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Williamson V, Murphy D, Bonson A, Biscoe N, Leightley D, Aldridge V, Greenberg N. Restore and Rebuild (R&R): a protocol for a phase 2, randomised control trial to compare R&R as a treatment for moral injury-related mental health difficulties in UK military veterans to treatment as usual. BMJ Open 2024; 14:e082562. [PMID: 38754887 PMCID: PMC11097824 DOI: 10.1136/bmjopen-2023-082562] [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: 11/27/2023] [Accepted: 04/21/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Exposure to potentially morally injurious events is increasingly recognised as a concern across a range of occupational groups, including UK military veterans. Moral injury-related mental health difficulties can be challenging for clinicians to treat and there is currently no validated treatment available for UK veterans. We developed Restore and Rebuild (R&R) as a treatment for UK veterans struggling with moral injury-related mental health difficulties. This trial aims to examine whether it is feasible to conduct a pilot randomised controlled trial (RCT) of R&R treatment compared with a treatment-as-usual (TAU) control group. METHODS We will use a feasibility single-blind, single-site RCT design. The target population will be UK military veterans with moral injury-related mental health difficulties. We will recruit N=46 veteran patients who will be randomly allocated to R&R (n=23) or TAU (n=23). Patients randomised to R&R will receive the 20-session one-to-one treatment, delivered online. Veterans allocated to TAU, as there are currently no manualised treatments for moral injury-related mental health problems available, will receive the one-to-one treatment (online) typically provided to veterans who enter the mental health service for moral injury-related mental health difficulties. We will collect outcome measures of moral injury, post-traumatic stress disorder (PTSD), alcohol misuse, common mental disorders and trauma memory at pretreatment baseline (before randomisation), end of treatment, 12 weeks and 24 weeks post-treatment. The primary outcome will be the proportion of patients who screen positive for PTSD and moral injury-related distress post-treatment. ETHICS AND DISSEMINATION This trial will establish whether R&R is feasible, well-tolerated and beneficial treatment for veterans with moral injury-related mental health difficulties. If so, the results of the trial will be widely disseminated and R&R may improve access to effective care for those who struggle following moral injury and reduce the associated negative consequences for veterans, their families and wider society. TRIAL REGISTRATION NUMBER ISRCTN99573523.
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Affiliation(s)
- Victoria Williamson
- Department of Psychology, University of Exeter, Exeter, UK
- King's College London, London, UK
| | - Dominic Murphy
- King's College London, London, UK
- Combat Stress, Leatherhead, UK
| | - Amanda Bonson
- King's College London, London, UK
- Combat Stress, Leatherhead, UK
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Brennan CJ, Roberts C, Cole JC. Prevalence of occupational moral injury and post-traumatic embitterment disorder: a systematic review and meta-analysis. BMJ Open 2024; 14:e071776. [PMID: 38382965 PMCID: PMC10882372 DOI: 10.1136/bmjopen-2023-071776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVES Occupational moral injury and post-traumatic embitterment disorder (PTED) describe the psychological distress caused by exposure to injustice at work. This meta-analysis aims to determine the prevalence of occupational moral injury and PTED and establish whether prevalence estimates differ depending on occupation. DESIGN A systematic review and meta-analysis. DATA SOURCES Google Scholar, PubMed, APA PsycINFO, Web of Science Core Collection, Scopus, ScienceDirect and Sage Journals Online were searched in June 2020 and updated in November 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Observational studies that measured prevalence or average scores of moral injury, or PTED in any occupational group and any geographical location. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened and coded eligible studies. Study design, participant demographics, sampling method, location, measurement tool and prevalence or average scores were extracted. Risk of bias was assessed using the Quality Assessment Checklist for Prevalence Studies tool. Meta-analysis was conducted using random effects models. Results that could not be combined were summarised qualitatively in a narrative synthesis using the Guidance for Systematic Reviews. RESULTS In total, 88 studies across armed forces and veterans, healthcare, first responders, educators, journalists, child protection service employees, the unemployed, public-sector employees and mixed occupations were included. Studies included in each separate meta-analysis based on the measure used ranged from 2 to 30. The pooled prevalence of clinically relevant moral injury in healthcare professionals was 45%, and exposure to any potentially morally injurious event (PMIE) across occupations was 67%. Exposure to transgressions by others and betrayal was significantly lower in the armed forces than civilian occupations. Pooled prevalence of PTED across occupations was 26%. CONCLUSION Exposure to PMIEs, moral injury symptoms and PTED are prevalent at work and exposure to transgressions by others and betrayal are more likely in civilian occupations than the armed forces. PROSPERO REGISTRATION NUMBER CRD42020191766.
