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The literature on moral injury (MI) is currently undermined by the lack of clear boundaries regarding the construct and a dearth of research on the processes by which potentially morally injurious events lead to MI. The heuristic continuum model of moral stressors proposes ways of distinguishing between moral frustrations, moral distress, and MI. In this commentary, we highlight five testable principles that can be derived from the heuristic model and evaluated using well-established constructs. Specifically, we describe meaningful distinctions between guilt and shame and address how these moral emotions can be used to distinguish between moral distress and MI. We also describe the potential role of event-related rumination, shame proneness, and cognitive flexibility in the development of MI following exposure to potentially morally injurious events. We believe that these principles offer critical next steps for the advancement of the MI field and illustrate how MI research can be generalized beyond the military context.

The literature on moral injury (MI) is currently undermined by the lack of clear boundaries regarding the construct and a dearth of research on the processes by which potentially morally injurious events lead to MI. The heuristic continuum model of moral stressors proposes ways of distinguishing between moral frustrations, moral distress, and MI. In this commentary, we highlight five testable principles that can be derived from the heuristic model and evaluated using well-established constructs. Specifically, we describe meaningful distinctions between guilt and shame and address how these moral emotions can be used to distinguish between moral distress and MI. We also describe the potential role of event-related rumination, shame proneness, and cognitive flexibility in the development of MI following exposure to potentially morally injurious events. We believe that these principles offer critical next steps for the advancement of the MI field and illustrate how MI research can be generalized beyond the military context.

There is conflicting evidence as to whether military populations (i.e., veteran and active-duty military service members) demonstrate a poorer response to psychotherapy for posttraumatic stress disorder (PTSD) compared to civilians. Existing research may be complicated by the fact that treatment outcomes differences could be due to the type of trauma exposure (e.g., combat) or population differences (e.g., military culture). This meta-analysis evaluated PTSD treatment outcomes as a function of trauma type (combat v. assault v. mixed) and population (military v. civilian). Unlike previous meta-analyses, we focused exclusively on manualized, first-line psychotherapies for PTSD as defined by expert treatment guidelines. Treatment outcomes were large across trauma types and population; yet differences were observed between trauma and population subgroups. Military populations demonstrated poorer treatment outcomes compared to civilians. The combat and assault trauma subgroups had worse treatment outcomes compared to the mixed trauma subgroup, but differences were not observed between assault and combat subgroups. Higher attrition rates predicted poorer treatment outcomes, but did not vary between military populations and civilians. Overall, manualized, first-line psychotherapies for PTSD should continue to be used for civilians and military populations with various trauma types. However, greater emphasis should be placed on enhancing PTSD psychotherapies for military populations and on treatment retention across populations based on findings from this meta-analysis.

There is conflicting evidence as to whether military populations (i.e., veteran and active-duty military service members) demonstrate a poorer response to psychotherapy for posttraumatic stress disorder (PTSD) compared to civilians. Existing research may be complicated by the fact that treatment outcomes differences could be due to the type of trauma exposure (e.g., combat) or population differences (e.g., military culture). This meta-analysis evaluated PTSD treatment outcomes as a function of trauma type (combat v. assault v. mixed) and population (military v. civilian). Unlike previous meta-analyses, we focused exclusively on manualized, first-line psychotherapies for PTSD as defined by expert treatment guidelines. Treatment outcomes were large across trauma types and population; yet differences were observed between trauma and population subgroups. Military populations demonstrated poorer treatment outcomes compared to civilians. The combat and assault trauma subgroups had worse treatment outcomes compared to the mixed trauma subgroup, but differences were not observed between assault and combat subgroups. Higher attrition rates predicted poorer treatment outcomes, but did not vary between military populations and civilians. Overall, manualized, first-line psychotherapies for PTSD should continue to be used for civilians and military populations with various trauma types. However, greater emphasis should be placed on enhancing PTSD psychotherapies for military populations and on treatment retention across populations based on findings from this meta-analysis.

BACKGROUND The increase in availability of patient data through consumer health wearable devices and mobile phone sensors provides opportunities for mental health treatment beyond traditional self-report measurements. Previous studies have suggested that wearables can be effectively used to benefit the physical health of people with mental health issues, but little research has explored the integration of wearable devices into mental health care. As such, early research is still necessary to address factors that might impact integration including patients' motivations to use wearables and their subsequent data. OBJECTIVE The aim of this study was to gain an understanding of patients' motivations to use or not to use wearables devices during an intensive treatment program for post-traumatic stress disorder (PTSD). During this treatment, they received a complementary Fitbit. We investigated the following research questions: How did the veterans in the intensive treatment program use their Fitbit? What are contributing motivators for the use and nonuse of the Fitbit? METHODS We conducted semistructured interviews with 13 veterans who completed an intensive treatment program for PTSD. We transcribed and analyzed interviews using thematic analysis. RESULTS We identified three major motivations for veterans to use the Fitbit during their time in the program: increase self-awareness, support social interactions, and give back to other veterans. We also identified three major reasons certain features of the Fitbit were not used: lack of clarity around the purpose of the Fitbit, lack of meaning in the Fitbit data, and challenges in the veteran-provider relationship. CONCLUSIONS To integrate wearable data into mental health treatment programs, it is important to understand the patient's perspectives and motivations in using wearables. We also discuss how the military culture and PTSD may have contributed to our participants' behaviors and attitudes toward Fitbit usage. We conclude with possible approaches for integrating patient-generated data into mental health treatment settings that may address the challenges we identified.

