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\begin{document}

\title{Using Mindfulness to Manage Moral Injury in Veterans: Feasibility,
Satisfaction, and Initial Evidence of a Live Web-based Randomized
Controlled Trial}



\author[1]{Michelle Kelley}%
\author[2]{Adrian J. Bravo}%
\author[2]{Elizabeth E. Burgin}%
\author[3]{Susan Gaylord}%
\author[4]{Christine Vinci}%
\author[1]{Megan Strowger}%
\author[1]{Jeff M. Gabelmann}%
\author[5]{Joseph Currier}%
\affil[1]{Old Dominion University}%
\affil[2]{William \& Mary}%
\affil[3]{The University of North Carolina at Chapel Hill School of Medicine}%
\affil[4]{Moffitt Cancer Center}%
\affil[5]{University of South Alabama}%


\vspace{-1em}



  
  \date{May 26, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
\textbf{Objective}: The present study assessed initial evidence of
program feasibility, satisfaction, and pre-to post-intervention changes
in moral injury symptoms among recent-era veterans who participated in
Mindfulness to Manage Moral Injury (MMMI), a live facilitated web-based
7-week mindfulness-based program targeting moral injury among veterans.
\textbf{Method:} Of 56 recent-era veterans who met study criteria and
were randomized, 40 (71.4\%) completed the pre- and post-intervention
survey and attended at least one treatment session. Of these 40, 21
completed MMMI and 19 completed an equally intensive educational support
(ES) control intervention. Among the analytic sample ( \emph{n} = 40),
most participants identified as White (77.5\%), were men (62.5\%), and
reported a service-connected disability (82.5\%). \textbf{Results:}
Participants attended on average 6.11 sessions. Program satisfaction was
moderately high across both conditions. Several significant condition x
time interactions were found, with those in the MMMI condition reporting
greater pre- to post-intervention decreases in moral injury (\selectlanguage{greek}η\selectlanguage{english}2=.121),
impaired functioning due to moral injury (\selectlanguage{greek}η\selectlanguage{english}2=.129), shame-related
experiences due to moral injury (\selectlanguage{greek}η\selectlanguage{english}2=.105), and other-directed moral
injury (e.g., betrayal, difficulty forgiving others; \selectlanguage{greek}η\selectlanguage{english}2=.129) as
compared to the ES condition. \textbf{Conclusions:} These preliminary
findings suggest MMMI appears feasible and acceptable and may be able to
reach veterans who may not seek traditional Veterans Affairs Medical
Center care or who prefer a web-based program. Given its promise for the
treatment of moral injury among veterans, MMMI warrants additional
large-scale clinical-trial testing.%
\end{abstract}%



\sloppy


\par\null

February 4, 2024

Using Mindfulness to Manage Moral Injury in Veterans: Feasibility,
Satisfaction, and Initial Evidence of a Live Web-based Randomized
Controlled Trial



\textbf{Abstract}

\textbf{Objective} : The present study assessed initial evidence of
program feasibility, satisfaction, and pre-to post-intervention changes
in moral injury symptoms among recent-era veterans who participated in
Mindfulness to Manage Moral Injury (MMMI), a live facilitated web-based
7-week mindfulness-based program targeting moral injury among
veterans.\textbf{Method:} Of 56 recent-era veterans who met study
criteria and were randomized, 40 (71.4\%) completed the pre- and
post-intervention survey and attended at least one treatment session. Of
these 40, 21 completed MMMI and 19 completed an equally intensive
educational support (ES) control intervention. Among the analytic sample
(\emph{n} = 40), most participants identified as White (77.5\%), were
men (62.5\%), and reported a service-connected disability (82.5\%).
\textbf{Results:}Participants attended on average 6.11 sessions. Program
satisfaction was moderately high across both conditions. Several
significant condition x time interactions were found, with those in the
MMMI condition reporting greater pre- to post-intervention decreases in
moral injury (\selectlanguage{greek}η\selectlanguage{english}2=.121), impaired functioning due to moral injury
(\selectlanguage{greek}η\selectlanguage{english}2=.129), shame-related experiences due to moral injury (\selectlanguage{greek}η\selectlanguage{english}2=.105), and
other-directed moral injury (e.g., betrayal, difficulty forgiving
others; \selectlanguage{greek}η\selectlanguage{english}2=.129) as compared to the ES condition. \textbf{Conclusions:}
These preliminary findings suggest MMMI appears feasible and acceptable
and may be able to reach veterans who may not seek traditional Veterans
Affairs Medical Center care or who prefer a web-based program. Given its
promise for the treatment of moral injury among veterans, MMMI warrants
additional large-scale clinical-trial testing.

\emph{Keywords} : mindfulness; moral injury; veterans; treatment

\emph{Public Health Statement:} Military members who violate their
deeply held personal values may experience moral injury. Findings point
to Mindfulness to Manage Moral Injury (MMMI) as a feasible and
acceptable treatment for reducing moral injury symptoms among veterans.



\textbf{Introduction}

Moral injury is theorized to be the consequence of events that are
perpetration-based (e.g., injuring a noncombatant, witnessing cruel
behavior but doing nothing to stop it) or betrayal-based (e.g., betrayal
by peers, leadership) that transgress one's deeply held morals and
values (Flipse Vargas et al., 2013; Litz et al., 2009; Shay, 1991). When
service members cannot reconcile their experiences with their moral
values and beliefs, the dissonance that results may cause a range of
negative emotions, cognitions, and attributions (e.g., anger, guilt,
shame, loss of trust, lack of forgiveness, self-condemnation, hostility
toward authority). These experiences are collectively known as moral
injury (Litz et al., 2009). Moral injury symptoms are associated with
depression, suicidality, and substance misuse (Bravo et al., 2020; Bryan
et al., 2014; Forkus et al., 2021; Kelley, Chae et al., 2021).
Consistent with `whole person approaches' to care (U.S. Department of
Veterans Affairs, 2020), there is growing interest in developing
flexible mind-body approaches for addressing moral injury (Kopacz et
al., 2016; Walser \& Wharton, 2021) that address the unique experiences
of veterans. In this paper, we present findings on feasibility,
satisfaction, and preliminary changes in moral injury outcomes from a
small, randomized controlled trial of Mindfulness to Manage Moral Injury
(MMMI), a live facilitated web-based 7-week mindfulness-based program
for veterans targeting moral injury symptoms.

