 95% confidence interval [CI: -0.58, -0.33]). The total effect of change of headache management self-efficacy scores on change in Headache Impact Test-6 scores was significant with a moderate-to-strong effect (b = -0.57, p = 0.001; 95% CI [-0.73, -0.41]). There was also an indirect effect through anxiety symptom severity change (b = -0.12, p = 0.003; 95% CI [-0.20, -0.04]). CONCLUSIONS: In this study, most of the improvements in headache-related disability were related to increased headache management self-efficacy with mediation occurring through change in anxiety. This indicates that headache management self-efficacy is a likely mechanism of change of posttraumatic headache-related disability with decreases in anxiety explaining part of the improvement in headache-related disability.

The interactions between patient preferences, expectancies, and stigma contribute to posttraumatic stress disorder treatment outcomes.

Cognitive processing therapy (CPT) is an effective treatment for posttraumatic stress disorder (PTSD); however, some patients do not improve to the same extent as others. It is important to understand potential factors that can be modified for better patient outcomes. This clinical trial implemented a three-arm, equipoise-stratified randomization design to allow for the accommodation of patient preference before randomization to one of three CPT treatment modalities: in-home, in-office, or telehealth. This study examined whether satisfaction with the modality, perceived stigma, expectations of therapy, and credibility of the therapist differed between modalities and whether these factors impacted treatment outcomes. We hypothesized that the contributions of these variables would depend upon whether participants opted out of any treatment arms and that these factors would predict treatment outcomes. Participants who endorsed less perceived stigma demonstrated larger reductions in PTSD symptom severity than those with similar levels of perceived stigma in the telehealth and in-office conditions, η2 = .12-.18. Participants who endorsed lower satisfaction with their treatment modality and were assigned to the in-home condition experienced larger PTSD symptom reductions than those with similar dissatisfaction in the telehealth and in-office conditions, η2 = .20. The results show the robustness of evidence-based therapies for PTSD given that dissatisfaction did not impede treatment success. In addition, they demonstrate that it is important for clinicians to address stigma before initiating evidence-based therapies for PTSD. Strategies to address these factors are discussed.

Treatment of comorbid sleep disorders and posttraumatic stress disorder in U.S. active duty military personnel: A pilot randomized clinical trial.

Insomnia and nightmares are common in patients with posttraumatic stress disorder (PTSD). They are associated with worse psychological and physical health and worse PTSD treatment outcomes. In addition, they are resistant to PTSD treatments, which do not typically address sleep disorders. Cognitive behavioral therapy for insomnia and nightmares (CBT-I&N) and cognitive processing therapy (CPT) for PTSD are first-line treatments, but limited evidence exists guiding the treatment of individuals with all three disorders. The current study randomized U.S. military personnel (N = 93) to one of three conditions: CBT-I&N delivered before CPT, CBT-I&N delivered after CPT, or CPT alone; all groups received 18 sessions. Across groups, participants demonstrated significantly improved PTSD symptoms. Because the study was terminated prematurely due to challenges with recruitment and retention, it was underpowered to answer the initially intended research questions. Nonetheless, statistical findings and relevant clinically meaningful changes were observed. Compared to participants who received CPT alone, those who received CBT-I&N and CPT, regardless of sequencing, demonstrated larger improvements in PTSD symptoms, d = -0.36; insomnia, d = -0.77; sleep efficiency, d = 0.62; and nightmares, d = -.53. Compared to participants who received CBT-I&N delivered before CPT, those who received CBT-I&N delivered after CPT demonstrated larger improvements in PTSD symptoms, d = 0.48, and sleep efficiency, d = -0.44. This pilot study suggests that treating comorbid insomnia, nightmares, and PTSD symptoms results in clinically meaningful advantages in improvement for all three concerns compared to treating PTSD alone.

In-office, in-home, and telehealth cognitive processing therapy for posttraumatic stress disorder in veterans: a randomized clinical trial.

