Measuring moral distress and moral injury: A systematic review and content analysis of existing scales.

BACKGROUND: Moral distress (MD) and moral injury (MI) are related constructs describing the negative consequences of morally challenging stressors. Despite growing support for the clinical relevance of these constructs, ongoing challenges regarding measurement quality risk limiting research and clinical advances. This study summarizes the nature, quality, and utility of existing MD and MI scales, and provides recommendations for future use. METHOD: We identified psychometric studies describing the development or validation of MD or MI scales and extracted information on methodological and psychometric qualities. Content analyses identified specific outcomes measured by each scale. RESULTS: We reviewed 77 studies representing 42 unique scales. The quality of psychometric approaches varied greatly across studies, and most failed to examine convergent and divergent validity. Content analyses indicated most scales measure exposures to potential moral stressors and outcomes together, with relatively few measuring only exposures (n = 3) or outcomes (n = 7). Scales using the term MD typically assess general distress. Scales using the term MI typically assess several specific outcomes. CONCLUSIONS: Results show how the terms MD and MI are applied in research. Several scales were identified as appropriate for research and clinical use. Recommendations for the application, development, and validation of MD and MI scales are provided.

Access to therapy for child sexual abuse survivors: Preliminary dialogue of barriers and facilitators between caregivers.

BACKGROUND: Difficulties in access to therapy were highlighted by COVID-19 measures restricting in-person gatherings. Additional challenges arise when focusing on caregivers of child sexual abuse (CSA) survivors in particular, which are a population that has been historically difficult to engage with due to issues of stigma and confidentiality. OBJECTIVES: To present preliminary qualitative results from caregivers of CSA survivors. METHODS: This study was conducted with caregivers of CSA survivors. Two hybrid webinar/focus groups were conducted using a video conferencing platform in fall of 2021 with two groups of stakeholders (11 caregivers and 5 moderators/clinical staff at Little Warriors, an intensive episodic treatment facility). Sessions were recorded, transcribed, and thematically-analyzed using standard qualitative methodology. RESULTS: A total of 11 caregivers contributed to the data. Themes include: (1) Challenges of starting and maintaining treatment (i.e., emotional impact of intake day, challenges of enrolling), (2) Therapeutic benefits of specialized treatment (i.e., feeling safe and supported and the importance of trauma-informed care), and (3) Barriers and facilitators of treatment (i.e., avenues to scale-up and self-care). CONCLUSION: The importance of a strong therapeutic alliance was highlighted by both caregivers/clinical staff and further support is needed for families post-treatment. The present hybrid webinar/focus group also achieved engagement goals in a population that is typically difficult to reach. Overall, the response rate (12%) was equivalent to reported registrant attendance rates for general business to consumer webinars and the recommended focus group size. This preliminary approach warrants replication in other populations outside our clinical context.

"Collapsing into Darkness": An Exploratory Qualitative Thematic Analysis of the Experience of Workplace Reintegration among Nurses with Operational Stress Injuries.

BACKGROUND: Nurses are engaged in an unpredictable and dynamic work environment where they are exposed to events that may cause or contribute to physical and/or psychological injuries. Operational stress injury (OSI) may lead to an extended time away from work or nurses leaving the profession altogether. A deliberate focus on the workplace reintegration phase of the mental health recovery process may lead to the increased retention of nurses in their profession. Prior to the creation and implementation of potential solutions to address workplace reintegration, it is imperative to explore the experiences and perceptions of nurses affected by OSI. This qualitative study aims to investigate the experiences and perceptions of nurses (N = 7) employed within a Canadian provincial healthcare system who have attempted workplace reintegration after being off of work with an OSI. METHODS: Nurses were recruited via social media, unit emails, and word of mouth. Data were collected through recorded semi-structured interviews conducted over videoconferencing. Once transcribed, the data were thematically analyzed using an inductive approach. RESULTS: The resulting themes included (1) heroes to zeros, (2) changing the status quo, (3) connection is key, and (4) post-traumatic growth: advocacy and altruism. Study participants indicated both that nursing culture and a cumulation of events contributed to a need for a leave of absence from work and that a formalized process was desired by nurses to assist in returning to work. CONCLUSIONS: The development, implementation, and exploration of innovative policies, procedures, and initiatives to bridge the gap from clinical interventions to workplace reintegration are needed for nurses experiencing OSI. Further research is also needed regarding mental health impacts and appropriate resources to support nurses in their workplace reintegration process after experiencing psychological and/or physical injury.