BACKGROUND:The increase in availability of patient data through consumer health wearable devices and mobile phone sensors provides opportunities for mental health treatment beyond traditional self-report measurements. Previous studies have suggested that wearables can be effectively used to benefit the physical health of people with mental health issues, but little research has explored the integration of wearable devices into mental health care. As such, early research is still necessary to address factors that might impact integration including patients' motivations to use wearables and their subsequent data. OBJECTIVE:The aim of this study was to gain an understanding of patients' motivations to use or not to use wearables devices during an intensive treatment program for post-traumatic stress disorder (PTSD). During this treatment, they received a complementary Fitbit. We investigated the following research questions: How did the veterans in the intensive treatment program use their Fitbit? What are contributing motivators for the use and nonuse of the Fitbit? METHODS:We conducted semistructured interviews with 13 veterans who completed an intensive treatment program for PTSD. We transcribed and analyzed interviews using thematic analysis. RESULTS:We identified three major motivations for veterans to use the Fitbit during their time in the program: increase self-awareness, support social interactions, and give back to other veterans. We also identified three major reasons certain features of the Fitbit were not used: lack of clarity around the purpose of the Fitbit, lack of meaning in the Fitbit data, and challenges in the veteran-provider relationship. CONCLUSIONS:To integrate wearable data into mental health treatment programs, it is important to understand the patient's perspectives and motivations in using wearables. We also discuss how the military culture and PTSD may have contributed to our participants' behaviors and attitudes toward Fitbit usage. We conclude with possible approaches for integrating patient-generated data into mental health treatment settings that may address the challenges we identified.

Moral injury refers to acts of commission or omission that violate individuals' moral or ethical standards. Morally injurious events are often synonymous with psychological trauma, especially in combat situations; thus, morally injurious events are often implicated in the development of PTSD for military service members and veterans. Although Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) have been well-established as effective treatments for veterans who are struggling with posttraumatic stress disorder (PTSD), it has been suggested that these two evidence-based therapies may not be sufficient for treating veterans whose PTSD resulted from morally injurious events. The purpose of this manuscript is to detail how the underlying theories of PE and CPT can account for moral-injury based PTSD and to describe two case examples of veterans with PTSD stemming from morally injurious events who were successfully treated with PE and CPT. The manuscript concludes with a summary of challenges that clinicians may face when treating veterans with PTSD resulting from moral injury using either PE or CPT.

Moral injury refers to a set of reactions to acts of perpetration or commission that violate an individual's deeply held beliefs and moral values. Although there is consensus that military service increases exposure to morally injurious events, there is no clear definition on what events do and do not constitute moral injury, which makes drawing firm conclusions regarding the prevalence of moral injury among military populations difficult. Exposure to morally injurious events places individuals at a greater risk for a range of poor mental health outcomes, which may be mediated by negative posttraumatic cognitions. Therefore, treatments that emphasize restructuring such cognitions are likely to be effective in treating the effects of moral injury, though data are lacking. In this article, we provide an overview of the key scientific findings regarding moral injury and highlight areas where future research is needed. Potential challenges in treating the negative sequelae of moral injury are also discussed.

Moral injury refers to a set of reactions to acts of perpetration or commission that violate an individual's deeply held beliefs and moral values. Although there is consensus that military service increases exposure to morally injurious events, there is no clear definition on what events do and do not constitute moral injury, which makes drawing firm conclusions regarding the prevalence of moral injury among military populations difficult. Exposure to morally injurious events places individuals at a greater risk for a range of poor mental health outcomes, which may be mediated by negative posttraumatic cognitions. Therefore, treatments that emphasize restructuring such cognitions are likely to be effective in treating the effects of moral injury, though data are lacking. In this article, we provide an overview of the key scientific findings regarding moral injury and highlight areas where future research is needed. Potential challenges in treating the negative sequelae of moral injury are also discussed.

