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In the current paper, we aim to expand the dialogue about applying psychological flexibility processes to moral injury-related spiritual suffering using Acceptance and Commitment Therapy (ACT). Psychological flexibility is the process of practicing present moment awareness and openness to experiences of emotions and thoughts, while also choosing to engage in actions that are consistent with one's values. This open, aware, and engaged approach to life fits well with spiritual endeavors. We provide a framework and a case example illustrating how spiritual care providers and Chaplains can use psychological flexibility processes to target spiritual suffering in the context of moral injury.

Improved, efficient, and acceptable treatments are needed for combat-related posttraumatic stress disorder (PTSD).To determine the efficacy of 2 compressed prolonged exposure (PE) therapy outpatient treatments for combat-related PTSD.This randomized clinical trial was conducted among military personnel and veterans at 4 sites in Texas from 2017 to 2019. Assessors were blinded to conditions. Data were analyzed from November 2020 to October 2022.The interventions were massed-PE, which included 15 therapy sessions of 90 minutes each over 3 weeks, vs intensive outpatient program PE (IOP-PE), which included 15 full-day therapy sessions over 3 weeks with 8 treatment augmentations. The IOP-PE intervention was hypothesized to be superior to massed-PE.Coprimary outcomes included the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) (CAPS-5) and the PTSD Checklist for DSM-5 (PCL-5) administered at baseline and posttreatment follow-ups. Measures ranged from 0 to 80, with higher scores indicating greater severity. Diagnostic remission and reliable change were secondary outcomes.Among 319 military personnel and veterans screened, 234 were randomized (mean [SD] age, 39.20 [7.72] years; 182 [78%] male participants), with 117 participants randomized to IOP-PE and 117 participants randomized to massed-PE. A total of 61 participants (26%) were African American, 58 participants (25%) were Hispanic, and 102 participants (44%) were White; 151 participants (65%) were married. Linear mixed-effects models found that CAPS-5 scores decreased in both treatment groups at the 1-month follow-up (IOP-PE: mean difference, -13.85 [95% CI, -16.47 to -11.23]; P .001; massed-PE: mean difference, -14.13 [95% CI, -16.63 to -11.62]; P .001). CAPS-5 change scores differed from 1- to 6-month follow-ups (mean difference, 4.44 [95% CI, 0.89 to 8.01]; P = .02). PTSD symptoms increased in massed-PE participants during follow-up (mean difference, 3.21 [95% CI, 0.65 to 5.77]; P = .01), whereas IOP-PE participants maintained treatment gains (mean difference, 1.23 [95% CI, -3.72 to 1.27]; P = .33). PCL-5 scores decreased in both groups from baseline to 1-month follow-up (IOP-PE: mean difference, -21.81 [95% CI, -25.57 to -18.04]; P .001; massed-PE: mean difference, -19.96 [95% CI, -23.56 to -16.35]; P .001) and were maintained at 6 months (IOP-PE: mean change, -0.21 [95% CI, -3.47 to 3.06]; P = .90; massed-PE: mean change, 3.02 [95% CI, -0.36 to 6.40]; P = .08). Both groups had notable PTSD diagnostic remission at posttreatment (IOP-PE: 48% [95% CI, 36% to 61%] of participants; massed-PE: 62% [95% CI, 51% to 73%] of participants), which was maintained at 6 months (IOP-PE: 53% [95% CI, 40% to 66%] of participants; massed-PE: 52% [95% CI, 38% to 66%] of participants). Most participants demonstrated reliable change on the CAPS-5 (61% [95% CI, 52% to 69%] of participants) and the PCL-5 (74% [95% CI, 66% to 81%] of participants) at the 1-month follow-up.These findings suggest that PE can be adapted into compressed treatment formats that effectively reduce PTSD symptoms.ClinicalTrials.gov Identifier: NCT03529435.

A Performance Improvement project conducted within Army Behavioral Health identified significant challenges associated with treating service members diagnosed with posttraumatic stress disorder (PTSD) including unavailability of frequent and consistent therapy, a low completion rate of evidence-based treatment, and a high non-response rate. In response to these findings, clinical staff at Brooke Army Medical Center developed an intensive outpatient program for the treatment of PTSD and combined Acceptance and Commitment Therapy with Prolonged Exposure therapy to create an integrative and uniquely tailored intervention. This project included 311 active duty service members who had not made significant progress in individual outpatient therapy for PTSD. Each participant completed pre- and post-treatment measures of symptoms, functioning, and processes related to psychological flexibility. Program evaluation also included participant interviews, survey responses, and clinician reports. Overall, the program was tolerable and reviewed favorably by participants. Preliminary pre-post treatment analyses revealed, on average, large reductions in PTSD symptoms as well as significant changes in the target direction on nine of ten outcome measures. These findings encourage further investigation of process-outcome relationships and future, rigorous implementation studies of ACT and exposure integration and culturally and contextually sensitive treatments for military-related PTSD.

