Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label PTSD. Show all posts
Showing posts with label PTSD. Show all posts

Saturday, September 23, 2023

Moral injury in post-9/11 combat-experienced military veterans: A qualitative thematic analysis.

Kalmbach, K. C., Basinger, E. D.,  et al. (2023). 
Psychological Services. Advance online publication.

Abstract

War zone exposure is associated with enduring negative mental health effects and poorer responses to treatment, in part because this type of trauma can entail crises of conscience or moral injury. Although a great deal of attention has been paid to posttraumatic stress disorder and fear-based physiological aspects of trauma and suffering, comparatively less attention has been given to the morally injurious dimension of trauma. Robust themes of moral injury were identified in interviews with 26 post-9/11 military veterans. Thematic analysis identified 12 themes that were subsumed under four categories reflecting changes, shifts, or ruptures in worldview, meaning making, identity, and relationships. Moral injury is a unique and challenging clinical construct with impacts on the individual as well as at every level of the social ecological system. Recommendations are offered for addressing moral injury in a military population; implications for community public health are noted.

Impact Statement

Military veterans who experienced moral injury—events that violate deeply held moral convictions or beliefs—reported fundamental changes following the morally injurious event (MIE). The MIE ruptured their worldview, or sense of right and wrong, and they struggled to reconcile a prior belief system or identity with their existence post-MIE. Absent a specific evidence-based intervention, clinicians are encouraged to consider adaptations to existing treatment models but to be aware that moral injury often does not respond to treatment as usual for PTSD or adjacent comorbid conditions.

The article is paywalled, with the link noted above.

My addition:

The thematic analysis identified 12 themes related to moral injury, which were grouped into four categories:
  • Changes in worldview: Veterans who experienced moral injury often reported changes in their worldview, such as questioning their beliefs about the world, their place in it, and their own goodness.
  • Changes in meaning making: Veterans who experienced moral injury often struggled to make meaning of their experiences, which could lead to feelings of emptiness, despair, and hopelessness.
  • Changes in identity: Veterans who experienced moral injury often reported changes in their identity, such as feeling like they were no longer the same person they were before the war.
  • Changes in relationships: Veterans who experienced moral injury often reported changes in their relationships with family, friends, and others. They may have felt isolated, misunderstood, or ashamed of their experiences.

Friday, December 16, 2022

How Bullying Manifests at Work — and How to Stop It

Ludmila N. Praslova, Ron Carucci, & Caroline Stokes
Harvard Business Review
Originally posted 4 NOV 22

While the organizational costs of incivility and toxicity are well documented, bullying at work is still a problem. An estimated 48.6 million Americans, or about 30% of the workforce, are bullied at work. In India, that percentage is reported to be as high as 46% or even 55%. In Germany, it’s a lower but non-negligible 17%. Yet bullying often receives little attention or effective action.

To maximize workplace health and well-being, it’s critical to create workplaces where all employees — regardless of their position — are safe. Systemic, organizational-level approaches can help prevent the harms associated with different types of bullying.

The term workplace bullying describes a wide range of behaviors, and this complexity makes addressing it difficult and often ineffective. Here, we’ll discuss the different types of bullying, the myths that prevent leaders from addressing it, and how organizations can effectively intervene and create a safer workplace.

The Different Types of Bullying

To develop more comprehensive systems of bullying prevention and support employees’ psychological well-being, leaders first need to be aware of the different types of bullying and how they show up. We’ve identified 15 different features of bullying, based on standard typologies of aggression, data from the Workplace Bullying Institute (WBI), and Ludmila’s 25+ years of research and practice focused on addressing workplace aggression, discrimination, and incivility to create healthy organizational cultures.

These 15 features can be mapped to some of the common archetypes of bullies. Take the “Screamer,” who is associated with yelling and fist-banging or the quieter but equally dangerous “Schemer” who uses Machiavellian plotting, gaslighting, and smear campaigns to strip others of resources or push them out. The Schemer doesn’t necessarily have a position of legitimate power and can present as a smiling and eager-to-help colleague or even an innocent-looking intern. While hostile motivation and overt tactics align with the Screamer bully archetype and instrumental, indirect, and covert bullying is typical of the Schemer, a bully can have multiple motives and use multiple tactics — consciously or unconsciously.

