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”).