Correction: Efficacy, Effectiveness, and Quality of Resilience-Building Mobile Health Apps for Military, Veteran, and Public Safety Personnel Populations: Scoping Literature Review and App Evaluation.

[This corrects the article DOI: 10.2196/26453.].

How Do We Keep our Heads above Water? An Embedded Mixed-Methods Study Exploring Implementation of a Workplace Reintegration Program for Nurses Affected by Operational Stress Injury.

BACKGROUND: Nurses are exposed to potentially psychologically traumatic events which can lead to operational stress injuries (OSI). Workplace reintegration after an OSI can be challenging, especially with repeated exposure to potentially traumatic scenarios and workplace demands. A workplace reintegration program (RP) originally developed for police officers may be of benefit for nurses returning to work after an OSI. The purpose of this study is to investigate the perceived need for an RP for nurses, and its potential contextualization and implementation in the nursing context using an implementation science approach. METHODS: This mixed-methods study collected data via questionnaires and focus groups from acute care nurses in Canada (N = 19). Data analysis was conducted using descriptive statistics, thematic analysis, and an organizational readiness assessment. RESULTS: Study participants indicated that formalized processes were rarely used to support nurses returning to work after time off due to mental health challenges. Themes included (1) "The Perfect Storm": the current state of return-to-work, (2) Integral Needs, and (3) A Break in the Clouds: hope for health. CONCLUSIONS: Exploration of innovative programs such as the RP may provide additional support to nurses affected by OSIs. Further research is needed regarding workplace reintegration for nurses, and contextualization and evaluation of the RP.

Reculturation: A new perspective on military-civilian transition stress.

Various forms of assistance are offered to help US Veterans achieve success in their post-military lives in recognition of their service. Despite the many successes, a significant number of Veterans continue to remain at risk for negative mental health outcomes, including suicidality and low levels of life satisfaction. These findings may be due to challenges arising from cultural identity dissonance. Problematic strategies used by Veterans to reduce this dissonance can result in a lack of belongingness, a key component in Joiner's Interpersonal Theory of Suicide. The authors suggest that research on the immigrant experience of acculturation may provide a new perspective to better understand issues of identity and sense of belonging in Veterans. Given that most Veterans return to the culture in which they grew up, the authors offer the term "reculturation." The authors propose clinical psychology focus on exploring the reculturation process of Veterans to support program engagement and suicide prevention.

Moving Forward from Moral Injury: A Mixed Methods Study Investigating the Use of 3MDR for Treatment-Resistant PTSD.

BACKGROUND: Exposure to trauma and potentially morally injurious events may lead to moral injury (MI). The link between MI and posttraumatic stress disorder (PTSD) may have particularly relevant implications for treatment-resistant PTSD (TR-PTSD). Multi-modal Motion-Assisted Memory Desensitization and Reconsolidation (3MDR), a technology-assisted exposure-based trauma therapy that has been used in the treatment of PTSD, may also be an acceptable modality for patients in the treatment of TR-PTSD and MI. This proof-of-concept study aimed to investigate (1) whether MI co-occurs in military members (MMs) and veterans with TR-PTSD, and (2) the perspectives of MMs and veterans with TR-PTSD utilizing 3MDR for MI. METHODS: This study employed a mixed-methods clinical trial. Military Members and veterans participated in this study (N = 11) through self-reported questionnaires, video recordings of treatment sessions, and semi-structured interviews post-session and post-intervention, with longitudinal follow-up to 6 months. RESULTS: MI scores correlated with self-reported measures of mental health symptoms related to PTSD. The thematic analysis revealed three emergent themes: (1) Realities of War, (2) Wrestling Scruples, and (3) Moral Sensemaking. CONCLUSION: MI was highly correlated with TR-PTSD and themes regarding MI. This result, while preliminary, allows for the postulation that MI may be contributing to the continuation of PTSD symptoms in TR-PTSD, and that 3MDR may be an acceptable modality for addressing these symptoms in MMs and veterans.