Moral injury refers to a set of reactions to acts of perpetration or commission that violate an individual's deeply held beliefs and moral values. Although there is consensus that military service increases exposure to morally injurious events, there is no clear definition on what events do and do not constitute moral injury, which makes drawing firm conclusions regarding the prevalence of moral injury among military populations difficult. Exposure to morally injurious events places individuals at a greater risk for a range of poor mental health outcomes, which may be mediated by negative posttraumatic cognitions. Therefore, treatments that emphasize restructuring such cognitions are likely to be effective in treating the effects of moral injury, though data are lacking. In this article, we provide an overview of the key scientific findings regarding moral injury and highlight areas where future research is needed. Potential challenges in treating the negative sequelae of moral injury are also discussed.

Moral injury refers to acts of commission or omission that violate individuals' moral or ethical standards. Morally injurious events are often synonymous with psychological trauma, especially in combat situations; thus, morally injurious events are often implicated in the development of PTSD for military service members and veterans. Although Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) have been well-established as effective treatments for veterans who are struggling with posttraumatic stress disorder (PTSD), it has been suggested that these two evidence-based therapies may not be sufficient for treating veterans whose PTSD resulted from morally injurious events. The purpose of this manuscript is to detail how the underlying theories of PE and CPT can account for moral-injury based PTSD and to describe two case examples of veterans with PTSD stemming from morally injurious events who were successfully treated with PE and CPT. The manuscript concludes with a summary of challenges that clinicians may face when treating veterans with PTSD resulting from moral injury using either PE or CPT.

ObjectiveThe purpose of the present research was to examine the demographic and mental health characteristics of veterans and service members who endorsed having caused harm, injury, or death to another person on deployment, while taking these individuals' total number of other lifetime traumas into account.MethodData for the present study were collected as part of the standard clinical evaluation for 228 treatment-seeking veterans and service members.ResultsThose who reported having caused harm, injury, or death to another person on deployment (22.4%) were more likely to be male, to have served in the Marines, to have served post 9/11, and to endorse other traumas commonly reported on deployment than those who did not endorse causing harm, injury, or death. Those who endorsed causing harm on deployment were less likely to have served in the Air Force, and to have experienced sexual assault than those who did not cause harm. Causing harm, injury, or death was associated with higher levels of posttraumatic stress disorder (PTSD), drug use, and expressive anger at the bivariate level, but was no longer associated with mental health problems after accounting for the number of other lifetime traumas.ConclusionsExamining the role of causing harm in isolation may lead to false conclusions. Clinicians and researchers should assess for veterans' and service members' entire trauma histories. (PsycINFO Database Record

OBJECTIVE: The purpose of the present research was to examine the demographic and mental health characteristics of veterans and service members who endorsed having caused harm, injury, or death to another person on deployment, while taking these individuals' total number of other lifetime traumas into account. METHOD: Data for the present study were collected as part of the standard clinical evaluation for 228 treatment-seeking veterans and service members. RESULTS: Those who reported having caused harm, injury, or death to another person on deployment (22.4%) were more likely to be male, to have served in the Marines, to have served post-9/11, and to endorse other traumas commonly reported on deployment than those who did not endorse causing harm, injury, or death. Those who endorsed causing harm on deployment were less likely to have served in the Air Force, and to have experienced sexual assault than those who did not cause harm. Causing harm, injury, or death was associated with higher levels of PTSD, drug use, and expressive anger at the bivariate level, but was no longer associated with mental health problems after accounting for the number of other lifetime traumas. CONCLUSIONS: Examining the role of causing harm in isolation may lead to false conclusions. Clinicians and researchers should assess for veterans' and service members' entire trauma histories.

BackgroundSocial support is consistently associated with reduced risk of depression. Few studies have investigated how this relationship may be modified by alcohol use, the effects of which may be particularly relevant in traumatized populations in which rates of alcohol use are known to be high.MethodsIn 2008 a representative sample of 1622 Jewish and Palestinian citizens in Israel were interviewed by phone at two time points during a period of ongoing terrorism and war threat. Two multivariable mixed effects regression models were estimated to measure the longitudinal association of social support from family and friends on depression symptoms. Three-way interaction terms between social support, alcohol use and time were entered into the models to test for effect modification.ResultsFindings indicated that increased family social support was associated with less depression symptomatology (p=<.01); this relationship was modified by alcohol use and time (p=<.01). Social support from friends was also associated with fewer depression symptoms (p=<.01) and this relationship was modified by alcohol use and time as well (p=<.01). Stratified analyses in both models revealed that the effect of social support was stronger for those who drank alcohol regularly than those who did not drink or drank rarely.ConclusionsThese findings suggest that social support is a more important protective factor for depression among regular drinkers than among those who do not drink or drink rarely in the context of political violence. Additional research is warranted to determine whether these findings are stable in other populations and settings.