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Kline AC, Harlé KM, Panza KE, Nichter B, Lyons R, Pitts M, Haller M, Allard CB, Capone C, Norman SB. Changes in guilt cognitions mediate the effect of trauma-informed guilt reduction therapy on PTSD and depression outcomes. J Clin Psychol 2024; 80:1147-1160. [PMID: 38340354 DOI: 10.1002/jclp.23659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/08/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE Trauma-informed guilt reduction therapy (TrIGR), a six-session cognitive behavioral therapy targeting trauma-related guilt and distress, reduces guilt and symptoms of posttraumatic stress disorder (PTSD) and depression, yet little is known regarding how and why TrIGR may be effective. METHOD This study examined treatment-related changes in avoidant coping and trauma-related guilt cognitions as possible mediators of treatment effects on PTSD and depression outcomes at 3- and 6-month follow-up. Data were from a randomized controlled trial for treatment of trauma-related guilt comparing TrIGR and supportive care therapy among 145 post-9/11 US veterans (Mage = 39.2 [8.1], 93.8% male). RESULTS At pretreatment, most (86%) met PTSD criteria. Intent to treat analyses using parallel mediation models indicated changes in guilt cognitions, but not avoidant coping, mediated the effect of TrIGR on reducing PTSD severity at 3-month (a × b = -0.15, p < 0.01, 95% CI: [-0.24 to -0.06], p = 0.001) and 6-month (a × b = -0.17, 95% CI: [-0.26 to -0.07], p = 0.001) follow-up. Similarly, changes in guilt cognitions, but not avoidant coping, mediated the effect of TrIGR on reducing depression severity at 3-month (a × b = -0.10, 95% CI: [-0.18 to -0.02], p = 0.02) and 6-month (a × b = -0.11, 95% CI: [-0.20 to -0.03], p = 0.01) follow-up. CONCLUSIONS Compared to guilt cognitions, changes in avoidant coping were less integral to downstream PTSD and depression symptom reduction. Guilt cognition change may be a salient active ingredient of PTSD and depression treatment for those with trauma-related guilt and a key therapy element to which providers should be attuned.
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Affiliation(s)
- Alexander C Kline
- VA San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Katia M Harlé
- VA San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Kaitlyn E Panza
- VA San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | | | - Robert Lyons
- VA San Diego Healthcare System, San Diego, California, USA
| | - Michelle Pitts
- VA San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Moira Haller
- VA San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Carolyn B Allard
- VA San Diego Healthcare System, San Diego, California, USA
- California School of Professional Psychology, Alliant International University, San Diego, California, USA
| | - Christy Capone
- Providence VA Medical Center, Providence, Rhode Island, USA
- Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Sonya B Norman
- VA San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
- VA Center of Excellence for Stress and Mental Health, San Diego, California, USA
- National Center for Posttraumatic Stress Disorder, White River Junction, Vermont, USA
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Lathan EC, Sheikh IS, Guelfo A, Choucair KC, Fulton T, Julian J, Mekawi Y, Currier JM, Powers A, Fani N. Moral injury appraisals and dissociation: Associations in a sample of trauma-exposed community members. J Trauma Dissociation 2023; 24:692-711. [PMID: 37387238 PMCID: PMC10771817 DOI: 10.1080/15299732.2023.2231010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 03/22/2023] [Indexed: 07/01/2023]
Abstract
Appraisal of trauma is a critical factor in the development of impairing post-traumatic stress symptoms, such as dissociation. Individuals may appraise trauma as morally injurious (i.e., moral injury exposure [MIE]) and experience subsequent moral distress related to this exposure (i.e., moral injury distress [MID]). To date, however, investigation into the relations between moral injury appraisals and dissociation has been limited, particularly within community populations. This study investigated MIE and MID in relation to six facets of dissociation (disengagement, depersonalization, derealization, memory disturbances, emotional constriction, identity dissociation) in a sample of trauma-exposed community members (n = 177, 58.2% Black, 89.3% female) recruited from a public hospital and/or community advertisements. Participants completed measures assessing trauma exposure, MIE, MID, dissociation, and posttraumatic stress disorder (PTSD) symptoms. Partial correlation analyses revealed that after controlling for PTSD symptoms, MIE was correlated with disengagement, r = .23, p ≤ .025, and depersonalization, r = .25, p ≤ .001, and MID was correlated with depersonalization, r = .19, p ≤ .025. Sex moderated each association, with stronger associations observed for female participants. Findings suggest that moral injury appraisals are linked to more severe dissociative symptoms among female civilians, and as such, may need to be specifically targeted in empirically supported treatments.