Caroline mediated a situation that illustrates both conscious and unconscious dynamics. At the reception to celebrate Ewa’s* national-level achievement award, Harper, her coworker, spent most of the time talking about her own accomplishments, then took the stage to congratulate herself on mentoring Ewa and letting her take “ownership” of their collective work. But there had been no mentorship or collective work. After overtly and directly putting Ewa down and (perhaps unconsciously) attempting to elevate herself, Harper didn’t stop. She “accidentally” removed Ewa from crucial information distribution lists — an act of indirect, covert sabotage.  

In another example, Ludmila encountered a mixed-motive, mixed-tactic situation. Charles, a manager with a strong xenophobic sentiment, regularly berated Noor, a work visa holder, behind closed doors — an act of hostile and direct bullying. Motivated by a desire to take over the high-stakes, high-visibility projects Noor had built, Charles also engaged in indirect, covert bullying by falsifying performance records to make a case for her dismissal.

Wednesday, May 11, 2022

Bias in mental health diagnosis gets in the way of treatment

Howard N. Garb
psyche.co
Originally posted 2 MAR 22

Here is an excerpt:

What about race-related bias? 

Research conducted in the US indicates that race bias is a serious problem for the diagnosis of adult mental disorders – including for the diagnosis of PTSD, depression and schizophrenia. Preliminary data also suggest that eating disorders are underdiagnosed in Black teens compared with white and Hispanic teens.

The misdiagnosis of PTSD can have significant economic consequences, in addition to its implications for treatment. In order for a US military veteran to receive disability compensation for PTSD from the Veterans Benefits Administration, a clinician has to diagnose the veteran. To learn if race bias is present in this process, a research team compared its own systematic diagnoses of veterans with diagnoses made by clinicians during disability exams. Though most clinicians will make accurate diagnoses, the research diagnoses can be considered more accurate, as the mental health professionals who made them were trained to adhere to diagnostic criteria and use extensive information. When veterans received a research diagnosis of PTSD, they should have also gotten a clinician’s diagnosis of PTSD – but this occurred only about 70 per cent of the time.

More troubling is that, in cases where research diagnoses of PTSD were made, Black veterans were less likely than white veterans to receive a clinician’s diagnosis of PTSD during their disability exams. There was one set of cases where bias was not evident, however. In roughly 25 per cent of the evaluations, clinicians administered a formal PTSD symptom checklist or a psychological test to help them make a diagnosis – and if this additional information was collected, race bias was not observed. This is an important finding. Clinicians will sometimes form a first impression of a patient’s condition and then ask questions that can confirm – but not refute – their subjective impression. By obtaining good-quality objective information, clinicians might be less inclined to depend on their subjective impressions alone.

Race bias has also been found for other forms of mental illness. Historically, research indicated that Black patients and sometimes Hispanic patients were more likely than white patients to be given incorrect diagnoses of schizophrenia, while white patients were more often given correct diagnoses of major depression and bipolar disorder. During the past 20 years, this appears to have changed somewhat, with the most accurate diagnoses being made for Latino patients, the least accurate for Black patients, and the results for white patients somewhere in between.

Wednesday, March 23, 2022

Moral Injury, Traumatic Stress, and Threats to Core Human Needs in Health-Care Workers: The COVID-19 Pandemic as a Dehumanizing Experience

Hagerty, S. L., & Williams, L. M. (2022)
Clinical Psychological Science. 
https://doi.org/10.1177/21677026211057554

Abstract

The pandemic has threatened core human needs. The pandemic provides a context to study psychological injury as it relates to unmet basic human needs and traumatic stressors, including moral incongruence. We surveyed 1,122 health-care workers from across the United States between May 2020 and August 2020. Using a mixed-methods design, we examined moral injury and unmet basic human needs in relation to traumatic stress and suicidality. Nearly one third of respondents reported elevated symptoms of psychological trauma, and the prevalence of suicidal ideation among health-care workers in our sample was roughly 3 times higher than in the general population. Moral injury and loneliness predict greater symptoms of traumatic stress and suicidality. We conclude that dehumanization is a driving force behind the psychological injury resulting from moral incongruence in the context of the pandemic. The pandemic most frequently threatened basic human motivations at the foundational level of safety and security relative to other higher order needs.

From the General Discussion

A subset of respondents added context to their experiences of moral injury in the form of narrative responses. These powerful accounts of the lived experiences of health-care workers provided us with a richer understanding of the construct of moral injury, especially as it relates to the novel context of the pandemic. Although betrayal is a known facet of moral injury from prior work (Bryan et al., 2016), our qualitative analysis suggests that dehumanization may also be a key phenomenon that underlies pandemic-related moral injury. Given our findings, we suggest that it may be important to attend to both betrayal and dehumanization when researching or intervening on the psychological sequelae of the pandemic. Our results support this because experiences of dehumanization in our sample were associated with greater symptoms of traumatic stress.