\textbf{Moral Injury Treatments}

Moral injury is not a diagnosable mental health disorder and may occur
from a `mixed' event that causes both a challenging moral dilemma and a
life threat event (Williamson et al., 2021). Many veterans who
experience traumatic warzone events seek treatment via Veterans Health
Administration settings (i.e., Veterans Affairs Medical Centers, Vet
Centers) and receive evidence-based treatments for PTSD, such as
cognitive processing therapy (CPT) and prolonged exposure (PE). These
treatments often focus on the hyperarousal and intrusion symptoms of a
fear-based disorder (Held et al., 2018). However, investigators have
called for mind-body programs as events that cause moral distress may
require different treatment approaches (Cenkner et al., 2021; Kopacz et
al., 2016; Steenkamp et al., 2015; Walser \& Wharton, 2021). In
addition, existing PTSD treatments might not be designed to attend to
moral injury developing from certain combat or non-combat experiences
including remote combat theatre (Kelley, Bravo et al., 2021), military
sexual assault (Hamrick et al., 2022; Maguen et al., 2022), or acts for
which no one is to blame (Fleming, 2021). Thus, moral injury might
extend beyond bioneurological effects (Starnino et al., 2020) into the
moral realm (Litz et al., 2009) in ways that treatments for PTSD may not
address the diverse trauma needs of veterans.

\textbf{Mindfulness, Moral Injury, Mindfulness to Manage Moral Injury
(MMMI)}

Kabat-Zinn (1991) defined mindfulness as ``paying attention in a
particular way: on purpose, in the present moment, and
non-judgmentally,'' (p. 4). Components of mindfulness (purposefully
paying attention to present-moment experiences) may benefit those with
moral injury symptoms (e.g., Lang et al., 2019; Zalta et al., 2018). For
instance, a cross-sectional study of veterans found that nonjudging of
inner experience and acting with awareness moderated the association
between moral injury and drug abuse symptoms (Davies et al., 2019). To
develop MMMI, we adapted the Mindfulness to Manage Chronic Pain (MMCP)
program. Designed by Miller and colleagues (Brintz et al., 2020), MMCP
is a web-delivered, group-based, interactive, instructor-taught,
six-session mindfulness training adapted from Kabat-Zinn's (1990)
in-person, group-based Mindfulness-based Stress-Reduction program
(MBSR). In adapting the program, we removed the emphasis on chronic pain
and replaced it with a focus on the psychological pain of moral injury.
We also extended the program to seven sessions to allow for an
additional focus on self-compassion/compassion, and compassion-related
exercises (see Author et al., 2022).

MBSR (Kabat-Zinn, 1991) is an empirically supported mindfulness training
which uses a range of mindfulness practices to increase awareness,
promote non-judgment and acceptance, and generate compassion. MBSR
shares tenets with Monitor and Acceptance Theory (MAT; Lindsay \&
Creswell, 2017, 2019). In MAT, Lindsay and Creswell (2019) contend that
with time and practice, attention monitoring and acceptance skills may
reduce negative affectivity, stress, and stress-related health outcomes
(Lindsay \& Creswell, 2019). Moral injury often involves guilt and shame
directed toward the self and other painful, other-directed emotions,
such as anger and wish for revenge. Thus, in MMMI, our goal was to teach
veterans to use mindfulness techniques to bring awareness to difficult
experiences and to simultaneously manage and release judgment by
bringing acceptance to psychologically painful emotions associated with
moral injury, thereby cultivating an attitude of compassion and
acceptance. By reducing condemnation, blame, anger, and simultaneously
increasing acceptance, we would expect veterans to view themselves and
others as worthwhile, despite being imperfect.

\textbf{Purpose of Present Study}

We had several aims for this initial evaluation of MMMI. The first aim
of this study was to evaluate the feasibility and acceptability of MMMI.
Second, given the strong focus of MMMI for the reduction of moral injury
symptoms, we explored whether there was initial evidence for the
effectiveness MMMI in reducing moral injury symptoms as compared to an
equally intensive intervention focusing on psychoeducation.
Notwithstanding the preliminary nature of this study, we hypothesized
that veterans in the MMMI group would report greater reductions in moral
injury symptoms compared with veterans randomized to an equivalent
seven-week, web-based live, instructor facilitated educational support
(ES) condition. Given the small clinical trial, we emphasized the
statistical significance and magnitude of effect size estimates (i.e.,
partial eta-squares) of treatment effects on outcomes.

\textbf{Method}

\textbf{Transparency and Openness}

We report how the sample size was determined, all data exclusions,
manipulations, and measures in the proceeding sections. A protocol of
this article is available (Author et al., 2022). The study was approved
by the human subjects committee at the first author's institution and
was preregistered on clinicaltrials.gov (blinded for review). The study
code, syntax, and output will be available in a repository via link
(blinded for review). The study manuals are available on request to the
first author.