Forgiveness: A Key Component of Healing From Moral Injury?

Service members and veterans can be exposed to potentially traumatic and morally injurious experiences (PMIEs) including participating in, witnessing, or failing to prevent an act(s) that transgresses their core beliefs. Violation of one's deeply held morals and values can be profoundly distressing and shatter one's sense of self at the deepest level. Relationships with self, others, the world, and for some, the Sacred, can also be fractured. Post-Traumatic Stress Disorder (PTSD) and/or Moral Injury (MI) can result. Left unresolved, MI can leave individuals struggling with guilt, shame, cognitive dissonance, and negative self-attributions. A holistic approach that addresses the psychological and spiritual harm associated with MI is warranted. We wonder if forgiveness can help individuals struggling with MI to address the harm caused by actions or inactions, release negative emotions, and mend relationships. Commonly used by Spiritual/Religious (S/R) Leaders, forgiveness practices are increasingly being explored by Mental Health Professionals as a complement to evidence-based treatment approaches. This article provides case examples that illustrate the use of forgiveness practices that promote recovery and identifies programs used in clinical practice that incorporate forgiveness. Research is yet needed to better understand the importance of forgiveness in the treatment and healing of PTSD and/or MI. This requires an interdisciplinary discourse between Mental Health Professionals and S/R Leaders working in the field of MI. Such engagement and integrated use of forgiveness practices may yield improved outcomes not only for service members and veterans, but for all those struggling as a result of PTSD and/or MI.

Quantitative changes in mental health measures with 3MDR treatment for Canadian military members and veterans.

OBJECTIVE: Military members and veterans are at elevated risk of treatment-resistant posttraumatic stress disorder (TR-PTSD) due to higher rates of exposure to potentially traumatic events during the course of duty. Knowledge of TR-PTSD is limited, and specific protocols or evidence-based TR-PTSD therapies are lacking. Multimodal motion-assisted memory desensitization and reconsolidation (3MDR) therapy is an emerging intervention for combat-related TR-PTSD. The purpose of this study was to preliminarily assess the effectiveness of 3MDR in addressing TR-PTSD in Canadian military members and veterans. METHODS: This study is a longitudinal mixed-methods clinical trial. English-speaking military members and veterans aged 18-60 with TR-PTSD were recruited to participate. The intervention consisted of six sessions of 3MDR therapy. Quantitative data were collected pretreatment, posttreatment, and longitudinally at 1, 3, and 6 months after completion of 3MDR. RESULTS: Results from the first 11 participants to complete the 3MDR protocol exhibited statistically significant improvement (surviving multiple comparison correction) in clinically administered and self-reported scores for PTSD (CAPS-5 and PCL-5), moral injury (MISS-M-SF), depression (PHQ-9), anxiety (GAD-7), emotional regulation (DERS-18), and resilience (CD-RS-25). CONCLUSION: The preliminary and exploratory results from this clinical trial support the growing body of literature illustrating 3MDR as an effective treatment for military-related TR-PTSD. These results are notable given participants' previous lack of success with frontline psychotherapeutic and pharmacological interventions. Given that there are currently very limited treatment options for TR-PTSD, 3MDR could prove to be a valuable treatment option for military members and veterans with TR-PTSD.

ESCMID recommendations for COVID-19 testing in asymptomatic persons to prevent transmission in health care.