Another lens through which to view the experiences of health-care workers in the pandemic is through unsatisfied basic human motivations. Given the obvious barriers the pandemic presents to human connection (Hagerty & Williams, 2020), we had an a priori interest in studying loneliness. Our results indeed suggest that need of social connection appears relevant to the mental-health experiences of health-care workers during the pandemic such that loneliness was associated with greater traumatic stress, moral injury, and suicidal ideation. Echoing the importance of this social factor are findings from prior research suggesting that social connectedness buffers the association between moral injury and suicidality (Kelley et al., 2019) and buffers the impact of PTSD symptoms on suicidal behavior (Panagioti et al., 2014). Thus, our work further highlights lack of social connection as possible risk factor among individuals who face moral injury and traumatic stress and demonstrates its relevance to the mental health of health-care workers during the pandemic.

Monday, November 9, 2020

Betrayal vs. Nonbetrayal Trauma: Different Effects of Social Support & Emotion Regulation on PTSD Symptom Severity

N. Kline & K.M. Palm Read
Psychological Trauma: 
Theory, Research, Practice, and Policy. 

Abstract

Objective: Betrayal Trauma Theory posits that interpersonal traumas are particularly injurious when the perpetrator is a person that the victim previously trusted and was close to. A relevant protective factor to examine is social support, which may influence PTSD symptomology through its influence on emotion regulation. The aim of the current study was to examine differences in the associations between social support, emotion regulation, and PTSD symptom severity for survivors of betrayal trauma and nonbetrayal trauma. 

Method: Two hundred and 73 trauma survivors (age: M = 25.96 years, SD = 9.42 years; 80.2% female; 63.7% White) completed the anonymous, online survey. Results: Across both groups, emotion regulation mediated the relationship between social support and PTSD symptom severity. A multiple-samples SEM analysis showed that the betrayal group evidenced a weaker relationship between social support and emotion regulation. 

Conclusions: Findings suggest that survivors of high betrayal trauma may not engage with their social support in ways that foster emotion regulation skills. Therefore, for high betrayal trauma survivors specifically, group interventions that involve the survivor and close contact(s), may be particularly beneficial in enhancing emotion regulation and decreasing PTSD symptomology.

Impact Statement

Findings suggest social support may influence the impact of trauma through improving survivors’ ability to regulate emotions. Survivors of betrayal trauma may not seek out social support to the same extent or manner as nonbetrayal trauma survivors, limiting opportunities for beneficial emotional regulation practices and support. Clinicians should consider focusing on how interpersonal processes can facilitate greater understanding, acceptance, and regulation of emotions following betrayal trauma. 

Monday, July 6, 2020

Reframing Clinician Distress: Moral Injury Not Burnout

W. Dean, S. Talbot, and A. Dean
Fed Pract. 2019 Sep; 36(9): 400–402.

For more than a decade, the term burnout has been used to describe clinician distress. Although some clinicians in federal health care systems may be protected from some of the drivers of burnout, other federal practitioners suffer from rule-driven health care practices and distant, top-down administration. The demand for health care is expanding, driven by the aging of the US population. Massive information technology investments, which promised efficiency for health care providers, have instead delivered a triple blow: They have diverted capital resources that might have been used to hire additional caregivers, diverted the time and attention of those already engaged in patient care, and done little to improve patient outcomes. Reimbursements are falling, and the only way for health systems to maintain their revenue is to increase the number of patients each clinician sees per day. As the resources of time and attention shrink, and as spending continues with no improvement in patient outcomes, clinician distress is on the rise. It will be important to understand exactly what the drivers of the problem are for federal clinicians so that solutions can be appropriately targeted. The first step in addressing the epidemic of physician distress is using the most accurate terminology to describe it.

Freudenberger defined burnout in 1975 as a constellation of symptoms—malaise, fatigue, frustration, cynicism, and inefficacy—that arise from “making excessive demands on energy, strength, or resources” in the workplace. The term was borrowed from other fields and applied to health care in the hopes of readily transferring the solutions that had worked in other industries to address a growing crisis among physicians. Unfortunately, the crisis in health care has proven resistant to solutions that have worked elsewhere, and many clinicians have resisted being characterized as burned out, citing a subtle, elusive disconnect between what they have experienced and what burnout encapsulates.