BACKGROUND: Trauma-focused psychotherapies for combat-related posttraumatic stress disorder (PTSD) in military veterans are efficacious, but there are many barriers to receiving treatment. The objective of this study was to determine if cognitive processing therapy (CPT) for PTSD among active duty military personnel and veterans would result in increased acceptability, fewer dropouts, and better outcomes when delivered In-Home or by Telehealth as compared to In-Office treatment. METHODS: The trial used an equipoise-stratified randomization design in which participants (N = 120) could decline none or any 1 arm of the study and were then randomized equally to 1 of the remaining arms. Therapists delivered CPT in 12 sessions lasting 60-min each. Self-reported PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5) served as the primary outcome. RESULTS: Over half of the participants (57%) declined 1 treatment arm. Telehealth was the most acceptable and least often refused delivery format (17%), followed by In-Office (29%), and In-Home (54%); these differences were significant (p = 0.0008). Significant reductions in PTSD symptoms occurred with all treatment formats (p < .0001). Improvement on the PCL-5 was about twice as large in the In-Home (d = 2.1) and Telehealth (d = 2.0) formats than In-Office (d = 1.3); those differences were statistically large and significant (d = 0.8, 0.7 and p = 0.009, 0.014, respectively). There were no significant differences between In-Home and Telehealth outcomes (p = 0.77, d = -.08). Dropout from treatment was numerically lowest when therapy was delivered In-Home (25%) compared to Telehealth (34%) and In-Office (43%), but these differences were not statistically significant. CONCLUSIONS: CPT delivered by telehealth is an efficient and effective treatment modality for PTSD, especially considering in-person restrictions resulting from COVID-19. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT02290847 (Registered 13/08/2014; First Posted Date 14/11/2014).

The associations between posttraumatic stress disorder and delay discounting, future orientation, and reward availability: A behavioral economic model.

The theoretical framework of behavioral economics, a metatheory that integrates operant learning and economic theory, has only recently been applied to posttraumatic stress disorder (PTSD). A behavioral economic theory of PTSD reflects an expansion of prior behavioral conceptualization of PTSD, which described PTSD in terms of respondent and operant conditioning. In the behavioral economic framework of PTSD, negatively reinforced avoidance behavior is overvalued, in part due to deficits in environmental reward, and may be conceptualized as a form of reinforcer pathology (i.e., excessive preference for and valuation of an immediate reinforcer). We investigated cross-sectional relationships between PTSD severity and several constructs rooted in this behavioral economic framework, including future orientation, reward availability, and delay discounting in a sample of 110 military personnel/veterans (87.2% male) who had served combat deployments following September 11, 2001. Total PTSD severity was inversely related to environmental reward availability, ß = -.49, ΔR2 = 0.24, p < .001; hedonic reward availability, ß = -.32, ΔR2 = 0.10, p = .001; and future orientation, ß = -.20, ΔR2 = 0.04, p = .032, but not delay discounting, r = -.05, p = .633. An examination of individual symptom clusters did not suggest that avoidance symptoms were uniquely associated with these behavioral economic constructs. The findings offer support for a behavioral economic model of PTSD in which there is a lack of positive reinforcement as well as a myopic focus on the present.

Secondary individual outcomes following multicouple group therapy for posttraumatic stress disorder: An uncontrolled pilot study with military dyads.

Cognitive-behavioral conjoint therapy (CBCT) for posttraumatic stress disorder (PTSD) has demonstrated efficacy for improving PTSD and comorbid symptoms and relationship adjustment. To enhance treatment efficiency and scalability, we developed a 2-day, abbreviated, intensive, multicouple group version of CBCT for PTSD (AIM-CBCT for PTSD). Prior work demonstrated that AIM-CBCT for PTSD wasassociated with reductions in PTSD and comorbid symptoms in a sample of 24 post-9/11 active duty military or veteran couples who received the treatment in a retreat format over a single weekend. The current study investigated secondary outcomes regarding trauma-related cognitions, psychosocial impairment, and insomnia. For trauma-related cognitions, reductions were nonsignificant and small at 1-month follow-up, ds = -0.14 to -0.32. However, by 3-month follow-up, there were significant, medium effect size reductions in total trauma-related cognitions, d = -0.68, and negative views of self and others, ds = -0.64 and -0.57, respectively, relative to baseline. There was also a nonsignificant, small-to-medium effect-size reduction in self-blame, d = -0.43, p = .053, by 3-month follow-up. For psychosocial impairment, there were significant and medium-to-large and large effect size reductions by 1- and 3-month follow-ups, ds = -0.73 and -0.81, respectively. There were nonsignificant, small effect size reductions in insomnia at both 1- and 3-month follow-ups relative to baseline, ds = -0.30 and -0.34, respectively. These findings suggest that AIM-CBCT for PTSD is associated with reductions in maladaptive posttraumatic cognitions and psychosocial impairment but that adjunctive interventions may be needed to address insomnia.

