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…”. 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).
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).
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.
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 =strongly disagree , 5 = 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 = strongly disagree , 10 = 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 = strongly disagree , 5 =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 = strongly disagree , 5 =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).