SOURCE CITATION: Carrara E, Ong DS, Hussein K, et al. ESCMID guidelines on testing for SARS-CoV-2 in asymptomatic individuals to prevent transmission in the health care setting. Clin Microbiol Infect. 2022;28:672-80. 35124258.

The Redesign and Validation of Multimodal Motion-Assisted Memory Desensitization and Reconsolidation Hardware and Software: Mixed Methods, Modified Delphi-Based Validation Study.

BACKGROUND: In recent years, the delivery of evidence-based therapies targeting posttraumatic stress disorder (PTSD) has been the focus of the Departments of Defense in countries such as Canada, the Netherlands, and the United States. More than 66% of military members continue to experience symptoms of PTSD that significantly impact their daily functioning and quality of life after completing evidence-based treatments. Innovative, engaging, and effective treatments for PTSD are needed. Multimodal motion-assisted memory desensitization and reconsolidation (3MDR) is an exposure-based, virtual reality-supported therapy used to treat military members and veterans with treatment-resistant PTSD. Given the demonstrated efficacy of 3MDR in recently published randomized control trials, there is both an interest in and a need to adapt the intervention to other populations affected by trauma and to improve accessibility to the treatment. OBJECTIVE: We aimed to further innovate, develop, and validate new and existing hardware and software components of 3MDR to enhance its mobility, accessibility, feasibility, and applicability to other populations affected by trauma, including public safety personnel (PSP), via international collaboration. METHODS: This study used a modified Delphi expert consultation method and mixed methods quasi-experimental validation with the purpose of software validation among PSP (first responders, health care providers) participants (N=35). A team of international experts from the Netherlands, the United States, and Canada met on the web on a weekly basis since September 2020 to discuss the adoption of 3MDR in real-world contexts, hardware and software development, and software validation. The evolution of 3MDR hardware and software was undertaken followed by a mixed methods software validation study with triangulation of results to inform the further development of 3MDR. RESULTS: This study resulted in the identification, description, and evolution of hardware and software components and the development of new 3MDR software. Within the software validation, PSP participants widely acknowledged that the newly developed 3MDR software would be applicable and feasible for PSP affected by trauma within their professions. The key themes that emerged from the thematic analysis among the PSP included the desire for occupationally tailored environments, individually tailored immersion, and the applicability of 3MDR beyond military populations. CONCLUSIONS: Within the modified Delphi consultation and software validation study, support for 3MDR as an intervention was communicated. PSP participants perceived that 3MDR was relevant for populations affected by trauma beyond military members and veterans. The resulting hardware and software evolution addressed the recommendations and themes that arose from PSP participants. 3MDR is a novel, structured, exposure-based, virtual reality-supported therapy that is currently used to treat military members and veterans with PTSD. Going forward, it is necessary to innovate and adapt 3MDR, as well as other trauma interventions, to increase effectiveness, accessibility, cost-effectiveness, and efficacy among other populations affected by trauma.

A Qualitative Analysis of the Mental Health Training and Educational Needs of Firefighters, Paramedics, and Public Safety Communicators in Canada.

Background-Public safety personnel (PSP) are at heightened risk of developing mental health challenges due to exposures to diverse stressors including potentially psychologically traumatic experiences. An increased focus on protecting PSP mental health has prompted demand for interventions designed to enhance resilience. While hundreds of available interventions are aimed to improve resilience and protect PSPs' mental health, research evidence regarding intervention effectiveness remains sparse. Methods-Focus groups with PSP elicited a discussion of psychoeducational program content, preferred modes of program delivery, when such training should occur, and to whom it ought to be targeted. Results-The results of thematic analyses suggest that PSP participants feel that contemporary approaches to improving mental health and resilience are lacking. While welcomed, the provision of sporadic one-off mental health and resilience programs by organizations was seen as insufficient, and the available organizational mental health supports were perceived as being questionable. The available programs also left participants feeling insufficiently prepared to deal with personal mental health problems and in discussing mental health concerns with co-workers. Conclusions-Participants reported needing more engaging methods for delivering information, career-long mental health knowledge acquisition, and a systems approach to improve the workplace culture, particularly regarding mental health.

