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.