Testing the role of aerobic exercise in the treatment of posttraumatic stress disorder (PTSD) symptoms in U.S. active duty military personnel: a pilot study.

The purpose of this pilot study was to determine if the efficacy of imaginal exposure for symptoms of posttraumatic stress disorder (PTSD) could be improved by adding aerobic exercise. We hypothesized that aerobic exercise would enhance the efficacy of exposure therapy. Active duty service members with clinically significant symptoms of posttraumatic stress (PTSD Checklist-Stressor-Specific Version, [PCL-S], ≥25) were randomized into one of four conditions: exercise only; imaginal exposure only; imaginal exposure plus exercise; no exercise/no exposure therapy (control). Participants (N = 72) were primarily male, Army, noncommissioned officers ranging in age from 22 to 52. PTSD symptom severity decreased over time (p < .0001); however, there were no significant differences between the experimental conditions. The prediction that imaginal exposure augmented with aerobic exercise would be superior to either imaginal exposure alone or aerobic exercise alone was not supported, suggesting that engaging in exercise and imaginal exposure simultaneously may not be any better than engaging in either activity alone. A better understanding of individually administered and combined exercise and exposure therapy interventions for PTSD is warranted.

Persistent posttraumatic headaches and functioning in veterans: Injury type can matter.

OBJECTIVE: To characterize the relationship between head trauma types (blast injury, blunt injury, combined blast+blunt injury) with subsequent headache presentations and functioning. BACKGROUND: Posttraumatic headaches (PTHs), the most common sequelae of traumatic brain injury (TBI), are painful and disabling. More than 400,000 veterans report having experienced a TBI, and understanding the predictors of PTHs may guide treatment developments. METHODS: This study used a nested-cohort design analyzing baseline data from a randomized clinical trial of cognitive behavioral therapy for PTH (N = 190). Participants had PTH (from blast and/or blunt head trauma) and symptoms of posttraumatic stress disorder (PTSD). The Structured Diagnostic Interview for Headache-Revised and Ohio State University Traumatic Brain Injury Identification Method were used to phenotype headaches and head injury histories, respectively. RESULTS: Individuals with persistent PTHs after a combined blast and blunt head trauma were more likely (OR =3.45; 95% CI [1.41, 8.4]) to experience chronic (vs. episodic) PTHs compared with the blunt trauma only group (23/33, 70% vs. 26/65, 40%, respectively); and they were more likely (OR =2.51; 95% CI [1.07, 5.9]) to experience chronic PTH compared with the blast trauma only group (44/92, 48%). There were no differences between head injury type on headache-related disability, depression symptoms, or severity of PTSD symptoms. CONCLUSION: The combination of blast and blunt injuries was associated with headache chronicity, but not headache disability. Considering the refractory nature of chronic headaches, the potential added and synergistic effects of distinct head injuries warrant further study.

Associations Between Service Members' Posttraumatic Stress Disorder Symptoms and Partner Accommodation Over Time.