Therapist and operator experiences utilizing multi-modal motion-assisted Memory Desensitization and Reconsolidation (3MDR) for treatment of combat related posttraumatic stress disorder amongst military and veteran populations.

Background: As provisions of mental healthcare services to military and veteran populations increases the risk to service providers developing secondary traumatic stress (STS), efforts are needed to examine the impact of delivering novel interventions which may include 3MDR. As a virtual-reality supported intervention, 3MDR exposes the patient, therapist and operator to graphic and sensory stimuli (i.e. narratives, imagery, smells, and music) in the course of the intervention. 3MDR is actively being researched at multiple sites internationally within military and veteran populations. It is, therefore, crucial to ensure the safety and wellbeing of 3MDR therapists and operators who are exposed to potentially distressing sensory stimuli. Objective: The purpose of this study is to qualitatively examine the impact and experiences of STS amongst therapists and operators in delivering 3MDR. For this study, impact will be defined as therapists or operators experiencing perceived STS as a result of delivering 3MDR. Methods: This exploratory qualitative study recruited 3MDR therapists and operators (N = 18) from Canada, the Netherlands, the United Kingdom, and the United States who had previously delivered 3MDR therapy. Telephone or video-conferencing interviews were used to gather data that was subsequently transcribed and thematically analyzed. Results: Four themes emerged among the therapists (n = 13) and operators (n = 5): (1) personal cost and benefits of 3MDR, (2) professional paradox of a 3MDR therapist, (3) perceived effect of 3MDR on patients, and (4) recommendations for future 3MDR use. Conclusions: STS was not noted to be a significant challenge for 3MDR therapists and operators. Future research may investigate optimal means of providing training and ongoing support for 3MDR therapists and operators. HIGHLIGHTS: Secondary Traumatic Stress was not noted to be a significant challenge for 3MDR therapists and operatorsFuture research may investigate optimal means of providing training and ongoing support for 3MDR therapists and operators.

Antecedentes: Dado que la prestación de servicios de atención en salud mental a poblaciones de militares y veteranas aumenta el riesgo de que los proveedores de la atención desarrollen estrés traumático secundario (STS en sus siglas en inglés), se requieren esfuerzos para examinar el impacto de la entrega de intervenciones novedosas que pueden incluir 3MDR. Una intervención de apoyo de realidad virtual, 3MDR expone al paciente, terapeuta y operador a estímulos sensoriales y gráficos (es decir, narrativas, imágenes, olores y música) en el transcurso de la intervención.3MD está siendo investigada activamente en múltiples sitios a nivel internacional dentro de poblaciones militares y de veteranos. Por lo tanto, es crucial garantizar la seguridad y bienestar de los terapeutas y operadores de 3MDR que están expuestos a estímulos sensoriales potencialmente perturbadores. Objetivo: El propósito de este estudio es examinar cualitativamente el impacto y las experiencias de STS entre terapeutas y operadores que entregan 3MDR. Para este estudio, el impacto se definirá como los terapeutas o los operadores experimentan los STS percibidos como resultado de la entrega de 3MDR. Método: Este estudio cualitativo exploratorio reclutó a terapeutas y operadores 3MDR (N = 18) de Canadá, Holanda, Reino Unido y Estados Unidos de Norteamérica, quienes previamente habían dado terapia 3MDR. Se usaron entrevistas telefónicas o por videoconferencias para reunir los datos que luego se transcribieron y analizaron temáticamente. Resultados: Emergieron 4 temas entre los terapeutas (N = 13) y operadores (N = 5): (1) costo personal y beneficios de 3MDR, (2) paradoja profesional de un terapeuta 3MDR, (3) efecto percibido de 3MDR en los pacientes, y (4) recomendaciones para el uso futuro de 3MDR. Conclusiones: No se notó que STS fuera un desafío significativo para los terapeutas y operadores de 3MDR. Investigaciones futuras pueden investigar medios óptimos para proporcionar formación y apoyo continuo para los terapeutas y operadores 3MDR. Destacados: No se observó que el Estrés Traumático Secundario fuera un desafío significativo para los terapeutas y operadores 3MDR. Investigaciones futuras pueden investigar medios óptimos para proporcionar formación y apoyo continuo para los terapeutas y operadores 3MDR.

