Using Prolonged Exposure and Cognitive Processing Therapy to Treat Veterans With Moral Injury-Based PTSD: Two Case Examples

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 posttraumatic stress disorder (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 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 paper 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 paper concludes with a summary of challenges that clinicians may face when treating veterans with PTSD resulting from moral injury using either PE or CPT.     

Meaning Made of Stress among Veterans Transitioning to College: Examining Unique Associations with Suicide Risk and Life‐Threatening Behavior

Meaning made of stress has been shown to be a unique predictor of mental and physical health. In this study, we examined the unique associations between two facets of meaning made of stress (comprehensibility and footing in the world) and suicide risk and life‐threatening behavior among military veterans who have transitioned to college were examined, controlling for demographic factors, religiousness, combat‐related physical injury, combat exposure, depressive symptoms, and posttraumatic stress symptoms. Findings suggest that comprehensibility (having “made sense” of a stressor) is uniquely associated with lower suicide risk and a lower likelihood of driving under the influence of drugs or alcohol and engaging in self‐mutilating behaviors.     

Adaptive disclosure: an open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries

We evaluated the preliminary effectiveness of a novel intervention that was developed to address combat stress injuries in active-duty military personnel. Adaptive disclosure (AD) is relatively brief to accommodate the busy schedules of active-duty service members while training for future deployments. Further, AD takes into account unique aspects of the phenomenology of military service in war in order to address difficulties such as moral injury and traumatic loss that may not receive adequate and explicit attention by conventional treatments that primarily address fear-inducing life-threatening experiences and sequelae. In this program development and evaluation open trial, 44 marines received AD while in garrison. It was well tolerated and, despite the brief treatment duration, promoted significant reductions in PTSD, depression, negative posttraumatic appraisals, and was also associated with increases in posttraumatic growth.     

Spirituality,Forgiveness, and Quality of Life: Testing a Mediational Model with Military Veterans with PTSD

Combat-related posttraumatic stress disorder (PTSD) can be a debilitating condition that has been linked with problems with forgiveness and impaired quality of life (QOL) in physical, psychological, social, and environmental domains. However, an amassing base of research studies also suggests that spirituality can be a vital resource for veterans exposed to severe traumas. Drawing on multidimensional assessments of spirituality and QOL, this study therefore tested direct/indirect associations between spirituality, forgiveness, and QOL among 678 military veterans with PTSD. When controlling for demographic risk factors, combat exposure, and PTSD symptom severity, structural equation modeling results revealed (a) an overall positive effect for spirituality on QOL and (b) that forgiveness fully mediated this link. These findings align with contemporary models of military trauma and suggest that forgiveness could be a critical pathway for promoting QOL as veterans attempt to recover from their posttraumatic symptomatology in treatment settings. Implications for clinical practice and future research are discussed in the article.     

The Role of Political Practices in Moral Injury: A Study of Afghanistan Veterans

While much research has been conducted on military trauma, conceptualizations of deployment‐related suffering have been predominantly approached through a medical, individual‐focused lens. Since the military is an instrument of the state, it is crucial to expand the conceptual scope to include political processes, particularly for the fast‐growing literature on “moral injury,” which refers to the emotional impact of perpetrating, witnessing, or falling victim to perceived wrongdoing. This article examines the role of political practices in the onset of moral injury as well as the micropolitical responses of morally injured veterans. A study of the Dutch mission in Uruzgan, Afghanistan, shows that decisions and frames at the political level helped create distressing quandaries on the ground and that in all the ways the political leadership acknowledged the problems that veterans subsequently developed, it also maintained a silence on its direct contribution to these problems, as such perpetuating them. Consequently, veterans tried to make the political leadership take a material and symbolic share in their burden. Clearly, moral conflict may exist both in the veteran and between the veteran and the political domain, and therefore, experiences of institutional betrayal and a resultant search for reparations should be included in theory on moral injury.     

EMPATHY AND THE EVOLUTION OF COMPASSION: FROM DEEP HISTORY TO INFUSED VIRTUE

This article poses a challenge to contemporary theories in psychology that portray empathy as a negative force in the moral life. Instead, drawing on alternative psychological and philosophical literature, especially Martha Nussbaum, I argue that empathy is related to the virtue of compassion and therefore crucial for moral action. Evidence for evolutionary anthropological accounts of compassion in early hominins provides additional arguments for its positive value in deep human history. I discuss this work alongside Thomistic notions of practical wisdom, compassion, misericordia, and the importance of reason in the moral life. The tension between “bottom up” accounts of empathy and that according to a theological interpretation of “infused” virtues also needs to be addressed. From a secular perspective, infused virtue is a projection of the ideal moral life, but from a theological perspective, it is a way of understanding how human capacities through the action of grace can reach beyond what seem to be the limits of psychological moral identity.     