When service members manifest symptoms of posttraumatic stress disorder (PTSD), intimate partners may engage in behaviors to accommodate their partners' experiences (e.g., helping service members avoid situations that could make them uncomfortable, not expressing own thoughts and feelings to minimize PTSD-related conflict), which may inadvertently serve to maintain or increase PTSD symptoms over time. In a sample of 274 male service member/female civilian couples, we evaluated hypothesized bidirectional pathways between self-reported service member PTSD symptoms and partner accommodation, assessed four times over an approximately 18-month period. A random-intercept cross-lagged panel model disaggregating between and within effects revealed that, on average, couples in which the service member had higher levels of total PTSD symptoms also scored higher in partner accommodation, between-couple correlation, r = .40. In addition, at time points when service members' PTSD symptoms were higher relative to their own average symptom level, their partners' level of accommodation was also higher than their personal average, within-couple correlation r = .22. Longitudinally, service member PTSD symptom scores higher than their personal average predicted subsequent increases in partner accommodation, ß = .19, but not vice versa, ß = .03. Overall, the findings indicate both stable and time-specific significant associations between service member PTSD symptoms and partner accommodation and suggest that higher levels of PTSD symptoms are a significant driver of later increases in partner accommodation. These findings add further support for treating PTSD in an interpersonal context to address the disorder and concomitant relational processes that can adversely impact individual and relational well-being.

The Impact of Hazardous Drinking Among Active Duty Military With Posttraumatic Stress Disorder: Does Cognitive Processing Therapy Format Matter?

This study was a secondary data analysis of clinical trial data collected from 268 active duty U.S. military service members seeking cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) at Fort Hood, Texas, related to combat operations following September 11, 2001. Our primary aim was to evaluate changes in PTSD symptom severity and alcohol misuse as a function of baseline hazardous drinking and treatment format (i.e., group or individual). At baseline and posttreatment, PTSD was assessed using the PTSD Symptom Scale-Interview Version and PTSD Checklist for DSM-5. Hazardous drinking was categorically defined as an Alcohol Use Disorder Identification Test total score of 8 or higher. Employing intent-to-treat, mixed-effects regression analysis, all groups reported reduced PTSD symptom severity, Hedges' gs = -0.33 to -1.01, except, unexpectedly, nonhazardous drinkers who were randomized to group CPT, Hedges' g = -0.12. Hazardous drinkers who were randomized to individual therapy had larger reductions in PTSD symptoms than nonhazardous drinkers who were randomized to group CPT, Hedges' g = -0.25. Hazardous drinkers also reported significant reductions in alcohol misuse, regardless of treatment format, Hedges' gs = -0.78 to -0.86. This study builds upon an emerging literature suggesting that individuals with PTSD and co-occurring alcohol use disorder can engage successfully in CPT, which appears to be an appropriate treatment for these individuals whether it is delivered individually or in a group format. However, as a portion of participants remained classified as hazardous drinkers at posttreatment, some individuals may benefit from integrated treatment.

A Closer Examination of Relational Outcomes from a Pilot Study of Abbreviated, Intensive, Multi-Couple Group Cognitive-Behavioral Conjoint Therapy for PTSD with Military Dyads.

Cognitive-behavioral conjoint therapy for posttraumatic stress disorder (CBCT for PTSD) is associated with improvements in patients' PTSD symptoms, partners' psychological distress, and relationship satisfaction. However, little is known about whether CBCT for PTSD is associated with changes in other relationship domains that have theoretical and clinical relevance to the relational context of PTSD. The current study is a secondary analysis of relational outcomes from an uncontrolled, within-group trial designed to examine whether an abbreviated, intensive, multi-couple group version of CBCT for PTSD (AIM-CBCT for PTSD) delivered in a retreat during a single weekend was associated with improvements in PTSD symptoms and relationship satisfaction. In this investigation, we examined whether AIM-CBCT for PTSD is also associated with improvements in ineffective arguing, supportive dyadic coping by partner, joint dyadic coping, and partners' accommodation of patients' PTSD symptoms. Participants were 24 couples who included a post-9/11 U.S. service member or veteran with PTSD. At 1- and 3-month follow-up, patients reported significant reductions in couples' ineffective arguing (ds = -.71 and -.78, respectively) and increases in supportive dyadic coping by partners relative to baseline (ds = .50 and .44, respectively). By 3-month follow-up, patients also reported significant increases in couples' joint dyadic coping (d = .57), and partners reported significant reductions in their accommodation of patients' PTSD symptoms (d = -.44). Findings suggest that AIM-CBCT for PTSD is associated with improvements in multiple relationship domains beyond relationship satisfaction but that these may be differentially salient for patients and partners.