In July 2018, the conversation about clinician distress shifted with an article we wrote in STAT that described the moral injury of health care. The concept of moral injury was first described in service members who returned from the Vietnam War with symptoms that loosely fit a diagnosis of posttraumatic stress disorder (PTSD), but which did not respond to standard PTSD treatment and contained symptoms outside the PTSD constellation. On closer assessment, what these service members were experiencing had a different driver. Whereas those with PTSD experienced a real and imminent threat to their mortality and had come back deeply concerned for their individual, physical safety, those with this different presentation experienced repeated insults to their morality and had returned questioning whether they were still, at their core, moral beings. They had been forced, in some way, to act contrary to what their beliefs dictated was right by killing civilians on orders from their superiors, for example. This was a different category of psychological injury that required different treatment.

The article is here.

Friday, April 3, 2020

Treating “Moral” Injuries

Anna Harwood-Gross
Scientific American
Originally posted 24 March 20

Here is an excerpt:

Though PTSD symptoms such as avoidance of reminders of the traumatic event and intrusive thought patterns may also be present in moral injury, they appear to serve different purposes, with PTSD sufferers avoiding fear and moral injury sufferers avoiding shame triggers. Few comparison studies of PTSD and moral injury exist, yet there has been research that indirectly compares the two conditions by differentiating between fear-based and non-fear-based (i.e., moral injury) forms of PTSD, which have been demonstrated to have different neurobiological markers. In the context of the military, there are countless examples of potentially morally injurious events (PMIEs), which can include killing or wounding others, engaging in retribution or disproportionate violence, or failing to save the life of a comrade, child or civilian. The experience of PMIEs has been demonstrated to lead to a larger range of psychological distress symptoms, including higher levels of guilt, anger, shame, depression and social isolation, than those seen in traditional PTSD profiles.

Guilt is difficult to address in therapy and often lingers following standardized PTSD treatment (that is, if the sufferer is able to access therapy). It may, in fact, be a factor in the more than 49 percent of veterans who drop out of evidence-based PTSD treatment or in why, at times, up to 72% of sufferers, despite meaningful improvement in their symptoms, do not actually recover enough after such treatment for their PTSD diagnosis to be removed. Most often, moral injury symptoms that are present in the clinic are addressed through traditional PTSD treatments, with thoughts of guilt and shame treated similarly to other distorted cognitions. When guilt and the events it relates to are treated as “a feeling and not a fact,” as psychologist Lisa Finlay put it in a 2015 paper, there is an attempt to lessen or relieve such emotions while taking a shortcut to avoid experiencing those that are legitimate and reasonable after-wartime activities. Continuing, Finlay stated that “the idea that we might get good, as a profession, at talking people out of guilt following their involvement in traumatic incidents is frighteningly short-sighted in more ways than one.”

The info is here.

Wednesday, December 4, 2019

Veterans Must Also Heal From Moral Injury After War

Camillo Mac Bica
truthout.org
Originally published Nov 11, 2019

Here are two excerpts:

Humankind has identified and internalized a set of values and norms through which we define ourselves as persons, structure our world and render our relationship to it — and to other human beings — comprehensible. These values and norms provide the parameters of our being: our moral identity. Consequently, we now have the need and the means to weigh concrete situations to determine acceptable (right) and unacceptable (wrong) behavior.

Whether an individual chooses to act rightly or wrongly, according to or in violation of her moral identity, will affect whether she perceives herself as true to her personal convictions and to others in the moral community who share her values and ideals. As the moral gravity of one’s actions and experiences on the battlefield becomes apparent, a warrior may suffer profound moral confusion and distress at having transgressed her moral foundations, her moral identity.

Guilt is, simply speaking, the awareness of having transgressed one’s moral convictions and the anxiety precipitated by a perceived breakdown of one’s ethical cohesion — one’s integrity — and an alienation from the moral community. Shame is the loss of self-esteem consequent to a failure to live up to personal and communal expectations.

(cut)

Having completed the necessary philosophical and psychological groundwork, veterans can now begin the very difficult task of confronting the experience. That is, of remembering, reassessing and morally reevaluating their responsibility and culpability for their perceived transgressions on the battlefield.

Reassessing their behavior in combat within the parameters of their increased philosophical and psychological awareness, veterans realize that the programming to which they were subjected and the experience of war as a survival situation are causally connected to those specific battlefield incidents and behaviors, theirs and/or others’, that weigh heavily on their consciences — their moral injury. As a consequence, they understand these influences as extenuating circumstances.