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Affiliation(s)
- Emma C. Lathan
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | | | - Alfonsina Guelfo
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Khaled C. Choucair
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Travis Fulton
- Molecular and Systems Pharmacology PhD Program, Emory University
| | - Jacob Julian
- Department of Psychology, Georgia State University
| | - Yara Mekawi
- Department of Psychological and Brain Sciences, University of Louisville
| | | | - Abigail Powers
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Negar Fani
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
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Borges LM, Holliman BD, Farnsworth JK, Barnes SM. Perceptions of Military Experience Among Veterans Reporting Lifetime Warzone Moral Injury. J Nerv Ment Dis 2023; 211:796-801. [PMID: 37782522 DOI: 10.1097/nmd.0000000000001676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
ABSTRACT Exposures to potentially morally injurious events (PMIEs) and possible moral injury are risk factors for a range of difficulties impacting individual functioning. Although exposure to PMIEs is a somewhat common product of war, qualitative methods to understand Veterans' experiences of moral injury and Veterans Affairs treatment are limited. To better characterize Veterans' experiences, 14 male warzone Veterans who reported moral injury post-warzone deployment and completed posttraumatic stress disorder treatment in the past year were asked to describe their military service as part of a qualitative study. Through thematic analysis, we found two moral injury-consistent themes and four subthemes. The first theme was "military experiences were associated with morally questioning one's self" with subthemes of "moral shift" and "depersonalization." The second theme was "military experiences were associated with morally questioning others" with subthemes of "disillusionment" and "resignation." Based on these findings, we conclude with a discussion of treatment implications for moral injury.
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Borges LM, Barnes SM, Farnsworth JK, Drescher KD, Walser RD. Case Conceptualizing in Acceptance and Commitment Therapy for Moral Injury: An Active and Ongoing Approach to Understanding and Intervening on Moral Injury. Front Psychiatry 2022; 13:910414. [PMID: 35845442 PMCID: PMC9279691 DOI: 10.3389/fpsyt.2022.910414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/10/2022] [Indexed: 11/18/2022] Open
Abstract
Acceptance and Commitment Therapy for Moral Injury (ACT-MI; 10-11), is an application of Acceptance and Commitment Therapy principles designed to help individuals live their values, even in the presence of moral pain. ACT-MI differs from other emerging treatments for moral injury in that ACT-MI is not based on a traditional syndromal approach to conceptualizing moral injury, which treats moral injury as a collection of signs and symptoms to be reduced. Rather than assuming moral injury causes suffering through a constellation of symptoms that a person has, in ACT-MI, moral injury is defined by what a person does in response to moral pain. Consistent with this framework, we present a unique approach to moral injury case conceptualization that emphasizes function over form, providing clients the opportunity to break free from the patterns of behavior that cause moral injury-related suffering to persist. Rooted in approaches to conceptualizing that have demonstrated utility in extant interventions (e.g., ACT), ACT-MI clinicians conduct ongoing functional analyses to inform case conceptualization and intervention. Functional analysis is used to disrupt the processes maintaining moral injury, as the client and therapist work to identify and intervene on the behaviors reinforcing avoidance and control of painful internal experiences causing moral injury. In the current article, we guide the reader through a framework for applying functional analysis to the conceptualization of moral injury where the reinforcers driving moral injury are explored. We also provide examples of questions that can be used to help uncover the functions of moral injury consistent behavior. Case examples based on our experiences treating moral injury are presented to demonstrate how various types of morally injurious events can evoke different features of moral pain which in turn motivate different repertoires of avoidance and control. These inflexible patterns of avoidance and control create suffering by engaging in behavior designed to escape moral pain, such as social isolation, spiritual disconnection, reduced self-care, suicidal ideation, and substance use. We discuss how to target this suffering using functional analysis to guide treatment decisions, matching interventional processes within ACT-MI to the specific functions that moral injury-related behavior is serving for an individual. We suggest that the use of functional analytic case formulation procedures described herein can assist clients in disrupting behavioral patterns maintaining moral injury and thereby free them to pursue lives of greater meaning and purpose.