La terapia cognitivo-conductual conjunta para el trastorno por estrés postraumático (TCC para el TEPT) está asociada con mejoras en los síntomas de TEPT de los pacientes, en el distrés psicológico de sus parejas y en la satisfacción con la relación. Sin embargo, se sabe poco acerca de si la TCC para el TEPT está asociada con cambios en otros aspectos de la relación que son de interés teórico y clínico para el contexto relacional del TEPT. El presente estudio es un análisis secundario de los resultados relacionales de un ensayo intragrupal no controlado diseñado para analizar si una versión grupal multipareja, intensiva y abreviada de la TCC para el TEPT (MIA-TCC para el TEPT) practicada en un retiro durante un solo fin de semana estuvo asociada con mejoras en los síntomas de TEPT y en la satisfacción con la relación. En esta investigación, analizamos si la MIA-TCC para el TEPT también está asociada con mejoras en las discusiones ineficaces, en el afrontamiento diádico comprensivo de la pareja del paciente, en el afrontamiento diádico conjunto y en la adaptación de las parejas de los pacientes a sus síntomas de TEPT. Los participantes fueron 24 parejas en las que había un miembro o veterano de las Fuerzas Armadas de los Estados Unidos que prestó servicio con posterioridad al 11/9 y que tenía TEPT. En el seguimiento del mes y de los tres meses, los pacientes informaron reducciones significativas de las discusiones ineficaces de la pareja (ds = -0.71 y -0.78, respectivamente) y aumentos del afrontamiento diádico comprensivo de sus parejas en relación con el momento basal (ds = 0.50 y 0.44, respectivamente). En el seguimiento de los tres meses, los pacientes también informaron aumentos significativos del afrontamiento diádico conjunto de las parejas (d = 0.57), y sus parejas informaron reducciones significativas de su adaptación a los síntomas de TEPT de los pacientes (d = -0.44). Los resultados sugieren que la MIA-TCC para el TEPT está asociada con mejoras en varios aspectos de las relaciones aparte del de la satisfacción en la pareja, pero que estos pueden tener una importancia diferente para los pacientes y sus parejas.

A Public Health Framework for Preventing Mental Disorders in the Context of Pandemics.

The COVID-19 pandemic has universally threatened the building blocks of mental health, well-being, and quality of life, namely, expectations of safety, connectedness, hope, and individual and societal efficacy. Consequently, unprecedently large numbers of individuals are significantly stressed and many are at risk for relapse of mental health problems, exacerbations of existing mental and behavioral health problems, and new onset clinical problems. Because of the scope of the problem, a population-based public health perspective is needed, which in the context of disasters has well-established theories and prevention approaches. Public health approaches to disasters and pandemics focus on preventing subclinical problems from becoming clinical disorders, in comparison to clinical care approaches that focus on treating established disorders. Fortunately, specialty care clinicians who typically think about assessing and treating established disorders have the training and clinical competencies to deliver prevention-focused interventions. This paper is designed to help specialty care clinicians who use cognitive-behavioral strategies to understand the biopsychosocial impacts and resource deficits associated with COVID-19-related stressors and the public health perspective to address them. We also provide ways clinicians can help people who are suffering from significant stress and resource deficits bounce back and regain functioning. We describe psychological first aid, stress management, repeated ecological assessment, writing about stressors, problem-solving, and behavioral activation approaches to assist individuals at risk for enduring stress-linked problems.

Manage Emotions to Reduce Aggression: A Pilot Study of a Brief Treatment to Help Veterans Reduce Impulsive Aggression.

Veterans with posttraumatic stress disorder (PTSD) report more aggression than civilians with PTSD. Because emotion regulation difficulties mediated the relationship between PTSD symptoms and impulsive aggression in veterans, we developed an intervention to increase emotion regulation skills. This pilot study tested the feasibility and acceptability of a three-session treatment, Manage Emotions to Reduce Aggression (MERA), and examined its effectiveness at reducing aggression and emotion dysregulation. Male combat veterans with PTSD and impulsive aggression completed assessments before and 4 weeks after MERA. Overt Aggression Scale measured frequency of aggression; Difficulties in Emotion Regulation Scale assessed emotion dysregulation. Most veterans (95%) who completed MERA and the posttreatment assessment (n = 20) reported MERA was helpful. Veterans in the intent-to-treat sample demonstrated a significant decrease in their frequency of aggression (Cohen's d = -0.55) and emotion dysregulation (Cohen's d = -0.55). MERA may be an innovative treatment that helps veterans reduce aggression.