Finally, as they morally reevaluate their actions in war, they see these incidents and behaviors in combat not as justifiable, but as understandable, perhaps even excusable, and their culpability mitigated by the fact that those who determined policy, sent them to war, issued the orders, and allowed the war to occur and/or to continue unchallenged must share responsibility for the crimes and horror that inevitably characterize war.

The info is here.

Monday, November 18, 2019

Suicide Has Been Deadlier Than Combat for the Military

Carol Giacomo
The New York Times
Originally published November 1, 2019

Here are two excerpts:

The data for veterans is also alarming.

In 2016, veterans were one and a half times more likely to kill themselves than people who hadn’t served in the military, according to the House Committee on Oversight and Reform.

Among those ages 18 to 34, the rate went up nearly 80 percent from 2005 to 2016.

The risk nearly doubles in the first year after a veteran leaves active duty, experts say.

The Pentagon this year also reported on military families, estimating that in 2017 there were 186 suicide deaths among military spouses and dependents.

(cut)

Experts say suicides are complex, resulting from many factors, notably impulsive decisions with little warning. Pentagon officials say a majority of service members who die by suicide do not have mental illness. While combat is undoubtedly high stress, there are conflicting views on whether deployments increase risk.

Where there seems to be consensus is that high-quality health care and keeping weapons out of the hands of people in distress can make a positive difference.

Studies show that the Department of Veterans Affairs provides high-quality care, and its Veterans Crisis Line “surpasses most crisis lines” operating today, according to Terri Tanielian, a researcher with the RAND Corporation. (The Veterans Crisis Line is staffed 24/7 at 800-273-8255, press 1. Services also are available online or by texting 838255.)

But Veterans Affairs often can’t accommodate all those needing help, resulting in patients being sent to community-based mental health professionals who lack the training to deal with service members.

The info is here.

Wednesday, March 20, 2019

Israel Approves Compassionate Use of MDMA to Treat PTSD

Ido Efrati
www.haaretz.com
Originally posted February 10, 2019

MDMA, popularly known as ecstasy, is a drug more commonly associated with raves and nightclubs than a therapist’s office.

Emerging research has shown promising results in using this “party drug” to treat patients suffering from post-traumatic stress disorder, and Israel’s Health Ministry has just approved the use of MDMA to treat dozens of patients.

MDMA is classified in Israel as a “dangerous drug”, recreational use is illegal, and therapeutic use of MDMA has yet to be formally approved and is still in clinical trials.

However, this treatment is deemed as “compassionate use,” which allows drugs that are still in development to be made available to patients outside of a clinical trial due to the lack of effective alternatives.

The info is here.

Monday, June 4, 2018

A narrative thematic analysis of moral injury in combat veterans

Held, P., Klassen, B. J., Hall, J. M., Friese, and others
Psychological Trauma: Theory, Research, Practice, and Policy. 
Advance online publication. http://dx.doi.org/10.1037/tra0000364

Here is a portion of the Introduction:

In war, service members sometimes have to make difficult decisions, some of which may violate their deeply held beliefs and moral values. The term moral injury was coined to refer to the enduring mental health consequences that can occur from participating in, witnessing, or learning about acts that violate one’s moral code (Drescher et al., 2011; Litz et al., 2009; Shay, 1994). Some examples of potentially morally injurious events include disproportionate violence, engaging in atrocities, or violations of rules of engagement (Litz et al., 2009; Stein et al., 2012). Although consensus regarding how best to measure moral injury has not been reached, one preliminary estimate suggested that as many as 25% of a representative sample of veterans endorsed exposure to morally injurious experiences (Wisco et al., 2017). Involvement in these situations has been shown to be associated with a range of negative psychological reactions, including the development of mental health symptoms, such as posttraumatic stress disorder (PTSD), depression (Held, Klassen, Brennan, & Zalta, 2017; Maguen et al., 2010), substance use problems (Wilk et al., 2010) and suicidal ideation (Maguen et al., 2012).

Litz and colleagues (2009) have proposed the sole theoretical model of how moral transgressions result in the development of mental health symptoms. Following the morally injurious event, individuals experience a conflict between the event and their own moral beliefs. For example, a service member may believe that civilians should not be harmed during combat but is involved in an event that involves the death of noncombatants. In an attempt to resolve this cognitive conflict, self-directed attributions of the event’s cause may be made, such as service members believing that they were complicit in noncombatants being harmed. The stable, internal, and global attributions that result lead to the development of painful emotions (e.g., guilt, shame, fear of social rejection) and withdrawal from social interaction. Lack of social contact leads to missed opportunities for potentially corrective information and further strengthens the painful emotions and the stable, internal, and global attributions about the morally injurious event (e.g., Martin et al., 2017). It has been proposed that unless addressed, the moral injury continues to manifest and perpetuate itself through intrusions, avoidance, and numbing in a manner similar to PTSD (Jinkerson, 2016; Farnsworth, Drescher, Nieu- wsma, Walser, & Currier, 2014; Litz, Lebowitz, Gray, & Nash, 2016; Litz et al., 2009).