Is this America? Unfinished business with the U.S. national imaginary,religion and violence

This article first proposes definitions and raises questions about what it means to be a nation. I then analyze the national imaginary of the United States, and suggest that at its deepest core we find “substitute ultimates” regarding America's sacrificial war‐culture. This cultural violence perpetuates destructive consequences, including the phenomena of “U.S. war‐culture,” and “moral injury” among military servicemembers and veterans. But widespread legitimation of the imaginary largely inhibits citizens from awareness about their own reality. Lastly, I inquire about the role of prophetic public theology to address nationalism, and engage in a thought experiment with an imagined community of diverse partners.     

“It’s Worth It in the End”: Veterans’ Experiences in Prolonged Exposure and Cognitive Processing Therapy

Despite the efficacy of evidence-based psychotherapies (EBP) for posttraumatic stress disorder (PTSD) and efforts to disseminate them, only 6–13% of veterans seeking care through the Veterans Affairs health care system receive these treatments. EBPs such as prolonged exposure (PE) and cognitive processing therapy (CPT) are exposure-based treatments. Provider and patient fears regarding the tolerability of exposure-based treatments likely impede their delivery and completion. The present study utilized qualitative interviews with 23 veterans who completed at least eight sessions of either PE or CPT to elicit firsthand accounts of veterans’ experiences in these EBPs. Results suggest that while a minority of veterans reported initial symptom worsening, the majority of veterans reported positive experiences and felt that, despite being stressful, these EBPs were “worth it.” Most veterans discussed thoughts of discontinuing treatment prematurely, but stated that adherence was encouraged by their commitment to finishing, desperation for relief, therapist/group support, and family support. Veterans believed exposure made an important contribution to symptom improvement, as did greater self-understanding and changing negative or unhelpful beliefs. These findings indicate veteran satisfaction with PE and CPT, and may assist providers to develop strategies to increase adherence and treatment completion.     

Associations of Stress Exposures and Social Support With Long-Term Mental Health Outcomes Among U.S. Iraq War Veterans

The long-term mental health effects of war-zone deployment in the Iraq and Afghanistan wars on military personnel are a significant public health concern. Using data collected prospectively at three distinct assessments during 2003–2014 as part of the Neurocognition Deployment Health Study and VA Cooperative Studies Program Study #566, we explored how stress exposures prior, during, and after return from deployment influence the long-term mental health outcomes of posttraumatic stress disorder (PTSD), depression, anxiety disorders, and problem drinking. Longer-term mental health outcomes were assessed in 375 service members and military veterans an average of 7.5 years (standard deviation = 1.0 year) after the initial (i.e., “index”) Iraq deployment following their predeployment assessment. Anxiety disorder was the most commonly observed long-term mental health outcome (36.0%), followed by depression (24.5%), PTSD (24.3%), and problem drinking (21.0%). Multivariable regression models showed that greater postdeployment stressors, as measured by the Post-Deployment Life Events scale, were associated with greater risk of depression, anxiety disorders, and problem drinking. Anxiety disorder was the only outcome affected by predeployment stress concerns. In addition, greater postdeployment social support was associated with lower risk of all outcomes except problem drinking. These findings highlight the importance of assessing postdeployment stress exposures, such as stressful or traumatic life events, given the potential impact of these stressors on long-term mental health outcomes. This study also highlights the importance of postdeployment social support as a modifiable protective factor that can be used to help mitigate risk of long-term adverse mental health outcomes following war-zone exposure.     

