Restore and Rebuild (R&R): a protocol for a phase 2, randomised control trial to compare R&R as a treatment for moral injury-related mental health difficulties in UK military veterans to treatment as usual.

BACKGROUND: Exposure to potentially morally injurious events is increasingly recognised as a concern across a range of occupational groups, including UK military veterans. Moral injury-related mental health difficulties can be challenging for clinicians to treat and there is currently no validated treatment available for UK veterans. We developed Restore and Rebuild (R&R) as a treatment for UK veterans struggling with moral injury-related mental health difficulties. This trial aims to examine whether it is feasible to conduct a pilot randomised controlled trial (RCT) of R&R treatment compared with a treatment-as-usual (TAU) control group. METHODS: We will use a feasibility single-blind, single-site RCT design. The target population will be UK military veterans with moral injury-related mental health difficulties. We will recruit N=46 veteran patients who will be randomly allocated to R&R (n=23) or TAU (n=23). Patients randomised to R&R will receive the 20-session one-to-one treatment, delivered online. Veterans allocated to TAU, as there are currently no manualised treatments for moral injury-related mental health problems available, will receive the one-to-one treatment (online) typically provided to veterans who enter the mental health service for moral injury-related mental health difficulties. We will collect outcome measures of moral injury, post-traumatic stress disorder (PTSD), alcohol misuse, common mental disorders and trauma memory at pretreatment baseline (before randomisation), end of treatment, 12 weeks and 24 weeks post-treatment. The primary outcome will be the proportion of patients who screen positive for PTSD and moral injury-related distress post-treatment. ETHICS AND DISSEMINATION: This trial will establish whether R&R is feasible, well-tolerated and beneficial treatment for veterans with moral injury-related mental health difficulties. If so, the results of the trial will be widely disseminated and R&R may improve access to effective care for those who struggle following moral injury and reduce the associated negative consequences for veterans, their families and wider society. TRIAL REGISTRATION NUMBER: ISRCTN99573523.

Restore and Rebuild (R&R) - a feasibility pilot study of a co-designed intervention for moral injury-related mental health difficulties.

BACKGROUND: Moral injury can significantly negatively impact mental health, but currently no validated treatment for moral injury-related mental health difficulties exists in a UK context. This study aimed to examine whether the Restore and Rebuild (R&R) treatment was feasible to deliver, acceptable and well tolerated by UK military veterans with moral injury related mental health difficulties. METHOD: The R&R treatment was delivered to 20 patients who reported distress related to exposure to a morally injurious event(s) during military service. R&R is a 20-session psychotherapy with key themes of processing the event, self compassion, connecting with others and core values. Treatment was delivered online, weekly, one-to-one by a single therapist. Qualitative interviews with patients and the therapist who delivered R&R were conducted to explore acceptability and analysed using thematic analysis. RESULTS: Following treatment, patients experienced a significant reduction in symptoms of post-traumatic stress disorder, depression, alcohol misuse and moral injury related distress. R&R was found to be well tolerated by patients and improved their perceived wellbeing. CONCLUSIONS: These results provide preliminary evidence that veterans struggling with moral injury related mental ill health can benefit from R&R treatment.

Evidence before this study: Moral injury can negatively impact the mental health of military veterans. Currently no validated treatment for moral injury related mental health difficulties exists for UK military personnel/veterans.Added value of this study: Restore and Rebuild (R&R) is a co-designed psychotherapy for moral injury-related mental health difficulties. This study provides the first evidence that R&R treatment is associated with a significant improvement in patient symptoms of PTSD, depression, alcohol misuse and moral injury related distress. R&R was feasible to deliver, acceptable to patients and well tolerated.Implications of all the available evidence: These results provide preliminary evidence that veterans struggling with moral injury related mental ill health can benefit from R&R treatment. With further evaluation, R&R may be beneficial to other occupational groups affected by moral injury.

Development of an intervention for moral injury-related mental health difficulties in UK military veterans: a feasibility pilot study protocol.

Background: Experiencing potentially morally injurious events (PMIEs) has been found to be significantly associated with poor mental health outcomes in military personnel/veterans. Currently, no manualised treatment for moral injury-related mental health difficulties for UK veterans exists. This article describes the design, methods and expected data collection of the Restore & Rebuild (R&R) protocol, which aims to develop procedures to treat moral injury related mental ill health informed by a codesign approach. Methods: The study consists of three main stages. First, a systematic review will be conducted to understand the best treatments for the symptoms central to moral injury-related mental ill health (stage 1). Then the R&R manual will be co-designed with the support of UK veteran participants with lived experience of PMIEs as well as key stakeholders who have experience of supporting moral injury affected individuals (stage 2). The final stage of this study is to conduct a pilot study to explore the feasibility and acceptability of the R&R manual (stage 3). Results: Qualitative data will be analysed using thematic analysis. Conclusions: This study was approved by the King's College London's Research Ethics Committee (HR-20/21-20850). The findings will be disseminated in several ways, including publication in academic journals, a free training event and presentation at conferences. By providing information on veteran, stakeholder and clinician experiences, we anticipate that the findings will not only inform the development of an acceptable evidence-based approach for treating moral injury-related mental health problems, but they may also help to inform broader approaches to providing care to trauma exposed military veterans.

Antecedentes: Se ha encontrado que experimentar eventos potencialmente dañinos para la moral (PMIE, por sus siglas en inglés) se asocia significativamente con malos resultados de salud mental en el personal militar/veteranos. Actualmente no existe un tratamiento manualizado para los problemas de salud mental relacionadas con daño moral para los veteranos del Reino Unido. Este artículo describe el diseño, los métodos y la recopilación de datos esperada del protocolo Restore & Rebuild (R&R), que tiene como objetivo desarrollar procedimientos para tratar la salud mental relacionada con el daño moral informado por un enfoque de codiseño.Métodos: El estudio consta de tres etapas principales. Primero, se realizará una revisión sistemática para comprender los mejores tratamientos para los síntomas centrales de la enfermedad mental relacionada con el daño moral (etapa 1). Luego, el manual de R&R se diseñará conjuntamente con el apoyo de participantes veteranos del Reino Unido con experiencia vivida de PMIE, así como con partes interesadas clave que tengan experiencia en el apoyo a las personas afectadas por daño moral (etapa 2). La etapa final de este estudio es realizar un estudio piloto para explorar la factibilidad y aceptabilidad del manual R&R (etapa 3).Resultados: Los datos cualitativos se analizarán mediante análisis temático.Conclusiones: Este estudio fue aprobado por el Comité de Ética en Investigación del King's College London (HR-20/21-20850). Los hallazgos se difundirán de varias maneras, incluida la publicación en revistas académicas, un evento de capacitación gratuito y presentaciones en conferencias. Al proporcionar información sobre las experiencias de veteranos, partes interesadas y médicos, anticipamos que los hallazgos no solo informarán el desarrollo de un enfoque basado en evidencia aceptable para tratar problemas de salud mental relacionados con daño moral, sino que también pueden ayudar a transmitir enfoques más amplios para proporcionar atención a veteranos militares expuestos a traumas.