The article is here.

Monday, April 23, 2018

Shared Decision-making for PTSD

Juliette Harik, PhD
PTSD Research Quarterly (2018) Volume 29 (1)

Here is an excerpt:

Although several different shared decision-making models exist (for a review see Lin & Fagerlin, 2014), one useful approach conceptualizes shared decision-making as consisting of three phases
(Elwyn et al., 2012): choice talk, option talk, and decision talk. Choice talk involves communicating
to patients that there is a decision to make and that they can be involved in this decision to the extent
that they are comfortable. Option talk consists of sharing accurate and comprehensive information
about treatment options. Ideally, this involves the use of a decision aid, which is an educational tool
such as a website, brochure, or video designed to help patients understand and compare various
options (for a review, see Stacey et al., 2017). The third and final step, decision talk, consists of an
exploration of the patient’s preferences and what matters most to him or her. The process of shared
decision-making is intended to help the patient develop informed preferences, and ultimately arrive
at the decision that is best for him or her. Importantly, patients with the same clinical condition may arrive at very different treatment decisions on the basis of unique values and preferences.

Shared decision-making has been evaluated most often among patients facing care decisions for chronic medical conditions, especially cancer. In medical patients, shared decision-making has been linked with greater confidence in the treatment decision, improved satisfaction with decision-making and with treatment, greater self-efficacy, and increased trust in the provider (Joosten et al., 2008; Shay & Lafata, 2015). In mental health, shared decision-making has been most often evaluated in the context of depression, yielding mixed results on both satisfaction and treatment outcomes (Duncan, Best, & Hagen, 2010). Fewer studies have evaluated the effectiveness of shared decision-making for other mental health conditions such as PTSD.

The information is here.

Thursday, April 5, 2018

Moral Injury and Religiosity in US Veterans With Posttraumatic Stress Disorder Symptoms

Harold Koenig and others
The Journal of Nervous and Mental Disease: February 28, 2018

Abstract

Moral injury (MI) involves feelings of shame, grief, meaninglessness, and remorse from having violated core moral beliefs related to traumatic experiences. This multisite cross-sectional study examined the association between religious involvement (RI) and MI symptoms, mediators of the relationship, and the modifying effects of posttraumatic stress disorder (PTSD) severity in 373 US veterans with PTSD symptoms who served in a combat theater. Assessed were demographic, military, religious, physical, social, behavioral, and psychological characteristics using standard measures of RI, MI symptoms, PTSD, depression, and anxiety. MI was widespread, with over 90% reporting high levels of at least one MI symptom and the majority reporting at least five symptoms or more. In the overall sample, religiosity was inversely related to MI in bivariate analyses (r = −0.25, p < 0.0001) and multivariate analyses (B = −0.40, p = 0.001); however, this relationship was present only among veterans with severe PTSD (B = −0.65, p = 0.0003). These findings have relevance for the care of veterans with PTSD.

The paper is here.

Saturday, November 4, 2017

Prince Harry: mental health should be at heart of armed forces training

Caroline Davies
The Guardian
Originally posted October 9, 2017

Prince Harry has said mental health strategies for armed forces personnel are crucial to create a “more confident, focused and, ultimately, more combat-ready military”.

In a speech at the Ministry of Defence, the 33-year-old prince, who spent 10 years in the army, said that as the number of active-duty personnel had been reduced there was a premium on “every individual being fighting fit and deployable”.

Announcing a joint initiative between the MoD and the Royal Foundation, created by the prince and the Duke and Duchess of Cambridge to tackle mental health issues, Harry said mental health strategies needed to be at the forefront of armed forces personnel training.

“Quite simply, these men and women are prized assets which need to be continually invested in. We surely have to think of them as high-performance athletes, carrying all their kit, equipment and a rifle,” he said. “Crucially, fighting fitness is not just about physical fitness. It is just as much about mental fitness too.”

The MoD said the move would build upon a recently launched government strategy aimed at improving mental health among military workers, civilian staff, their families and veterans.

The article is here.

Wednesday, September 20, 2017

What is moral injury, and how does it affect journalists covering bad stuff?