\textbf{Participants}

In total, 56 post-9/11 veterans were recruited with 28 randomized to the
MMMI condition and 28 to the ES condition. All participants were
post-9/11 veterans who met the following criteria: (1) at least one
deployment to the regions of Iraq and/or Afghanistan and (2) endorsed
(agree or strongly agree) two or more (M = 7.98; SD = 4.81) moral injury
symptoms on the 17-item Expressions of Moral Injury Scale-Military
Version (EMIS-M; Currier et al., 2018) prior to treatment. Potential
participants were excluded if they: (1) had a current suicide plan, (2)
had a dishonorable discharge, and/or (3) had no access to the internet.
Among the 56 veterans who consented to participate, most participants
identified as being White (71.4\%), were men (66.1\%), and reported a
service-connected disability (87.5\%). They reported a mean age of 41.50
years (\emph{Median} = 39.50, \emph{SD} = 9.26) and on average served
12.13 years (\emph{Median} = 9.00, \emph{SD} = 8.58). The Army (55.4\%),
Navy (12.5\%), and Air Force (10.7\%) were the most represented
branches.

\textbf{Procedure}

Potential participants were recruited via a marketing firm that
specializes in recruitment for clinical health research (\emph{n} = 41),
student announcements at two universities (\emph{n} = 15), and word of
mouth (\emph{n} = 7). See Figure 1 for the CONSORT flowchart. After
completing an online screening survey, potential participants met with a
research assistant in an online platform meeting during which the
participant was verbally screened, the study focus and random assignment
were explained, veteran status was verified via display of their veteran
identification card, and consent was obtained. Next, the research
assistant collected demographic information (e.g., age, service branch)
and ensured the participant's understanding of basic platform functions.
Given that military specialty may differ for women (e.g., infantry) and
gender differences in prevalence of exposure to potentially morally
injurious events and outcomes (Maguen et al., 2020), we matched on
gender and then randomly assigned to conditions.

\textbf{Interventions}

A total of four intervention groups (2 MMMI; 2 ES) were conducted over
the course of the trial between May and August of 2022. Weekly MMMI and
ES group sessions took place in the evening and were approximately 75 to
90 minutes. Both interventions were manualized, and sessions were
structured similarly, including an ice breaker, session objectives,
discussion of home practice/exercises, didactic content about moral
injury and the session topic, and group discussion. Didactic content was
presented with multimedia tools that frequently included pictures,
videos, cartoons, role-plays, and figures. At the end of the session,
the facilitator reviewed the cumulative `toolkit', assigned home
practice/exercises, and each group member checked out by responding to
the prompt, ``I am feeling\ldots{}''. To optimize participant engagement
and relational support, facilitators were trained to be non-judgmental
and flexible.

With the consent of all participants, sessions were recorded using the
online platform and stored on a secured server. The recordings were used
to facilitate make-up sessions for participants who were unable to
attend a live session and assess facilitator adherence to both MMMI and
ES manualized weekly program objectives. Participants who missed a
session were sent a study link to the session, which was available for
two weeks. A study investigator or research assistant reviewed all
sessions for adherence to session objectives. Adherence to program
objectives was 100\% and 92.7\% across the two MMMI and ES groups,
respectively.

All study facilitators were licensed doctoral-level mental health
professionals with considerable knowledge of moral injury and extensive
experience working with trauma-exposed veterans. In addition, the MMMI
facilitator worked at a VA hospital and had training and experience
facilitating mindfulness programs for veterans. There were two ES
facilitators; one conducted the first ES intervention; the second
conducted the second intervention. The first ES facilitator was a study
investigator and participated in MMMI and ES development; the second
facilitator was experienced in delivering programs to military veterans.

MMMI. We introduced mindfulness and instructed participants through a
series of brief exercises and home practice to help veterans notice what
is happening in their body and mind in the moment, gently redirecting
the mind to the breath or chosen object as necessary, and bringing
awareness to how they typically respond to thoughts and experiences.
Initial exercises focused on what mindfulness is, applied mindfulness in
everyday activities (e.g., mindful walking), and encouraged participants
to become aware of thoughts, emotions, and sensations, without trying to
avoid or change them. We alternated mindfulness exercises with moral
injury discussion, progressively making veterans aware of how
thoughts/emotions/sensations are related to moral injury experiences and
how related symptoms can be managed in a nonjudging, compassionate
manner. Beginning in session three, instruction and activities focused
on compassion toward others/self, reducing blame, condemnation, and
increasing acceptance.

ES. Moral injury content was identical in both groups (e.g., explanation
of moral injury, discussion of how moral injury may be related to mental
health and substance use). In place of mindfulness exercises, themes
were relevant to moral injury and included management of stress and
moral emotions, exercise, self-care, peer support, boundaries, sleep,
and implementing and maintaining new wellness practices. The facilitator
led the discussion of didactic material designed to encourage peer
support and self-awareness as group members reflected on their strengths
and existing supports, and challenges and barriers to engaging in
wellness practices. For a detailed description of program development,
and session objectives, and content, see Author (2022).

\textbf{Survey Measures}

After completing the online meeting, four weeks prior to the start of
the programs, participants received a unique secure survey link (i.e.,
baseline survey) that lasted approximately 25 minutes to complete.
Following the last session, participants were sent a survey link and had
four weeks to complete a final survey (i.e., post-intervention survey).
Participants received \$30 for completing the baseline survey and \$50
for completing the post intervention survey. An in-depth description of
the program development, study methodology, and a full list of the
measures can be found in Author et al. (2022).

\textbf{Program Satisfaction.} Based on Kirkpatrick's model (Kirkpatrick
\& Kirkpatrick, 2016), we evaluated four aspects of program
satisfaction: reactions (``How satisfied are you with the training
program you attended''; 3 items), attitudes/learning/knowledge (``How
well do you feel you understand moral injury?''; 3 items), behavior
(``How much have you put what you learned into practice?''; 3 items) and
return on investment (``How much has this program benefitted you?''; 1
item). Items were rated on a 5-point scale (1-5; unique response options
to each item) and higher scores indicate greater satisfaction.