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Affiliation(s)
- Lauren M. Borges
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Sean M. Barnes
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | | | | | - Robyn D. Walser
- National Center for PTSD, Palo Alto, CA, United States
- Department of Psychology, University of California, Berkeley, Berkeley, CA, United States
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Fischer IC, Norman SB, Feder A, Feingold JH, Peccoralo L, Ripp J, Pietrzak RH. Downstream consequences of moral distress in COVID-19 frontline healthcare workers: Longitudinal associations with moral injury-related guilt. Gen Hosp Psychiatry 2022; 79:158-161. [PMID: 36403350 PMCID: PMC9664834 DOI: 10.1016/j.genhosppsych.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 11/11/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine the longitudinal associations between dimensions of COVID-19 pandemic-related moral distress (MD) and moral injury (MI)-related guilt in a large sample of frontline COVID-19 healthcare workers (FHCWs). METHODS Data from a diverse occupational cohort of 786 COVID-19 FHCWs were collected during the initial peak of the COVID-19 pandemic in New York City and again 7 months later. Baseline MD and MI-related guilt at follow-up were assessed in three domains: family-, work-, and infection-related. Social support was evaluated as a potential moderator of associations between MD and MI-related guilt. RESULTS A total of 66.8% of FHCWs reported moderate-or-greater levels of MI-related guilt, the most prevalent of which were family (59.9%) or work-related (29.4%). MD was robustly predictive of guilt in a domain-specific manner. Further, among FHCWs with high levels of work-related MD, those with greater perceptions of supervisor support were less likely to develop work-related guilt 7 months later. DISCUSSION MD was found to be highly prevalent in FHCWs during the initial wave of the COVID-19 pandemic and was linked to the development of MI-related guilt over time. Prevention and early intervention efforts to mitigate MD and bolster supervisor support may help reduce risk for MI-related guilt in this population.
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Affiliation(s)
- Ian C. Fischer
- US Department of Veterans Affairs National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA,Corresponding author at: US Department of Veteran Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, USA
| | - Sonya B. Norman
- US Department of Veterans Affairs National Center for PTSD, White River Junction VA Medical Center, White River Junction, VT, USA,Department of Psychiatry, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Adriana Feder
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jordyn H. Feingold
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lauren Peccoralo
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Office of Well-Being and Resilience, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan Ripp
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Office of Well-Being and Resilience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robert H. Pietrzak
- US Department of Veterans Affairs National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Office of Well-Being and Resilience, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
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Mooren N, Boelen PA, de la Rie SM. The impact of morally injurious events in a refugee sample: A quantitative and qualitative study. Front Psychiatry 2022; 13:904808. [PMID: 36159931 PMCID: PMC9492849 DOI: 10.3389/fpsyt.2022.904808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/22/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Posttraumatic Stress Disorder (PTSD) is often reported by refugees that faced violence and persecution. Some stressful events may also entail moral conflicts or dilemmas, described as "potentially morally injurious events" (PMIE). Very few studies have yet investigated the nature of these PMIEs in traumatized refugees, using both quantitative and qualitative data. METHOD For this retrospective study, secondary data analysis was used to examine the traumatic events of 183 patients. Based on established definitions of a PMIE, participants were allocated to a Moral Injury (MI) group if they reported lasting distress after exposure to an event of which they indicated that it transgressed their moral beliefs. The remaining participants were allocated to the No-MI group. The type of PMIEs was categorized using qualitative analysis. The groups were compared in terms of PTSD severity, feelings of guilt, and general mental health symptoms. RESULTS Of the total sample, 55 participants reported one or more acts of transgression (MI group) and 128 reported no acts of transgression (No-MI group). Analyses of PMIEs revealed six themes 1) failing to prevent harm to others, 2) not giving aid to people in need, 3) leaving family members behind that consequently lead to injury or death of others, 4) making indirect and direct moral decisions leading to injury or death of others, 5) betrayal, and 6) engaging in the harm of others. No differences were found between groups on the clinical outcomes, except for feelings of guilt. CONCLUSION A considerable number of traumatized refugees reported confrontation with PMIEs. Experiencing PMIEs appeared unrelated to elevated posttraumatic mental health issues.
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Affiliation(s)
- Nora Mooren
- ARQ National Psychotrauma Centre, Diemen, Netherlands.,Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, Netherlands
| | - Paul A Boelen
- ARQ National Psychotrauma Centre, Diemen, Netherlands.,Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, Netherlands
| | - Simone M de la Rie
- ARQ National Psychotrauma Centre, Diemen, Netherlands.,Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, Netherlands
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