Thomas Ricks
Foreign Policy
Originally published September 5, 2017

Here is an excerpt:

They noted that moral injury is the damage done to a “person’s conscience or moral compass by perpetrating, witnessing, or failing to prevent acts that transgress personal moral and ethical values or codes of conduct.”

While not all journalists were affected the same way, the most common reactions were feelings of guilt at not having done enough personally to help refugees and shame at the behavior of others, such as local authorities, they wrote.

Journalists with children had more moral injury-related distress while those working alone said they were more likely to have acted in ways that violated their own moral code. Those who said they had not received enough support from their organization were more likely to admit seeing things they perceived as morally wrong. Less control over resources to report on the crisis also correlated significantly with moral injury. And moral injury scores correlated significantly with guilt. Greater guilt, in turn, was noted by journalists covering the story close to home and by those who had assisted refugees, the report added.

Feinstein and Storm wrote that moral injury can cause “considerable emotional upset.” They noted that journalists reported symptoms of intrusion. While they didn’t go into detail, intrusion can mean flashbacks, nightmares and unwanted memories. These can disrupt normal functioning. In my view, guilt and shame can also be debilitating.

The article is here.

Friday, September 8, 2017

Errors in the 2017 APA Clinical Practice Guideline for the Treatment of PTSD: What the Data Actually Says

Dominguez, S. and Lee, C.
Front. Psychol., 22 August 2017

Abstract

The American Psychological Association (APA) Practice Guidelines for the Treatment of Posttraumatic Stress Disorder (PTSD) concluded that there was strong evidence for cognitive behavioral therapy (CBT), cognitive processing therapy (CPT), cognitive therapy (CT), and exposure therapy yet weak evidence for eye movement desensitization and reprocessing (EMDR). This is despite the findings from an associated systematic review which concluded that EMDR leads to loss of PTSD diagnosis and symptom reduction. Depression symptoms were also found to improve more with EMDR than control conditions. In that review, EMDR was marked down on strength of evidence (SOE) for symptom reduction for PTSD. However, there were several problems with the conclusions of that review. Firstly, in assessing the evidence in one of the studies, the reviewers chose an incorrect measure that skewed the data. We recalculated a meta-analysis with a more appropriate measure and found the SOE improved. The resulting effect size for EMDR on PTSD symptom reduction compared to a control condition was large for studies that meet the APA inclusion criteria (SMD = 1.28) and the heterogeneity was low (I2 = 43%). Secondly, even if the original measure was chosen, we highlight inconsistencies with the way SOE was assessed for EMDR, CT, and CPT. Thirdly, we highlight two papers that were omitted from the analysis. One of these was omitted without any apparent reason. It found EMDR superior to a placebo control. The other study was published in 2015 and should have been part of APA guidelines since they were published in 2017. The inclusion of either study would have resulted in an improvement in SOE. Including both studies results in standard mean difference and confidence intervals that were better for EMDR than for CPT or CT. Therefore, the SOE should have been rated as moderate and EMDR assessed as at least equivalent to these CBT approaches in the APA guidelines. This would bring the APA guidelines in line with other recent practice guidelines from other countries. Less critical but also important, were several inaccuracies in assessing the risk of bias and the failure to consider studies supporting strong gains of EMDR at follow-up.

The article is here.

Friday, June 23, 2017

Moral Injury, Posttraumatic Stress Disorder, and Suicidal Behavior Among National Guard Personnel.

Craig Bryan, Anna Belle Bryan, Erika Roberge, Feea Leifker, & David Rozek
Psychological Trauma: Theory, Research, Practice, and Policy 

Abstract

To empirically examine similarities and differences in the signs and symptoms of posttraumatic stress disorder (PTSD) and moral injury and to determine if the combination of these 2 constructs is associated with increased risk for suicidal thoughts and behaviors in a sample of U.S. National Guard personnel. Method: 930 National Guard personnel from the states of Utah and Idaho completed an anonymous online survey. Exploratory structural equation modeling (ESEM) was used to test a measurement model of PTSD and moral injury. A structural model was next constructed to test the interactive effects of PTSD and moral injury on history of suicide ideation and attempts. Results: Results of the ESEM confirmed that PTSD and moral injury were distinct constructs characterized by unique symptoms, although depressed mood loaded onto both PTSD and moral injury. The interaction of PTSD and moral injury was associated with significantly increased risk for suicide ideation and attempts. A sensitivity analysis indicated the interaction remained a statistically significant predictor of suicide attempt even among the subgroup of participants with a history of suicide ideation. Conclusion: PTSD and moral injury represent separate constructs with unique signs and symptoms. The combination of PTSD and moral injury confers increased risk for suicidal thoughts and behaviors, and differentiates between military personnel who have attempted suicide and those who have only thought about suicide.