\textbf{Moral Injury.} Given discrepancies in the literature regarding
an operational definition of moral injury, moral injury was assessed
using four distinct measures of moral injury. Participants completed the
17-item Expressions of Moral Injury Scale -- Military Version (EMIS-M;
Currier et al. 2018, 2020). Measured on a 5-point response scale (1
=\emph{strongly disagree} , 5 = \emph{strongly agree} , items are
divided into two domains: 1) self-directed symptoms (9 items, e.g., ``I
am an unforgiveable person'') and 2) other-directed symptoms (8 items,
e.g., ``I feel anger over being betrayed''). Participants also completed
the 10-item Moral Injury Symptom Scale -- Military Version Short Form
(MISS-M-SF; Koenig et al., 2018). Measured on a 10-point response scale
(1 = \emph{strongly disagree} , 10 = \emph{strongly agree} ), a total
score was calculated by summing up responses across the items (e.g., ``I
feel guilt over failing to save the life of someone in war'').
Participants also completed the 8-item Moral Paradox Scale (MP; Fleming,
2021). Measured on a 5-point scale (1 = \emph{strongly disagree} , 5
=\emph{strongly agree} ), a total score was calculated by summing up
responses across the items (e.g., ``The world makes much less sense to
me since my military experience''). Finally, participants also completed
the 14-item Moral Injury Outcome Scale (MIOS; Litz et al. 2022).
Measured on a 5-point scale (1 = \emph{strongly disagree} , 5
=\emph{strongly agree} ), the MIOS assesses moral injury broadly (i.e.,
a total score) and two specific domains: shame-related experiences (``I
blame myself'') and trust-violation-related outcomes (e.g., ``I lost
trust in others''). Moreover, the MIOS includes 7 additional items
(summed for a total score) adapted from the Brief Inventory of
Psychosocial Functioning (Kleiman et al., 2020) to assess impaired
functioning due to moral injury across differing life domains (e.g.,
family relationships, work, friendships).

\textbf{Data Analytic Plan}

To determine program feasibility, we report attendance for all consented
participants. We then report attendance and program satisfaction by
group for the analytic sample (MMMI \emph{n} = 21; ES \emph{n =} 19).
Next, we report results of a series of repeated measures ANCOVA models
in SPSS 28 for the analytic sample, to determine if there were
significant pre-to-post intervention changes as determined by effect
sizes in moral injury outcomes and whether these changes differed by
group (i.e., condition x time interaction effects). Given the pilot
nature of the project and sample size, the main focus was on effect size
estimates (i.e., partial eta squares). The magnitude of effects was
interpreted based on guidelines for small (\selectlanguage{greek}η\selectlanguage{english}2 = .01), medium (\selectlanguage{greek}η\selectlanguage{english}2 = .06),
and large (\selectlanguage{greek}η\selectlanguage{english}2 = .14) effects (Richardson, 2011).

\textbf{Results}

\textbf{Attendance and Program Satisfaction}

Of the 56 participants who consented to participate across both
treatment conditions, 82.1\% of veterans attended at least one treatment
session and 44.6\% completed all seven sessions, with the average being
4.73 sessions attended across conditions. Regarding surveys, 3 (5.4\%)
veterans did not complete the baseline survey and 15 did not complete
the follow-up survey (26.8\%). Of the 56 who consented, 40 (71.43\%)
completed all study components (i.e., completed both baseline and
follow-up surveys and attended at least one treatment session) and were
considered the analytic sample for analyses (MMMI \emph{n} = 21;
ES\emph{n =} 19). There were no significant statistical differences on
demographic characteristics (e.g., age, years in military, gender) and
baseline scores on outcome variables between the analytic group
(\emph{n} = 40) and those not in the analytic group (\emph{n} = 16).

Among the 40 veterans in the analytic sample, most participants
identified as being White (77.5\%), were men (62.5\%), and reported a
service-connected disability (82.5\%). They reported a mean age of 42.70
years (\emph{Median} = 41.00, \emph{SD} = 10.07) and on average served
13.01 years in the military (\emph{Median} = 8.00, \emph{SD} = 9.57).
The Army (55.0\%) and Navy (12.5\%) were the most represented branches.
Within our analytic sample, there were no significant differences in the
average number of sessions attended between the MMMI (\emph{M =}
6.10,\emph{SD} = 1.48) and the ES (\emph{M =} 6.11, \emph{SD} = 1.37)
groups.

In Table 1, we provide information on treatment satisfaction (i.e.,
reactions, attitudes/learning/knowledge, behavior, return on investment,
and total score on satisfaction) by treatment condition (MMMI \emph{n} =
21; ES \emph{n =} 19). Regarding specific satisfaction questions, the
MMMI condition reported significantly higher confidence in their ability
to apply the program content to their daily live since the training
(Cohen's D = 1.19), reported more often having put the things they have
learned into practice (Cohen's D = 0.83), and reported that they
benefitted more from the program (Cohen's D = 0.78). Regarding
subscales, the MMMI condition reported higher satisfaction in behavior
(Cohen's D = 0.67) and return on investment (Cohen's D = 0.78). No other
statistically significant program satisfaction differences were noted.

\textbf{Exploratory Testing of Treatment Effects on Moral Injury}

Bivariate correlations and descriptive statistics of all study variables
across time points are presented in Table 2. There were no statistically
significant differences on demographic characteristics (except for age,
participants were significantly older in the MMMI condition {[}\emph{M}=
45.81 years; \emph{SD} = 10.51{]} than the ES condition {[}\emph{M} =
39.26 years; \emph{SD} = 8.57{]}) and baseline scores on all outcomes
across treatment conditions, thus ensuring the two analytic treatment
groups (MMMI and ES) were largely similar. All results of our repeated
measures ANCOVA models are found in Table 3.