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Affiliation(s)
| | - Carl Roberts
- Psychology, University of Liverpool, Liverpool, UK
| | - Jon C Cole
- Psychology, University of Liverpool, Liverpool, UK
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Shi C, Ren Z, Zhao C, Zhang T, Chan SHW. Shame, guilt, and posttraumatic stress symptoms: A three-level meta-analysis. J Anxiety Disord 2021; 82:102443. [PMID: 34265540 DOI: 10.1016/j.janxdis.2021.102443] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/21/2021] [Accepted: 06/29/2021] [Indexed: 01/03/2023]
Abstract
Existing empirical findings are inconsistent on the correlations of shame and guilt with posttraumatic stress symptoms (PTSS). This study aimed to quantitatively summarize the strength of the associations of shame and guilt with PTSS and explore potential moderators. Based on a three-level meta-analytic method, shame was positively correlated with PTSS, no matter whether the effects of guilt were controlled; guilt also had a positive correlation with PTSS, regardless of whether the effects of shame were partialling out. Moderator analyses showed that type of shame measure (generalized vs. contextual vs. trauma-specific shame) moderated the relation between shame and PTSS, and type of guilt measure (generalized vs. contextual vs. trauma-specific guilt) moderated the relation between guilt and PTSS. In addition, culture had a marginally significant moderating effect on the relation between guilt and PTSS, with a stronger association of guilt with PTSS in Western culture than in Eastern culture. These results supported the links of shame and guilt to PTSS and implied that we should focus on the conceptual underpinnings of the manifest psychometric issue and maintain cultural sensitivity in future research. The implications for posttraumatic stress disorder treatment were also discussed.
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Affiliation(s)
- Congrong Shi
- Key Laboratory of Adolescent Cyberpsychology and Behaviour (Ministry of Education), Key Laboratory of Human Development and Mental Health of Hubei Province, School of Psychology, Central China Normal University, Wuhan, China
| | - Zhihong Ren
- Key Laboratory of Adolescent Cyberpsychology and Behaviour (Ministry of Education), Key Laboratory of Human Development and Mental Health of Hubei Province, School of Psychology, Central China Normal University, Wuhan, China.
| | - Chunxiao Zhao
- Key Laboratory of Adolescent Cyberpsychology and Behaviour (Ministry of Education), Key Laboratory of Human Development and Mental Health of Hubei Province, School of Psychology, Central China Normal University, Wuhan, China
| | - Tao Zhang
- Key Laboratory of Adolescent Cyberpsychology and Behaviour (Ministry of Education), Key Laboratory of Human Development and Mental Health of Hubei Province, School of Psychology, Central China Normal University, Wuhan, China
| | - Sunny Ho-Wan Chan
- Department of Rehabilitation Sciences, the Hong Kong Polytechnic University, Hong Kong, China
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Lloyd CS, Nicholson AA, Densmore M, Théberge J, Neufeld RWJ, Jetly R, McKinnon MC, Lanius RA. Shame on the brain: Neural correlates of moral injury event recall in posttraumatic stress disorder. Depress Anxiety 2021; 38:596-605. [PMID: 33369799 DOI: 10.1002/da.23128] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/21/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Moral injury (MI) is consistently associated with adverse mental health outcomes, including the development of posttraumatic stress disorder (PTSD) and suicidality. METHODS We investigated neural activation patterns associated with MI event recall using functional magnetic resonance imaging in participants with military and public safety-related PTSD, relative to civilian MI-exposed controls. RESULTS MI recall in the PTSD as compared to control group was associated with increased neural activation among salience network nodes involved in viscerosensory processing and hyperarousal (right posterior insula, dorsal anterior cingulate cortex; dACC), regions involved in defensive responding (left postcentral gyrus), and areas responsible for top-down cognitive control of emotions (left dorsolateral prefrontal cortex; dlPFC). Within the PTSD group, measures of state and trait shame correlated negatively with activity among default mode network regions associated with self-related processing and moral cognition (dorsomedial prefrontal cortex; dmPFC) and salience network regions associated with viscerosensory processing (left posterior insula), respectively. CONCLUSIONS These findings suggest that MI event processing is altered in military and public safety-related PTSD, relative to MI-exposed controls. Here, it appears probable that as individuals with PTSD recall their MI event, they experience a surge of blame-related processing of bodily sensations within salience network regions, including the right posterior insula and the dACC, which in turn, prompt regulatory strategies at the level of the left dlPFC aimed at increasing cognitive control and inhibiting emotional affect. These results are consistent with previous findings showing enhanced sensory processing and altered top-down control in PTSD samples during autobiographical memory recall.
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Affiliation(s)
- Chantelle S Lloyd
- Department of Psychology, Neuroscience, and Behaviour, McMaster University, Hamilton, Ontario, Canada.,Department of Psychiatry, Western University, London, Ontario, Canada.,Mood Disorders Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada.,Homewood Research Institute, Homewood Health, Guelph, Ontario, Canada
| | - Andrew A Nicholson
- Homewood Research Institute, Homewood Health, Guelph, Ontario, Canada.,Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Maria Densmore
- Department of Psychiatry, Western University, London, Ontario, Canada.,Imaging Division, Lawson Health Research Institute, London, Ontario, Canada
| | - Jean Théberge
- Department of Psychiatry, Western University, London, Ontario, Canada.,Imaging Division, Lawson Health Research Institute, London, Ontario, Canada.,Department of Medical Biophysics, Western University, London, Ontario, Canada
| | - Richard W J Neufeld
- Department of Psychiatry, Western University, London, Ontario, Canada.,Department of Psychology, Western University, London, Ontario, Canada.,Department of Neuroscience, Western University, London, Ontario, Canada
| | - Rakesh Jetly
- Canadian Forces, Health Services, Ottawa, Ontario, Canada
| | - Margaret C McKinnon
- Mood Disorders Program, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada.,Homewood Research Institute, Homewood Health, Guelph, Ontario, Canada.,Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Ruth A Lanius
- Department of Psychiatry, Western University, London, Ontario, Canada.,Homewood Research Institute, Homewood Health, Guelph, Ontario, Canada.,Imaging Division, Lawson Health Research Institute, London, Ontario, Canada.,Department of Neuroscience, Western University, London, Ontario, Canada
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