Perceived Ability to Cope With Trauma Among U.S. Combat Veterans

The Perceived Ability to Cope With Trauma (PACT) scale measures perceived forward-focused and trauma-focused coping. This measure may also have significant utility measuring positive adaption to life-threatening trauma, such as combat. Our objective was to examine perceived ability to cope with trauma, as measured by the PACT, and the relationships between this perceived ability and clinically pertinent information (anxiety, depression, posttraumatic stress disorder [PTSD]) among U.S. military veterans. Data were provided from 71 combat veterans, consisting of 47 veterans with PTSD and 24 veterans without PTSD who had subthreshold symptoms of the disorder. All veterans completed standardized clinical interviews as well as a battery of well-validated self-report symptom measures. We found that veterans with PTSD had significantly lower PACT scores than veterans without PTSD; those without PTSD self-reported more ability to engage in forward-focused and trauma-focused coping than those with PTSD. Importantly, we also showed relationships between the PACT scores and indices of psychological difficulties as both Forward Focus and Trauma Focus coping scores negatively correlated with PTSD, depression, anxiety, and alexithymia. Finally, the Forward Focus PACT scale improved prediction of PTSD severity over combat exposure alone. The PACT, especially the Forward Focus scale, appears to be a useful measure of perceived positive coping ability with trauma in combat-exposed veterans who report symptoms of traumatic stress, extending the utility of the measure from normative to clinical populations. The importance of adopting forward-focused coping is discussed.     

Suicide Exposure and Posttraumatic Stress Disorder: Is Marriage a Protective Factor for Veterans?

Alarming numbers of military veterans end their lives each day which has a profound effect on the military population. This study examines a sample (N?=?434) of suicide-exposed (i.e., personally knowing someone who has died by suicide) veterans to determine whether the proportion of individuals who report high impact from suicide exposure and those who have clinically-significant posttraumatic stress disorder symptoms is related to marital status. Using Hill’s (Social Casework 49: 139–150, 1958) ABC-X model for conceptualizing the relationships between variables, mean scores for posttraumatic stress disorder were significantly different between groups, and the odds of a married veteran reporting high-impact suicide exposure were 2.19 times lower than the odds of a single veteran reporting high-impact. Likewise, the odds of a veteran with high-impact suicide exposure having clinically-significant posttraumatic stress disorder symptoms were 10.04 times higher than veterans with low-impact suicide exposure. Findings indicate that veterans who are married are less likely to be highly-affected by another individual’s suicide. Thus, marriage is a protective factor for suicide-exposed veterans.     

Is the moral domain unique? A social influence perspective for the study of moral cognition

The nature of the cognitive processes that give rise to moral judgment and behavior has been a central question of psychology for decades. In this paper, we suggest that an often ignored yet fruitful stream of research for informing current debates on the nature of moral cognition is social influence. We introduce what we call the “social‐moderation‐of‐process” perspective, a methodological framework for leveraging insights from social influence research to inform debates in moral psychology over the mechanisms underlying moral cognition and the moral domains in which those mechanisms operate. We demonstrate the utility of the social‐moderation‐of‐process perspective by providing a detailed example of how research on social influence in behavioral ethics can be utilized to test a research question related to a debate between two prominent theories in moral psychology. We then detail how researchers across the field of moral psychology can utilize our social‐moderation‐of‐process perspective.     

The Political Consequences of Combat: Post‐Traumatic Stress and Political Alienation Among Vietnam Veterans

On average, veterans are more civically and politically engaged than civilians. Previous research on the effects of military service, however, did not account for differences in veterans’ combat experiences. Using survey data from a representative sample of Vietnam veterans, this study presents evidence that veterans who were exposed to severe combat trauma and veterans who exhibited attitudes and fears associated with post‐traumatic stress had significantly lower levels of political efficacy and trust. The negative consequences of combat exposure and post‐traumatic stress are not mitigated when veterans have quality social support or when they seek professional counseling. These findings inform political psychology and hold implications for claims regarding the empowering influence of service in the U.S. military, increased political engagement, in particular. Among Vietnam veterans, exposure to severe combat trauma and post‐traumatic stress were both associated with reduced political efficacy and trust.     

Suspicious Minds at Risk? The Role of Meaning in Processing War and Peacekeeping Experiences

The purpose of this study was to examine meaning as a mediator between perceived threat and posttraumatic stress responses among a sample of 1,561 veterans who participated in war or peacekeeping operations. Data were collected by questionnaire. Path analysis was performed to assess the expected relationships between the observed variables. Meaning in terms of distrust and personal benefits partially mediated the relation between perceived threat and posttraumatic stress responses. Distrustful beliefs about others and the world were strongly associated with perceived threat, as well as intrusive and avoidant thoughts. Creating meaning in terms of a positive worldview appears to be an important mission after military deployment.     