\textbf{Exploratory testing of effects on MMMI on moral injury
outcomes\emph{.}} We generally found medium-large effect sizes (.08
\textless{} \selectlanguage{greek}η\selectlanguage{english}2 \textgreater{} .26). Regarding those that were
statistically significant, we found significant decreases in EMIS-M
other-directed (betrayal-based) moral injury collapsing across
conditions (\selectlanguage{greek}η\selectlanguage{english}2 = .195); however, this finding was qualified by a
significant interaction (\emph{p} = .023; \selectlanguage{greek}η\selectlanguage{english}2 = .129), such that there
was a larger decrease in the MMMI condition (T1: \emph{M} = 28.57, SE =
1.53; T2: \emph{M} = 24.71, SE = 1.41; \emph{M} difference = -3.86, SE =
0.98, \emph{p} \textless{} .001) compared to the ES condition
(T1:\emph{M} = 28.37, SE = 1.61; T2: \emph{M} = 27.90, SE = 1.48;
\emph{M}difference = -0.47, SE = 1.04, \emph{p} = .650). While no
significant interaction was found for EMIS-M self-directed scores
(\emph{p} = .071, \selectlanguage{greek}η\selectlanguage{english}2 = .083), significant decreases in EMIS-M
self-directed scores emerged when collapsing across the MMMI and ES
conditions (\selectlanguage{greek}η\selectlanguage{english}2 = .100; T1:\emph{M} = 25.17, SE = 1.29; T2: \emph{M} =
23.04, SE = 1.10; \emph{M}difference = -2.13, SE = 1.03, \emph{p} =
.046). Similarly, while no significant interaction was found for MISS
scores (\emph{p} = .061, \selectlanguage{greek}η\selectlanguage{english}2 = .089), we found significant decreases in
MISS total scores collapsing across the MMMI and ES conditions (\selectlanguage{greek}η\selectlanguage{english}2 =
.216; T1: \emph{M} = 54.83, SE = 2.35; T2: \emph{M} = 48.69, SE = 2.01;
\emph{M} difference = -6.14, SE = 1.90, \emph{p} = .003).

Regarding the MIOS measure, we found significant decreases in MIOS total
scores collapsing across the MMMI and ES conditions (\selectlanguage{greek}η\selectlanguage{english}2 = .132);
however, this outcome was also qualified by a significant interaction
(\emph{p} = .028; \selectlanguage{greek}η\selectlanguage{english}2 = .121), such that there was a larger decrease in
the MMMI condition (T1: \emph{M} = 26.86, SE = 2.15; T2: \emph{M} =
20.29, SE = 2.10; \emph{M} difference = -6.57, SE = 1.93, \emph{p} =
.002) compared to the ES condition (T1: \emph{M} = 28.68, SE = 2.26;
T2:\emph{M} = 28.53, SE = 2.21; \emph{M} difference = -0.16, SE =
2.03,\emph{p} = .938). We also found a significant interaction for MIOS
-- shame-related experiences (\emph{p} = .042; \selectlanguage{greek}η\selectlanguage{english}2 = .105), such that
there was a significant decrease in the MMMI condition (T1: \emph{M} =
12.24, SE = 1.41; T2: \emph{M} = 9.57, SE = 1.29; \emph{M} difference =
-2.67, SE = 1.18, \emph{p} = .030) compared to a marginal increase in
the ES condition (T1: \emph{M} = 12.84, SE = 1.48; T2: \emph{M} = 13.79,
SE = 1.36; \emph{M} difference = 0.95, SE = 1.24, \emph{p} = .451).

While no significant interaction was found for MIOS --
trust-violation-related scores (\emph{p} = .050, \selectlanguage{greek}η\selectlanguage{english}2 = .097), significant
decreases in MIOS -- trust-violation-related scores emerged when
collapsing across the MMMI and ES conditions (\selectlanguage{greek}η\selectlanguage{english}2 = .256; T1: \emph{M} =
15.23, SE = 0.82; T2: \emph{M} = 12.73, SE = 0.79; \emph{M} difference =
-2.51, SE = 0.69, \emph{p} = \textless{}.001). Finally, we also found
significant decreases in MIOS impaired functioning due to moral injury
scores collapsing across conditions (\selectlanguage{greek}η\selectlanguage{english}2 = .167); however, this was
qualified by a significant interaction (\emph{p} = .023; \selectlanguage{greek}η\selectlanguage{english}2 = .129),
such that there was a larger decrease in the MMMI condition (T1:\emph{M}
= 42.94, SE = 3.74; T2: \emph{M} = 28.96, SE = 3.53; \emph{M}difference
= -13.98, SE = 3.76, \emph{p} \textless{} .001) compared to the ES
condition (T1: \emph{M} = 40.45, SE = 3.74; T2: \emph{M} = 39.40, SE =
3.72; \emph{M} difference = -1.05, SE = 3.95, \emph{p} = .791).

\textbf{Discussion}

The present study assessed program feasibility, satisfaction, and
changes from pre- to post-intervention in moral injury outcomes among
recent-era veterans who participated in a mindfulness versus educational
support program for moral injury. Both programs were well received,
particularly for the MMMI condition in which participants reported
significantly more use of what they had learned, perceived more
confidence in using what they had learned, and reported greater return
on investment. During MMMI sessions, participants had a chance to
practice mindfulness exercises which might have contributed to higher
use and confidence scores. Also, results of our initial testing found
MMMI treatment had a larger impact in decreasing moral injury symptoms
than the ES treatment. Taken together, we found effect sizes consistent
with change in moral injury symptoms within the time frame examined in
this study. In general, effect sizes for condition x time effects were
in the medium to large range, whereas after collapsing across
conditions, our findings showed mostly large effect sizes (Richardson,
2011) on moral injury from pre- to post-treatment.