The article is here.

Friday, May 26, 2017

What is moral injury in veterans?

Holly Arrow and William Schumacher
The Conversation
Originally posted May 21, 2017

Here is an excerpt:

The moral conflict created by the violations of “what’s right” generates moral injury when the inability to reconcile wartime actions with a personal moral code creates lasting psychological consequences.

Psychiatrist Jonathan Shay, in his work with Vietnam veterans, defined moral injury as the psychological, social and physiological results of a betrayal of “what’s right” by an authority in a high-stakes situation. In “Achilles In Vietnam,” a book that examines the psychological devastation of war, a Vietnam veteran described a situation in which his commanding officers used tear gas on a village after the veteran and his unit had their gas masks rendered ineffective due to water damage. The veteran stated, “They gassed us almost to death.” This type of “friendly fire” incident is morally wounding in a way that attacks by an enemy are not.

Psychologist Brett Litz and his colleagues expanded this to include self-betrayal and identified “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” as the cause of moral injury.

Guilt and moral injury

A research study published in 1991 identified combat-related guilt as the best predictor of suicide attempts among a sample of Vietnam veterans with PTSD. Details of the veterans’ experiences connected that guilt to morally injurious events.

The article is here.

Tuesday, October 25, 2016

Dear Donald Trump: I treat combat veterans with PTSD, and they are not weak

Joan Cook
The Conversation
Originally published October 5, 2016

Here is an excerpt:

Combat trauma is a powerful predictor for a number of mental health problems. PTSD is, of course, the most notable consequence, but veterans who have served in war zones also suffer alarming rates of depression, anxiety and substance abuse. And in recent years, the high suicide rates among U.S. service members have soared to an estimated 22 dying by their own hand each day.

If knowing that isn’t enough to make most Americans – including you – hang their heads, pause in appreciation and potentially cry, I’m not sure what would.

Sadly, veterans with PTSD also have what health care professionals call a “reduced quality of life.” They go to work less and use more health care services.

Unless treated, PTSD typically runs a chronic course and haunts a person for many years or decades. Thus, the substantial burden of PTSD is not just on a veteran’s back, but on their families, their communities and society as well.

The article is here.

Monday, August 1, 2016

A Review of Research on Moral Injury in Combat Veterans

Sheila Frankfurt and Patricia Frazier
Military Psychology
http://dx.doi.org/10.1037/mil0000132

Abstract


The moral injury construct has been proposed to describe the suffering some veterans experience when they engage in acts during combat that violate their beliefs about their own goodness or the goodness of the world. These experiences are labeled transgressive acts to identify them as potentially traumatic experiences distinct from the fear-based traumas associated with posttraumatic stress disorder. The goal of this article was to review empirical and clinical data relevant to transgressive acts and moral injury, to identify gaps in the literature, and to encourage future research and interventions. We reviewed literature on 3 broad arms of the moral injury model proposed by Litz and colleagues (2009): (a) the definition, prevalence, and potential correlates of transgressive acts (e.g., military training and leadership, combat exposure, and personality), (b) the relations between transgressive acts and the moral injury syndrome (e.g., self-handicapping, self-injury, demoralization), and (c) some of the proposed mechanisms of moral injury genesis (e.g., shame, guilt, social withdrawal, and self-condemnation). We conclude with recommendations for future research for veterans suffering with moral injury.


Combat can require individuals to violate their consciences repeatedly. For several decades, clinicians have noted the psychological impact on veterans of engaging in killing, committing atrocities, and violating the rules of engagement (Haley, 1974). Despite this clinical attention, most psychological research on veterans' war wounds has focused on post traumatic stress disorder (PTSD; American Psychiatric Association, 2013), a fear-based disorder that results from exposure to life-threatening events, rather than on the consequences of active participation in warfare.

The moral injury syndrome was proposed to describe the constellation of shame and guilt based disturbances that some combat veterans experience after engaging in wartime acts of commission (e.g., killing) or omission (e.g., failing to prevent atrocities; Litz et al., 2009). The moral injury syndrome was proposed to be constituted of the PTSD symptoms of intrusive memories, emotional numbing, and avoidance, along with collateral effects such as self-injury, demoralization, and self-handicapping (Litz et al., 2009).

The article is here.