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.