Prolonged Exposure (PE) is a highly effective treatment for posttraumatic stress disorder (PTSD) across a variety of delivery formats and samples. However, for military service members, the treatment tends to be less effective than for civilians. One explanation for the reduced response to PE in military service members is the frequency, intensity, and heterogeneity of combat trauma. Combat trauma may yield a variety of posttraumatic responses, including moral injury, or the psychosocial-spiritual suffering consequent of exposure to moral injurious events. Despite rapidly increasing research on combat-related moral injury, little clinical guidance exists on how or if moral injury may be addressed via trauma-focused treatments such as PE. This case report describes the facilitation of moral healing for a U.S. Army soldier with combat-related PTSD in a 3-week intensive outpatient PE program. While PTSD symptoms were reduced from pre- to posttreatment, even more substantial treatment gains were observed in the soldier’s functional changes, engagement with values-based activities, and his reported willingness to embrace moral pain. Although not explicit in the PE manual, targeting these latter outcomes in PE can facilitate moral healing in service members with PTSD. This case report provides a detailed description of how PE procedures were targeted to address moral injury and where theory-driven augmentations were included to facilitate moral healing.

Community mental health providers play an essential role in delivering services to veterans who either have limited access to U.S. Department of Veterans Affairs (VA) facilities or who prefer to seek care outside of the VA. However, there are limited training opportunities in evidence-based treatments for posttraumatic stress disorder (PTSD) outside of the VA. In 2017, the STRONG STAR Training Initiative was established to develop competency-based training in two evidence-based therapies for PTSD and to provide that training for mental health providers serving veterans and their families in community settings in Texas. This article describes the program's development and implementation, baseline characteristics of participating clinicians, and lessons learned toward the scale-up and extension of this competency-based training effort to include other interventions and locations.

Current clinical practice guidelines for the treatment of post-traumatic stress disorder (PTSD) strongly recommend individual manualized trauma-focused therapy. However, it can be challenging for patients to complete a full course of treatment. There has been recent interest in modifying the format of evidence-based psychotherapies for PTSD to be delivered within a shorter time frame to reduce the likelihood of dropout and optimize the potential for a positive treatment outcome. This article will review the existing literature on massed psychotherapies for PTSD, including only the treatments highly recommended by the current PTSD treatment guidelines that have been modified to an intensive format. The literature supporting massed treatment formats for PTSD is limited to date. Two randomized clinical trials (RCTs) provide the strongest evidence for efficacy for prolonged exposure and cognitive therapy for PTSD, and preliminary studies of cognitive processing therapy and eye movement desensitization and reprocessing are promising. Current results suggest that massed formats of existing evidence-based psychotherapies for PTSD are promising efficient and effective methods to expedite recovery from PTSD symptoms. Additional RCTs are needed to demonstrate the efficacy of these treatments in a range of patient populations.

Recently, the legal landscape for sexual minorities in the United States has changed dramatically, prompting empirical research on lesbian, gay, and bisexual (LGB) couples and LGB service members. This study examined the relationship characteristics and mental health of LGB service members in couple relationships and compared partnered and single LGB service members. A total of 238 LGB service members completed an anonymous survey, including questions about demographics, identity, military experiences, and mental health symptoms. Results of descriptive and exploratory analyses revealed no significant differences in mental health between partnered and single participants. However, partnered individuals reported higher outness and lower internalized homophobia compared with their single counterparts. Analyses also revealed negative associations between relationship satisfaction and mental health symptoms among partnered participants. Among the first to examine LGB service members’ romantic relationships, the results of this study have important clinical and policy implications and inform next steps in researching this population.

Community mental health providers play an essential role in delivering services to veterans who either have limited access to U.S. Department of Veterans Affairs (VA) facilities or who prefer to seek care outside of the VA. However, there are limited training opportunities in evidence-based treatments for posttraumatic stress disorder (PTSD) outside of the VA. In 2017, the STRONG STAR Training Initiative was established to develop competency-based training in two evidence-based therapies for PTSD and to provide that training for mental health providers serving veterans and their families in community settings in Texas. This article describes the program's development and implementation, baseline characteristics of participating clinicians, and lessons learned toward the scale-up and extension of this competency-based training effort to include other interventions and locations.

Literature clearly elucidates the association between unit cohesion and service members’ well-being. Similarly, social support/acceptance of sexual identity is related to better mental health among...

This study is among the first examining lesbian, gay, and bisexual (LGB) service members in the United States following the “don’t ask, don’t tell” policy repeal. Higher levels of outness predict better mental health among general LGB populations. The military environment, like other traditional/conservative settings, may alter this relation; however, no data are available on outness among LGB service members in the United States. We examined 236 service members’ level of outness and satisfaction with outness in relation to depression and anxiety symptoms. Results revealed greater level of outness was related to higher satisfaction with outness, with each variable related to better mental health. Importantly, satisfaction fully mediated the relation between level of outness and mental health, indicating satisfaction to be a more salient predictor than level alone. Findings relevant to military policy makers and health-care providers are discussed along with recommendations for advancement of research into outness among LGB people.

