Can a New Treatment Help Veterans Heal from Moral Injury?

What you need to know

• Moral injury can occur when someone experiences events that violate their moral beliefs, leading to mental health difficulties
• A new therapy called Restore and Rebuild (R&R) has been developed specifically to treat moral injury in UK veterans
• This study will compare R&R to usual treatment to see if it is feasible and potentially more effective for moral injury

What is moral injury?

Moral injury is a term used to describe the psychological and emotional impact that can occur when someone experiences events that violate their moral or ethical code. For military veterans, this could include things like:

• Being unable to help civilians due to rules of engagement
• Witnessing or participating in actions that harm innocent people
• Feeling betrayed by leadership decisions
• Being given inadequate equipment for a mission

While not everyone who experiences these types of events will develop moral injury, for some it can lead to profound negative changes in how they view themselves and the world. Common reactions include intense feelings of guilt, shame, anger, and a loss of trust in oneself or others.

It’s important to note that moral injury itself is not a mental health diagnosis. However, struggling with moral injury is associated with an increased risk of developing mental health conditions like post-traumatic stress disorder (PTSD), depression, anxiety, and suicidal thoughts.

Why is moral injury challenging to treat?

Currently, there is no validated treatment specifically designed for moral injury-related mental health problems in the UK. This presents a significant challenge for mental health providers trying to help veterans struggling with these issues.

While treatments exist for conditions like PTSD, research suggests that moral injury may require a different approach. The thought patterns and emotions involved in moral injury (like guilt, shame, and anger) may not be fully addressed by standard trauma-focused therapies.

Some experts have even raised concerns that certain PTSD treatments could potentially make symptoms of guilt and shame worse in cases of moral injury. There’s a clear need for treatments tailored to the unique aspects of moral injury.

What is Restore and Rebuild (R&R)?

Restore and Rebuild (R&R) is a new therapy developed specifically to treat moral injury-related mental health difficulties in UK military veterans. It was created through collaboration between international experts on moral injury and UK veterans who have personal experience with these issues.

R&R is a 20-session therapy delivered one-on-one between a therapist and patient. Key components include:

• Education about moral injury
• Discussing the morally injurious event(s)
• Exploring how the event(s) changed the person’s beliefs and thought processes
• Working to adaptively update unhelpful beliefs
• Examining core values and setting goals for the future

The therapy involves both in-session discussions and written exercises or worksheets for patients to complete between sessions.

How will this study work?

This study aims to test whether R&R is feasible to deliver and potentially more effective than usual treatment for veterans with moral injury-related mental health problems. Here’s an overview of how it will work:

Participants: The study will recruit 46 UK military veterans who are struggling with moral injury-related mental health difficulties. Veterans will be identified through Combat Stress, a UK charity that provides mental health services to veterans.

Treatment Groups: Participants will be randomly assigned to one of two groups:

1. R&R treatment (23 veterans)
2. Treatment as usual (23 veterans)

R&R Group: Veterans in this group will receive the full 20-session R&R treatment, delivered online via video calls.

Treatment as Usual Group: Since there’s no standard treatment for moral injury currently, veterans in this group will receive the typical one-on-one therapy that would be offered to someone entering Combat Stress with moral injury-related issues. This will also be delivered online.

Assessments: All participants will complete questionnaires measuring various aspects of their mental health and well-being at several points:

• Before starting treatment
• Near the end of treatment (session 19)
• At the end of treatment
• 12 weeks after treatment ends
• 24 weeks after treatment ends

Interviews: Up to 23 veterans who received R&R will also be invited to participate in interviews about their experience with the treatment.

What will the study measure?

The study will look at several key areas to determine if R&R is feasible and potentially beneficial:

Primary Outcomes:

• Symptoms of moral injury
• Symptoms of PTSD and complex PTSD

Secondary Outcomes:

• Depression symptoms
• Anger
• Alcohol use
• Social support
• Overall mental well-being
• Physical health

The researchers will also collect information on:

• How many treatment sessions participants attend
• Whether there are any negative effects from treatment
• If participants drop out of treatment early

Why is this study important?

This study is an crucial step in developing better treatments for veterans struggling with moral injury. Here’s why it matters:

1. Addressing an unmet need: Currently, there’s no validated treatment specifically for moral injury-related mental health problems in the UK. This study could lead to more effective care for veterans dealing with these issues.

2. Tailored approach: R&R was designed with input from veterans who have experienced moral injury. This means it may be better suited to address the unique challenges they face compared to general trauma treatments.

3. Potential wider impact: While this study focuses on veterans, moral injury can affect people in many professions (healthcare workers, first responders, journalists, etc.). If R&R proves effective, it could potentially be adapted to help a broader range of people.

4. Reducing long-term consequences: Moral injury can have severe, long-lasting effects on mental health and quality of life. An effective treatment could help veterans heal and reduce negative impacts on their relationships, work, and overall well-being.

What are the potential limitations?

It’s important to consider some potential limitations of this study:

• Small sample size: With only 46 participants, this is a relatively small study. While it can provide valuable initial information, larger studies would be needed to draw firm conclusions about R&R’s effectiveness.

• Online delivery: Both R&R and usual treatment will be delivered via video calls. This could potentially exclude veterans who don’t have reliable internet access or aren’t comfortable with online therapy.

• Single location: The study is being conducted through one veterans’ mental health charity in the UK. Results might not generalize perfectly to other healthcare settings or countries.

• Short follow-up: The study will only follow participants for 24 weeks after treatment ends. Longer-term follow-up would be needed to assess the lasting effects of R&R.

Conclusions

• This study will test a new therapy called Restore and Rebuild (R&R) designed specifically to treat moral injury in UK veterans.
• The results will help determine if R&R is feasible to deliver and potentially more effective than usual care for moral injury-related mental health problems.
• If successful, this research could lead to improved treatment options for veterans struggling with the psychological effects of morally injurious experiences.