Workplace Reintegration Facilitator Training Program for Mental Health Literacy and Workplace Attitudes of Public Safety Personnel: Pre-Post Pilot Cohort Study.

BACKGROUND: Public safety personnel (PSP) impacted by operational stress injuries can find themselves needing both time off work and support reintegrating back into the workforce. Work reintegration programs have been introduced in PSP organizations to support those who aim to return to work. One such peer-led workplace reintegration program (RP) was created in 2009 by members of the Edmonton Police Service (EPS). The primary goal of the EPSRP is to assist PSP in returning to work as soon as possible following a critical incident, illness, or injury while diminishing the potential for long-term psychological injury. The EPSRP is delivered by peers through 3 interrelated components: (1) the Reintegration Program Facilitator Training (RPFT) Program; (2) a short-term Critical Incident RP; and (3) a long-term RP. There is a dire need for research that incorporates strong study designs to the determine long-term effectiveness of the program on increasing workplace reintegration, improving mental health knowledge, and creating culture change within PSP organizations. Simultaneously, the efficacy, effectiveness, and fidelity of the RPFT in providing the tools, mental health knowledge, and skills the RP peer facilitators will need for the RP must be evaluated. OBJECTIVE: The purpose of this quasi-experimental pre-post pilot cohort study is to evaluate the effectiveness of the EPSRPFT course on influencing mental health knowledge and attitudes of RPFT attendees who will be future RP peer facilitators. METHODS: This pre-post cohort study collected data via 2 questionnaires from RPFT participants (N=60) which included the Mental Health Knowledge Survey (MAKS) and the Open Minds Survey of Workplace Attitudes (OMSWA). Descriptive, parametric (sample t tests), and nonparametric (Wilcoxon signed rank tests) statistics were used to compare the pre- and post-RPFT results and to analyze results by gender and profession. RESULTS: Statistically significant changes were observed in pre-post questionnaire scores in the domains of mental health attitudes and knowledge. CONCLUSIONS: Although results are explorative, the RPFT may facilitate positive changes in workplace mental health attitudes and knowledge among PSP. It is hoped these findings will contribute to a broader evidence base that can inform changes to the program, practices, and policies, and inform decision-making regarding the EPSRP.

Technology Acceptance and Usability of a Virtual Reality Intervention for Military Members and Veterans With Posttraumatic Stress Disorder: Mixed Methods Unified Theory of Acceptance and Use of Technology Study.

BACKGROUND: Military members and veterans exhibit higher rates of injuries and illnesses such as posttraumatic stress disorder (PTSD) because of their increased exposure to combat and other traumatic scenarios. Novel treatments for PTSD are beginning to emerge and increasingly leverage advances in gaming and other technologies, such as virtual reality. Without assessing the degree of technology acceptance and perception of usability to the end users, including the military members, veterans, and their attending therapists and staff, it is difficult to determine whether a technology-based treatment will be used successfully in wider clinical practice. The Unified Theory of Acceptance and Use of Technology model is commonly used to address the technology acceptance and usability of applications in 5 domains. OBJECTIVE: Using the Unified Theory of Acceptance and Use of Technology model, the purpose of this study was to determine the technology acceptance and usability of multimodal motion-assisted memory desensitization and reconsolidation (3MDR) on a virtual reality system in the primary user group (military members and veterans with treatment-resistant PTSD, 3MDR therapists, and virtual reality environment operators). METHODS: This mixed methods embedded pilot study included military members (n=3) and veterans (n=8) with a diagnosis of combat-related PTSD, as well as their therapists (n=13) and operators (n=5) who completed pre-post questionnaires before and on completion of 6 weekly sessions of 3MDR. A partial least squares structural equation model was used to analyze the questionnaire results. Qualitative data from the interviews were assessed using thematic analysis. RESULTS: Effort expectancy, which was the most notable predictor of behavioral intention, increased after a course of 3MDR with the virtual reality system, whereas all other constructs demonstrated no significant change. Participants' expectations of the technology were met, as demonstrated by the nonsignificant differences in the pre-post scores. The key qualitative themes included feasibility and function, technical support, and tailored immersion. CONCLUSIONS: 3MDR via a virtual reality environment appears to be a feasible, usable, and accepted technology for delivering 3MDR to military members and veterans who experience PTSD and 3MDR therapists and operators who facilitate their treatment.