The term moral injury has been coined to describe the suffering that may develop following a violation of deeply held moral beliefs and values and subsequent difficulties in functioning. Yet despite an increase in research and intervention approaches for this topic, the relationship between moral injury and mental health diagnoses such as Posttraumatic Stress Disorder (PTSD) remains unclear and concern exists that, in some cases, moral injury might be used to unnecessarily pathologize moral processes. With the goal of further refining the construct, we argue that moral injury is a condition distinct from PTSD and other disorders and, using a functional approach, propose enhanced definitions for the terms, morally injurious event , moral pain , moral injury, and moral healing . Consistent with these new definitions, we then argue for Acceptance and Commitment Therapy (ACT) as a feasible and promising treatment for moral injury and present initial qualitative data supporting the intervention.

Objective Concern about symptom worsening with trauma-focused treatment may be one factor hindering the implementation of evidence-based treatments for PTSD, like cognitive processing therapy (CPT), despite evidence for their efficacy. Previous studies have examined the frequency and effect of symptom exacerbation, or temporary symptom increases, on outcomes, but primarily in randomized clinical trials. Method We examined this issue in a community sample of participants receiving CPT from front-line clinicians learning to deliver CPT in a randomized controlled implementation trial of training strategies. Patient participants (n = 183) completed self-report measures of PTSD symptoms at each session. Results Most participants (67.3%) experienced at least one temporary symptom increase during CPT (only 1.6% continued to have higher symptoms by the end of treatment). Demographic variables, comorbid conditions (i.e., depression, anxiety, substance use), and baseline PTSD symptom levels did not predict symptom increases. Importantly, symptom increases did not predict treatment noncompletion, posttreatment PTSD symptom levels, or loss of probable PTSD diagnosis. Moreover, growth curve modeling revealed that temporary symptom increases did not predict the trajectory of PTSD symptoms over the course of treatment. Conclusions The rates of symptom increases, which were higher than in previous studies, may be attributed to a routine care sample or to the differences in session timing and measurement. These results add to a nascent literature documenting that symptom increases may be a normal, transient part of treatment that do not impact a patient's ability to have symptom improvement during a course of CPT. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Combat-related posttraumatic stress disorder (PTSD) is the most common psychological health condition in military service members and veterans who have deployed to the combat theater since September 11, 2001. One of the highest research priorities for the Department of Defense and the Department of Veterans Affairs is to develop and evaluate the most efficient and efficacious treatments possible for combat-related PTSD. However, the treatment of combat-related PTSD in military service members and veterans has been significantly more challenging than the treatment of PTSD in civilians. Randomized clinical trials have demonstrated large posttreatment effect sizes for PTSD in civilian populations. However, recent randomized clinical trials of service members and veterans have achieved lesser reductions in PTSD symptoms. These results suggest that combat-related PTSD is unique. Innovative approaches are needed to augment established evidence-based treatments with targeted interventions that address the distinctive elements of combat-related traumas. This paper describes the design, methodology, and protocol of a randomized clinical trial to compare two intensive prolonged exposure therapy treatments for combat-related PTSD in active duty military service members and veterans and that can be administered in an acceptable, efficient manner in this population. Both interventions include intensive daily treatment over a 3-week period and a number of treatment enhancements hypothesized to result in greater reductions in combat-related PTSD symptoms. The study is designed to advance the delivery of care for combat-related PTSD by developing and evaluating the most potent treatments possible to reduce PTSD symptomatology and improve psychological, social, and occupational functioning.

Objective Potentially morally injurious events (PMIEs)-violations (perpetrated or witnessed) of one's deeply held beliefs or values-have been associated with several forms of psychological distress. The values violated by PMIEs are often influenced by one's religion/spirituality (r/s). Struggles with one's r/s beliefs and/or practices may also contribute to elevated psychological distress. To further develop a framework for understanding and treating the sequelae of PMIE exposure, we examined the role of r/s struggles in the relation between PMIE exposure and psychological distress. Method A diverse sample of 155 veterans at a large Veterans Affairs medical center completed questionnaires assessing PMIE exposure, r/s struggles, and psychological distress. Results Findings revealed greater PMIE exposure predicted elevated r/s struggles as well as elevated symptoms of anxiety and posttraumatic stress disorder (PTSD). Likewise, greater r/s struggles predicted elevated anxiety, PTSD, and depression symptoms. Regression analyses revealed r/s struggles fully mediated the relation between PMIE exposure and anxiety as well as PTSD, and a significant indirect effect of PMIE exposure on depression symptoms through r/s struggles was observed. Follow-up analyses revealed that no specific domain of r/s struggles accounted for the relation between PMIE exposure and psychological distress; rather, the overarching construct of r/s struggles accounted for this relation. Conclusion These findings advance the evolving theoretical framework of moral injury, elucidating the salience of r/s struggles in the development of distress. Implications for moral injury intervention call for attention to potential dissonance between actions (witnessed or perpetrated) and r/s underpinnings of the individual's moral framework. (PsycINFO Database Record