More specifically, when we examined pre-post changes by condition on
effects sizes, we found four interactions for the treatment conditions
over time. As compared to the ES condition, participants in the MMMI
condition reported greater reductions in total MIOS scores,
shame-related experiences due to moral injury, and impaired functioning
due to moral injury on the MIOS domain (Litz et al., 2022). Results from
the EMIS-M other-directed domain (Currier et al., 2018) showed veterans
in the MMMI condition had reductions in moral injury symptoms associated
with betrayal (e.g., betrayal, feelings of revenge, hostility toward
authority). Shame-related moral injury (e.g., guilt, shame,
self-condemnation) is theorized to result from acts for which the
veteran experiences personal responsibility (e.g., injuring a
non-combatant) or accidental, inappropriate, or prohibited behaviors the
veteran witnessed but did not counter (e.g., watching peers treat
civilians with disrespect but doing anything; Litz et al., 2009).
Shame-related moral injury had been examined in Marines or soldiers who
were directly attached to a combat arms unit (e.g., infantry, artillery)
(e.g., Drescher et al., 2011; Flispe Vargas et al., 2013). We did not
restrict our sample to veterans who were directly attached to a combat
arms unit.

The condition x time effect for shame-related moral injury may reflect
that sessions in the MMMI program focused on helping veterans use
mindfulness to cultivate and practice extending compassion and
acceptance toward themselves. Service members often have high standards
regarding self-sacrifice, duty, and honor, which may increase guilt and
shame from behaviors they perceive as unethical. In fact, a purported
hallmark of moral injury entails difficulty with self-forgiveness for
perceived or actual wrongdoing. This finding is important as veterans
often have difficulty extending compassion and acceptance toward
themselves particularly for events they perceive as their responsibility
(see Purcell et al., 2018 for a discussion). Further, self-condemnation,
self-harm, and self-sabotage are features of moral injury in which some
veterans feel the need to punish themselves for self-perpetrated acts
that took place in combat (Litz et al., 2009). Researchers have argued
that fostering self-empathy and forgiveness are key to healing from
moral injury (Evans et al., 2020; ter Heide, 2020).

We also found changes in other-directed (i.e., betrayal-based) moral
injury as measured by the EMIS-M (Currier et al., 2018). MMMI focused on
cultivating and practicing acts that would help veterans extend
compassion and empathy toward others for actions that were transgressed
against them. The distinction between self-directed (shame-related moral
injury) and other-directed (betrayal-based) moral injury is important.
Much of the existing literature has focused on self-directed moral
injury, which stems from commission or omission of violence (e.g.,
Purcell et a., 2018). However, there is growing evidence that moral
injury also comes from victimization, such as in the case of military
sexual assault (Hamrick et al., 2022; Maguen et al., 2022) or acts for
which no one is to blame (Fleming, 2021) and the moral injury symptoms
may differ as a function of the type of events experienced (Currier et
al., 2018).

After collapsing across conditions, significant pre-post effect size
changes were found on all moral injury domains except the MP scale
(Fleming, 2021). The lack of significant changes from pre-to post on the
MP (Fleming, 2021) may reflect that most moral injury scales (e.g.,
EMIS-M, MISS, MIOS) focus on effects, symptoms, and moral emotions
associated with moral injury (e.g., guilt, anger), whereas the MP scale
assesses core views that are discrepant and disrupt underlying moral
assumptions. These beliefs are not necessarily responses to acts of
perpetration, omission, or betrayal (i.e., ``I often think that life is
absurd since my experience in the military'').

\textbf{Strengths and Limitations}

Favorable study outcomes should be interpreted while considering the
study limitations. The study was a small RCT, whose primary focus was
examining feasibility and intervention satisfaction. Given our the
primary focus of MMMI is to reduce moral injury symptoms we explored
whether MMMI may have greater benefit for moral injury symptoms. Our
initial evidence points to MMMI as having benefits for the reduction of
moral injury. Taken together, these findings are promising, but clearly
a fully powered clinical trial is needed to make convincing conclusions
regarding the benefits of MMMI for moral injury. With this important
caveat, several strengths should be noted. We compared MMMI to a
comparable ES program, strengthening the design by providing an active
comparison group (Byrd-Bredbenner et al., 2017). Also, talking with
other veterans was a ``top resource for coping with stress'' (Franklin
et al., 2015); thus, an ES program that addressed moral injury and
coping strategies could benefit veterans and ES did have some equivalent
benefits for moral injury. Also, by developing the active control in a
similar way, we were able to structure, manualize, and deliver the
programs similarly. Perhaps most importantly, both the MMMI and the ES
programs presented identical moral injury content. However, other group
treatments or other mind-body programs may benefit those with moral
injury.

Of the 56 participants who consented, 40 (71.43\%) completed the pre-
and post- surveys and attended at least one session. Across 20 studies
involving routine or clinical trials for PTSD, the pooled rate of
drop-out was 36\% (Goetter et al., 2015). Across frontline trauma
treatments, results of a meta-analysis found a 28.2\% dropout rate among
military personnel (Varker et al., 2021). Although drop-out in the
present study was a concern, more globally, attrition from mental health
treatment is a significant challenge among military populations. Future
research should address why some veterans did not complete any or all
study aspects, especially given the study convenience.