Efficacy, Effectiveness, and Quality of Resilience-Building Mobile Health Apps for Military, Veteran, and Public Safety Personnel Populations: Scoping Literature Review and App Evaluation.

BACKGROUND: Military members (MMs) and public safety personnel (PSP) are vulnerable to occupational stress injuries because of their job demands. When MMs and PSP transition out of these professions, they may continue to experience mental health challenges. The development and implementation of resilience-building mobile health (mHealth) apps as an emergent mental health intervention platform has allowed for targeted, cost-effective, and easily accessible treatment when in-person therapy may be limited or unavailable. However, current mHealth app development is not regulated, and often lacks both clear evidence-based research and the input of health care professionals. OBJECTIVE: This study aims to evaluate the evidence-based quality, efficacy, and effectiveness of resilience-building mobile apps targeted toward the MMs, PSP, and veteran populations via a scoping literature review of the current evidence base regarding resilience apps for these populations and an evaluation of free resilience apps designed for use among these populations. METHODS: The studies were selected using a comprehensive search of MEDLINE, CINAHL Plus, PsycINFO, SocINDEX, Academic Search Complete, Embase, and Google and were guided by PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). A narrative synthesis of the resulting papers was performed. The Alberta Rating Index for Apps was used to conduct a review of each of the identified apps. The inclusion criteria consisted of apps that were free to download in either the Google Play Store or the Apple App Store; updated within the last 3 years; available in English and in Canada; and intended for use by MMs, veterans, and PSP. RESULTS: In total, 22 apps met the inclusion criteria for evaluation. The resilience strategies offered by most apps included psychoeducation, mindfulness, cognitive behavioral therapy, and acceptance and commitment therapy. Overall, 50% (11/22) of apps had been tested in randomized controlled trials, 7 (32%) apps had been evaluated using other research methods, and 5 (23%) apps had not been studied. Using the Alberta Rating Index for Apps, the app scores ranged from 37 to 56 out of 72, with higher rated apps demonstrating increased usability and security features. CONCLUSIONS: The mHealth apps reviewed are well-suited to providing resilience strategies for MMs, PSP, and veterans. They offer easy accessibility to evidence-based tools while working to encourage the use of emotional and professional support with safety in mind. Although not intended to function as a substitute for professional services, research has demonstrated that mHealth apps have the potential to foster a significant reduction in symptom severity for posttraumatic stress disorder, depression, anxiety, and other mental health conditions. In clinical practice, apps can be used to supplement treatment and provide clients with population-specific confidential tools to increase engagement in the treatment process.

Meat in a Seat: A Grounded Theory Study Exploring Moral Injury in Canadian Public Safety Communicators, Firefighters, and Paramedics.