Rates of Subthreshold PTSD Among U.S. Military Veterans and Service Members: A Literature Review

The current study’s goal was to provide a comprehensive review of current subthreshold posttraumatic stress disorder (PTSD) rates among U.S. military veterans and service members. PubMed, PsycInfo, ProQuest, Web of Knowledge, Google Scholar, and any relevant articles’ reference lists identified studies of subthreshold PTSD in the U.S. military. Search terms included PTSD in combination with partial, subthreshold or sub-threshold, subsyndromal or sub-syndromal, subclinical or sub-clinical, and military or veteran. Sixteen articles met criteria for review. Current subthreshold PTSD rates ranged from 2.3% to 22.3%, with a weighted mean rate of 7.6%. Definitional variation within and across the “below threshold” terms produced some variability in rates reported. Few studies consistently reported on impairment and comorbidity in the subthreshold PTSD population. Variability of current subthreshold PTSD rates may be due to methodological issues such as sampling methods, sample sizes, and how below threshold PTSD was assessed and defined. Based on our findings, we provide a number of recommendations that can be used to inform future research of subthreshold PTSD among U.S. military veterans and service members. These recommendations include having a standardized term and definition, determining how to more properly assess subthreshold PTSD symptomatology, clarifying subthreshold PTSD diagnostic stability, and identifying appropriate sampling methods.     

Sexuality among wounded veterans of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND): Implications for rehabilitation psychologists

OBJECTIVE: The sexual lives of returning Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans have only been discussed minimally in the psychological literature. Given the nature of military social and cultural contexts, the potential for exposure to combat-related stressors that may lead to posttraumatic stress disorder (PTSD), and the risk of traumatic brain injury secondary to physical injury, the potential for significant psychological and relational ramifications exists. This article focuses on the intimate relationships and sexuality of returning OIF/OEF/OND veterans within the context of their personal cultural variables and the diverse experience of being a part of military life. CONCLUSIONS: Culturally competent assessment and evidenced-based treatment approaches are highlighted to offer clinicians initial strategies to begin treatment of sexuality issues within the returning Veteran population. These clinical tools are discussed within a positive psychology approach that emphasizes healthy sexuality as a part of overall satisfactory quality of life.     

Anticipatory Anxiety in the Treatment of Combat Veterans with Posttraumatic Stress Disorder

Combat veterans have experienced a transformational process during war zone deployment, including emotional, cognitive, and sensory processing changes. They also return entrenched in military expectations of conduct and behavior. These changes result in anticipatory anxiety that makes it difficult to reintegrate into the civilian world, and are related to symptoms of posttraumatic stress disorder (PTSD). The PTSD Recovery Program at the McGuire Veterans Affairs Medical Center (VAMC) is a manualized treatment that focuses on the personal and daily experiences of combat veterans rather than exposure to traumatic memories. Program evaluation data demonstrated significant reduction in PTSD symptoms and improvements in general self-efficacy and adaptive behaviors. Results support the PTSD Recovery Program as an effective treatment that enhances readjustment to civilian life.     

Healing from Moral Injury: A Qualitative Evaluation of the Impact of Killing Treatment for Combat Veterans

This paper evaluates the Impact of Killing (IOK) treatment—a psychological intervention designed to address moral injury and trauma associated with killing in war. Using qualitative data from interviews with 28 combat veterans, we examine IOK’s impact, how it differs from other trauma-focused treatments, and how it can be improved to better meet veterans’ needs. We found that many veterans processed their killing experiences for the first time in IOK, even though all had previously completed evidence-based treatments for posttraumatic stress disorder. Several described killing in war as the most distressing and transformative trauma of their lives, and all affirmed the value of an intervention focused directly and explicitly on moral injury and killing. IOK helped veterans to acknowledge their grief, shame, and distress; gently but critically examine their thoughts and beliefs about killing in war; and make strides toward acceptance, reconciliation, and forgiveness.     

An Innovative Approach to Treating Combat Veterans with PTSD at Risk for Suicide

Suicide rates among military personnel had a significant drop in 2013, but there is no evidence of a drop among veterans. The problem of suicide among combat veterans with posttraumatic stress disorder (PTSD) remains a source of concern. The Department of Defense and the Department of Veterans Affairs are now calling for innovative treatment approaches to the problem. A short‐term psychodynamic therapy presented here may be able to fill that need by dissipating the guilt from veterans' combat‐related actions that leads to suicidal behavior. The treatment showed promise of success with veterans of the war in Vietnam. Preliminary work with combat veterans of the wars in Iraq and Afghanistan indicates that it may be equally successful in treating them. Basic aspects of the psychodynamic approach could be incorporated into current therapies and should improve their ability to treat veterans with PTSD at risk for suicide.