\textbf{Conclusions}

Overall, MMMI appeared to be feasible and acceptable for addressing
issues related to moral injury among veterans in our sample. Initial
evidence based on changes in effect sizes from the small RCT indicated
MMMI is a promising strategy for reducing moral injury symptoms and
impaired functioning related to moral injury in veterans. Moral injury
has been associated with a host of problems including depression,
suicidality, substance misuse, interpersonal conflicts, and
stress-related illness (Bravo et al., 2020; Dennis et al., 2017; Evans
et al., 2018; Forkus et al., 2021; Kelley, Chae et al., 2021). Whole
person approaches that target integrated primary prevention for service
members (Cabrera, 2023) and improve global functioning among veterans
(U.S. Department of Veterans Affairs, 2020) are now key to service
members and veteran health. These findings warrant large-scale
randomized trials and follow-up testing to determine whether MMMI can be
used as a first-line treatment or complementary treatment for veterans
with moral injury.

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Table 1. \emph{Mean Scores on}

\emph{Treatment Satisfaction Reports by Treatment Condition (n = 40)}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Treatment Satisfaction Question\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
ES (\emph{n} = 19)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
MMMI (\emph{n} = 21)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Cohen's \emph{d}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
How valuable did you find the training\textsuperscript{1}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.47\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.90\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.45\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
How satisfied are you with the training program you
attended\textsuperscript{1}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.00\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.29\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.36\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
How difficult/easy was the program content to
understand\textsuperscript{1}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.37\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.29\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.13\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
How well do you feel you understand the topics covered
overall\textsuperscript{2}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.05\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.05\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.01\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
How well do you feel you understand moral
injury\textsuperscript{2}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.89\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.10\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.27\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
How confident are you in your ability to apply the content covered in
your daily life since the training\textsuperscript{2}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.58\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.33\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.19*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
How much have you put what you learned into
practice\textsuperscript{3}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.16\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.76\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.83*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
How much do you feel like the training and practices you have learned
have helped with your stress and moral injury
symptoms\textsuperscript{3}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.05\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.52\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.57\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
How much do you agree with this statement: I intend to use the knowledge
I acquired from this program in the future\textsuperscript{3}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.05\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.29\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.28\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
How much has this program benefitted you\textsuperscript{4}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.26\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.05\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.78*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Reactions Subscale\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.95\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.16\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.32\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Attitudes/Learning/Knowledge Subscale\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.84\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.16\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.62\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Behavior Subscale\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.42\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.86\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.67*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Return on Investment Subscale\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.23\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.05\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.78*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Total Score\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.74\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.06\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.62\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\emph{Note.} Item subscripts refer to each subscale:
\textsuperscript{1}= Reactions; \textsuperscript{2} =
Attitudes/Learning/Knowledge,\textsuperscript{3} = Behavior, and
\textsuperscript{4} = Return on Investment. Responses for each item
ranged from 1 -- 5 and higher scores indicate higher satisfaction. *
Indicates significant mean differences based on independent
\emph{t}-test at \emph{p} \textless{} .05.

Table 2. \emph{Bivariate correlations among study variables among
analytic sample (n = 40)}\selectlanguage{english}
\begin{longtable}[]{@{}lllllllllllllllllll@{}}
\toprule
& 1 & 2 & 3 & 4 & 5 & 6 & 7 & 8 & 9 & 10 & 11 & 12 & 13 & 14 & 15 & 16 &
M & \emph{SD}\tabularnewline
\midrule
\endhead
1. EMIS-- Self T1 & \emph{.91} & & & & & & & & & & & & & & & & 25.20 &
8.05\tabularnewline
2. EMIS--Self T2 & \textbf{.61} & \emph{.90} & & & & & & & & & & & & & &
& 22.98 & 6.99\tabularnewline
3. EMIS--Other T1 & \textbf{.49} & \textbf{.55} & \emph{.88} & & & & & &
& & & & & & & & 28.48 & 6.93\tabularnewline
4. EMIS--Other T2 & .15 & \textbf{.64} & \textbf{.75} & \emph{.89} & & &
& & & & & & & & & & 26.23 & 6.56\tabularnewline
5. MP T1 & \textbf{.82} & \textbf{.60} & \textbf{.54} & \textbf{.33} &
\emph{.86} & & & & & & & & & & & & 23.98 & 6.93\tabularnewline
6. MP T2 & \textbf{.49} & \textbf{.85} & \textbf{.61} & \textbf{.72} &
\textbf{.64} & \emph{.90} & & & & & & & & & & & 22.25 &
7.33\tabularnewline
7. MISS T1 & \textbf{.72} & \textbf{.55} & \textbf{.40} & .21 &
\textbf{.71} & \textbf{.44} & \emph{.73} & & & & & & & & & & 54.73 &
14.78\tabularnewline
8. MISS T2 & \textbf{.47} & \textbf{.78} & \textbf{.41} & \textbf{.56} &
\textbf{.53} & \textbf{.72} & \textbf{.63} & \emph{.70} & & & & & & & &
& 48.40 & 13.82\tabularnewline
9. MIOS--Total T1 & \textbf{.72} & \textbf{.63} & \textbf{.57} &
\textbf{.36} & \textbf{.78} & \textbf{.53} & \textbf{.76} & \textbf{.53}
& \emph{.87} & & & & & & & & 27.73 & 9.77\tabularnewline
10. MIOS--Total T2 & \textbf{.40} & \textbf{.74} & \textbf{.47} &
\textbf{.69} & \textbf{.52} & \textbf{.73} & \textbf{.37} & \textbf{.71}
& \textbf{.58} & \emph{.90} & & & & & & & 24.20 & 10.39\tabularnewline
11. MIOS--Shame T1 & \textbf{.79} & \textbf{.57} & \textbf{.36} & .13 &
\textbf{.75} & \textbf{.43} & \textbf{.78} & \textbf{.50} & \textbf{.88}
& \textbf{.43} & \emph{.89} & & & & & & 12.53 & 6.39\tabularnewline
12. MIOS--Shame T2 & \textbf{.50} & \textbf{.75} & \textbf{.40} &
\textbf{.54} & \textbf{.56} & \textbf{.72} & \textbf{.46} & \textbf{.70}
& \textbf{.60} & \textbf{.92} & \textbf{.60} & \emph{.90} & & & & &
11.58 & 6.22\tabularnewline
13. MIOS--Trust T1 & \textbf{.38} & \textbf{.50} & \textbf{.64} &
\textbf{.52} & \textbf{.54} & \textbf{.47} & \textbf{.47} & \textbf{.39}
& \textbf{.81} & \textbf{.55} & \textbf{.42} & \textbf{.39} & \emph{.80}
& & & & 15.20 & 5.17\tabularnewline
14. MIOS--Trust T2 & .23 & \textbf{.57} & \textbf{.45} & \textbf{.72} &
\textbf{.35} & \textbf{.59} & .17 & \textbf{.58} & \textbf{.42} &
\textbf{.88} & .14 & \textbf{.62} & \textbf{.63} & \emph{.81} & & &
12.63 & 5.32\tabularnewline
15. MIOS--Funct T1 & \textbf{.46} & \textbf{.48} & \textbf{.37} & .25 &
\textbf{.36} & \textbf{.44} & \textbf{.49} & .25 & \textbf{.55} &
\textbf{.38} & \textbf{.54} & \textbf{.51} & \textbf{.38} & .14 &
\emph{.90} & & 41.76 & 16.13\tabularnewline
16. MIOS--Funct T2 & .28 & \textbf{.39} & \textbf{.32} & \textbf{.37} &
.27 & \textbf{.35} & \textbf{.46} & \textbf{.47} & .27 & \textbf{.45} &
.22 & \textbf{.43} & .23 & .\textbf{39} & \textbf{.39} & \emph{.89} &
33.92 & 16.84\tabularnewline
\bottomrule
\end{longtable}