Response to Zalta and Held's "Commentary on the Special Issue on Moral Injury: Leveraging Existing Constructs to Test the Heuristic Model of Moral Injury".

Zalta and Held (2020) generated some interesting and potentially useful principles to distinguish moral distress and moral injury, leveraging ideas from our introduction to the Journal of Traumatic Stress special issue on moral injury. In this response, I provide feedback and commentary about the principles generated by Zalta and Held. I also attempt to modify and expand the various principles to accommodate any moral emotion and all possible dimensions of response to exposure to potentially morally injurious experiences.

Changes in anger and aggression after treatment for PTSD in active duty military.

OBJECTIVE: To examine whether treating posttraumatic stress disorder (PTSD) reduces anger and aggression and if changes in PTSD symptoms are associated with changes in anger and aggression. METHOD: Active duty service members (n = 374) seeking PTSD treatment in two randomized clinical trials completed a pretreatment assessment, 12 treatment sessions, and a posttreatment assessment. Outcomes included the Revised Conflict Tactics Scale and state anger subscale of the State-Trait Anger Expression Inventory. RESULTS: Treatment groups were analyzed together. There were small to moderate pretreatment to posttreatment reductions in anger (standardized mean difference [SMD] = -0.25), psychological aggression (SMD = -0.43), and physical aggression (SMD = -0.25). The majority of participants continued to endorse anger and aggression at posttreatment. Changes in PTSD symptoms were mildly to moderately associated with changes in anger and aggression. CONCLUSIONS: PTSD treatments reduced anger and aggression with effects similar to anger and aggression treatments; innovative psychotherapies are needed.

The pattern of symptom change during prolonged exposure therapy and present-centered therapy for PTSD in active duty military personnel.

BACKGROUND: Few studies have investigated the patterns of posttraumatic stress disorder (PTSD) symptom change in prolonged exposure (PE) therapy. In this study, we aimed to understand the patterns of PTSD symptom change in both PE and present-centered therapy (PCT). METHODS: Participants were active duty military personnel (N = 326, 89.3% male, 61.2% white, 32.5 years old) randomized to spaced-PE (S-PE; 10 sessions over 8 weeks), PCT (10 sessions over 8 weeks), or massed-PE (M-PE; 10 sessions over 2 weeks). Using latent profile analysis, we determined the optimal number of PTSD symptom change classes over time and analyzed whether baseline and follow-up variables were associated with class membership. RESULTS: Five classes, namely rapid responder (7-17%), steep linear responder (14-22%), gradual responder (30-34%), non-responder (27-33%), and symptom exacerbation (7-13%) classes, characterized each treatment. No baseline clinical characteristics predicted class membership for S-PE and M-PE; in PCT, more negative baseline trauma cognitions predicted membership in the non-responder v. gradual responder class. Class membership was robustly associated with PTSD, trauma cognitions, and depression up to 6 months after treatment for both S-PE and M-PE but not for PCT. CONCLUSIONS: Distinct profiles of treatment response emerged that were similar across interventions. By and large, no baseline variables predicted responder class. Responder status was a strong predictor of future symptom severity for PE, whereas response to PCT was not as strongly associated with future symptoms.

Introduction to the Special Issue on Moral Injury: Conceptual Challenges, Methodological Issues, and Clinical Applications.