The work of public safety personnel (PSP) is inherently moral; however, the ability of PSP to do what is good and right can be impeded and frustrated, leading to moral suffering. Left unresolved, moral suffering may develop into moral injury (MI) and potential psychological harm. The current study was designed to examine if MI is relevant to frontline public safety communicators, firefighters, and paramedics. Semi-structured interviews (n = 3) and focus groups (n = 3) were conducted with 19 participants (public safety communicators (n = 2); paramedics (n = 7); and firefighters (n = 10)). Interviews and focus groups were audio-recorded, transcribed, coded, and constantly compared in accordance with the grounded theory method. A conceptual theory of "frustrating moral expectations" emerged, with participants identifying three interrelated properties as being potentially morally injurious: chronic societal problems, impaired systems, and organizational quagmires. Participants navigated their moral frustrations through both integrative and disintegrative pathways, resulting in either needing to escape their moral suffering or transforming ontologically. The current study results support MI as a relevant concept for frontline PSP. Given the seriousness of PSP leaving their profession or committing suicide to escape moral suffering, the importance of the impact of MI on PSP and public safety organizations cannot be ignored or underestimated. Understanding the similarities and differences of morally injurious exposures of frontline PSP may be critical for determining mental health and resilience strategies that effectively protect PSP.

Decreased Emotional Dysregulation Following Multi-Modal Motion-Assisted Memory Desensitization and Reconsolidation Therapy (3MDR): Identifying Possible Driving Factors in Remediation of Treatment-Resistant PTSD.

Multi-modal motion-assisted memory desensitization and reconsolidation therapy (3MDR), an interactive, virtual reality-assisted, exposure-based intervention for PTSD, has shown promising results for treatment-resistant posttraumatic stress disorder (TR-PTSD) among military members (MMs) and veterans in randomized controlled trials (RCT). Previous research has suggested that emotional regulation (ER) and emotional dysregulation (ED) may be factors which are correlated with symptom severity and maintenance of TR-PTSD. This embedded mixed-methods pilot study (n = 9) sought to explore the impact of 3MDR on ER and ED of MMs and veterans. Difficulties in Emotional Regulation Scale (DERS-18) data were collected at baseline, prior to each session, and at one week, one month, and three months postintervention and analyzed. Qualitative data collected from sessions, debriefs, and follow-up interviews were transcribed and descriptively analyzed. Results demonstrated statistically significant decreases in DERS-18 scores from preintervention to postintervention at each timepoint. Qualitatively, participants perceived improvements in ER within specified DERS-18 domains. We describe how 3MDR's unique and novel approach addresses ED through cognitive-motor stimulation, narration, divergent thinking, reappraisal of aversive stimuli, dual-task processing, and reconsolidation of traumatic memories. More studies are needed to better understand the underlying neurobiological mechanisms by which 3MDR addresses ER and PTSD.

Resilient Parents Resilient Communities: A Pilot Study Trialing the Bounce Back and Thrive! Resilience-Training Program With Military Families.

INTRODUCTION: The resilience of Canadian military families (CMFs) - the main support of the Canadian Armed Forces service members (SMs) - is imperative. The Canadian Armed Forces aims to ensure that SMs and their families are resilient and SMs ready to respond when called upon for combat, peacekeeping or pandemic/disaster-response. Family concerns, however, can realistically distract SMs from the mission, potentially compromising themselves, their unit and the mission. Resilience-training programs such as Bounce Back and Thrive! (BBT) can help families manage the realities of military life. OBJECTIVE: This pilot study aimed to evaluate suitability of BBT implementation by Military Family Resource Centers (MFRCs), including whether BBT: (1) fosters resilience-building among parents, (2) facilitates CMF resilience-building, (3) can be contextualized for CMFs, and (4) supports MFRCs in cultivating a culture of resilience. METHODS: An exploratory qualitative design was used. BBT was offered to parents face-to-face. Participants completed focus groups after the first 6 sessions, final 4 sessions, and one-year post-intervention. Data was thematically analyzed. RESULTS: Nine military parents participated. Four major themes resulted: (1) military parent resilience-building, (2) CMF resilience-building, (3) BBT program feedback and contextualization, and (4) MFRCs as community resilience hubs. DISCUSSION: BBT enabled parents to gain a new perspective on resilience, engage in dialogue and intentionally role model resilience skills. Military-specific BBT contextualization and online-delivery formats would increase suitability and access for CMFs. Access to resilience programs delivered through MFRCs would support CMFs. Further research is warranted.