\emph{Note} . Significant correlations are in bold typeface for emphasis
and were determined \emph{p} \textless{} .05. Cronbach's alphas are
underlined and shown on the diagonals. T1 = Baseline survey, T2 =
Post-intervention survey. EMIS = Expressions of Moral Injury Scale --
Military Version; MP = Moral Paradox Scale; MISS = Moral Injury Symptom
Scale -- Military Version Short Form; MIOS = Moral Injury Outcome Scale;
MIOS--Shame = Shame-related experiences; MIOS--Trust = MIOS
Trust-violation-related Outcomes; MIOS-Funct = MIOS Impaired Functioning
Subscale.

Table 3. \emph{Initial Evidence of Effects on Moral Injury Outcomes (n =
40; MMMI = 21; ES = 19)}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\emph{Predictor} & \emph{F} & \emph{p-value} & \selectlanguage{greek}\emph{η2}\selectlanguage{english} &
\emph{Observed Power}\tabularnewline
EMIS -- Self Directed (across time) & \textbf{4.24} & \textbf{.046} &
\textbf{.100} & \textbf{.518}\tabularnewline
EMIS -- Self Directed X Treatment Condition & 3.44 & .071 & .083 &
.440\tabularnewline
EMIS -- Other Directed (across time) & \textbf{9.19} & \textbf{.004} &
\textbf{.195} & \textbf{.840}\tabularnewline
EMIS -- Other Directed X Treatment Condition & \textbf{5.61} &
\textbf{.023} & \textbf{.129} & \textbf{.636}\tabularnewline
MP (across time) & 3.05 & .089 & .074 & .398\tabularnewline
MP X Treatment Condition & 1.07 & .308 & .027 & .172\tabularnewline
MISS (across time) & \textbf{10.44} & \textbf{.003} & \textbf{.216} &
\textbf{.883}\tabularnewline
MISS X Treatment Condition & 3.72 & .061 & .089 & .469\tabularnewline
MIOS -- Total (across time) & \textbf{5.78} & \textbf{.021} &
\textbf{.132} & \textbf{.649}\tabularnewline
MIOS -- Total X Treatment Condition & \textbf{5.25} & \textbf{.028} &
\textbf{.121} & \textbf{.607}\tabularnewline
MIOS -- Shame-related Experiences (across time) & 1.00 & .323 & .026 &
.164\tabularnewline
MIOS -- Shame-related Experiences X Treatment Condition & \textbf{4.44}
& \textbf{.042} & \textbf{.105} & \textbf{.537}\tabularnewline
MIOS -- Trust-violation-related Outcomes (across time) & \textbf{13.08}
& \textbf{\textless{}.001} & \textbf{.256} &
\textbf{.941}\tabularnewline
MIOS -- Trust-violation-related Outcomes X Treatment Condition & 4.08 &
.050 & .097 & .504\tabularnewline
MIOS -- Impaired Functioning (across time) & \textbf{7.61} &
\textbf{.009} & \textbf{.167} & \textbf{.767}\tabularnewline
MIOS -- Impaired Functioning X Treatment Condition & \textbf{5.63} &
\textbf{.023} & \textbf{.129} & \textbf{.638}\tabularnewline
\bottomrule
\end{longtable}

\emph{Note.} Statistically significant effects (\emph{p} \textless{}
.05) are bolded for emphasis. EMIS = Expressions of Moral Injury Scale
-- Military Version; MPDOX = Moral Paradox Scale; MISS = Moral Injury
Symptom Scale -- Military Version Short Form; MIOS = Moral Injury
Outcome Scale.

Figure 1.

\emph{CONSORT Flowchart of Participants}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