This article introduces a special issue of the Journal of Traumatic Stress devoted to new directions in the study of moral injury (MI), defined as transgressive harms and the outcomes of those experiences. Although a significant body of research has emerged devoted to the study of the MI construct, a number of conceptual and empirical challenges have arisen; these are summarized and discussed in the present article. In addition, this article proposes ways of overcoming these challenges in order to further research and clinical practice in the field. We then go on to introduce the content and themes of the present collection of articles in this special issue, all of which provide examples of some of the most innovative and forward-looking work on the topic and expand into new conceptual frameworks, new methods of investigation, and new populations and contexts.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Introducción al número especial sobre daño moral: desafíos conceptuales, problemas metodológicos y aplicaciones clínicas INTRODUCCION AL NÚMERO ESPECIAL DE DAÑO MORAL Este artículo introduce el número especial de la Revista de Estrés Traumático (Journal of Traumatic Stress en su nombre en inglés) dedicado a nuevas direcciones en el estudio del daño moral (DM), definido como daños transgresores y los resultados de esas experiencias. Aunque surgió un importante cuerpo de investigación dedicado al estudio del constructo de DM, surgieron varios desafíos conceptuales y empíricos; Estos se resumen y discuten en el presente artículo. Además, este artículo propone formas de superar estos desafíos con el fin de promover la investigación y la práctica clínica en este campo. A continuación, presentamos el contenido y los temas de la presente colección de artículos en este especial temático, todos los cuales proporcionan ejemplos de algunos de los trabajos más innovadores y prospectivos sobre el tema y se expanden a nuevos marcos conceptuales, nuevos métodos de investigación y nuevas poblaciones y contextos.

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.

Defining and Measuring Moral Injury: Rationale, Design, and Preliminary Findings From the Moral Injury Outcome Scale Consortium.

In the current paper, we first describe the rationale for and methodology employed by an international research consortium, the Moral Injury Outcome Scale (MIOS) Consortium, the aim of which is to develop and validate a content-valid measure of moral injury as a multidimensional outcome. The MIOS Consortium comprises researchers and clinicians who work with active duty military service members and veterans in the United States, the United Kingdom, the Netherlands, Australia, and Canada. We describe the multiphase psychometric development process being conducted by the Consortium, which will gather phenomenological data from service members, veterans, and clinicians to operationalize subdomains of impact and to generate content for a new measure of moral injury. Second, to illustrate the methodology being employed by the Consortium in the first phase of measure development, we present a small subset of preliminary results from semistructured interviews and questionnaires conducted with care providers (N = 26) at three of the 10 study sites. The themes derived from these initial preliminary clinician interviews suggest that exposure to potentially morally injurious events is associated with broad psychological/behavioral, social, and spiritual/existential impacts. The early findings also suggest that the outcomes associated with acts of commission or omission and events involving others' transgressions may overlap. These results will be combined with data derived from other clinicians, service members, and veterans to generate the MIOS.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Definiendo y midiendo el daño moral: fundamentos, diseño y resultados preliminares de la escala consorcio de consecuencias del daño moral DEFINIENDO Y MIDIENDO EL DAÑO MORAL En el documento actual, describimos en primer lugar los fundamentos y la metodología empleados por un consorcio internacional de investigación, la Escala Consorcio de consecuencias del daño moral (MIOS en sus siglas en inglés), cuyo objetivo es desarrollar y validar una medida de daño moral con contenido válido y como consecuencias multidimensionales. El Consorcio MIOS está compuesto por investigadores y clínicos que trabajan con miembros del servicio militar activos y veteranos en los Estados Unidos, el Reino Unido, los Países Bajos, Australia y Canadá. Describimos el proceso de desarrollo psicométrico multifase que está llevando a cabo el Consorcio, que recopilará datos fenomenológicos de miembros del servicio, veteranos y clínicos para poner en práctica subdominios de impacto y generar contenido para una nueva medida de daño moral. En segundo lugar, para ilustrar la metodología empleada por el Consorcio en la primera fase de desarrollo de la medida, presentamos un pequeño subconjunto de resultados preliminares de entrevistas semiestructuradas y cuestionarios realizados con proveedores de atención (N = 26) en tres de los 10 sitios de estudio. Los temas derivados de estas primeras entrevistas clínicas preliminares sugieren que la exposición a eventos potencialmente dañinos moralmente está asociada con amplios impactos psicológicos / conductuales, sociales y espirituales / existenciales. Los primeros hallazgos también sugieren que los resultados asociados con actos de comisión u omisión y eventos que involucran las transgresiones de otros pueden superponerse. Estos resultados se combinarán con datos derivados de otros clínicos, miembros del servicio y veteranos para generar el MIOS.