Interventions
A total of four intervention groups (2 MMMI; 2 ES) were conducted over the course of the trial between May and August of 2022. Weekly MMMI and ES group sessions took place in the evening and were approximately 75 to 90 minutes. Both interventions were manualized, and sessions were structured similarly, including an ice breaker, session objectives, discussion of home practice/exercises, didactic content about moral injury and the session topic, and group discussion. Didactic content was presented with multimedia tools that frequently included pictures, videos, cartoons, role-plays, and figures. At the end of the session, the facilitator reviewed the cumulative ‘toolkit’, assigned home practice/exercises, and each group member checked out by responding to the prompt, “I am feeling…”. To optimize participant engagement and relational support, facilitators were trained to be non-judgmental and flexible.
With the consent of all participants, sessions were recorded using the online platform and stored on a secured server. The recordings were used to facilitate make-up sessions for participants who were unable to attend a live session and assess facilitator adherence to both MMMI and ES manualized weekly program objectives. Participants who missed a session were sent a study link to the session, which was available for two weeks. A study investigator or research assistant reviewed all sessions for adherence to session objectives. Adherence to program objectives was 100% and 92.7% across the two MMMI and ES groups, respectively.
All study facilitators were licensed doctoral-level mental health professionals with considerable knowledge of moral injury and extensive experience working with trauma-exposed veterans. In addition, the MMMI facilitator worked at a VA hospital and had training and experience facilitating mindfulness programs for veterans. There were two ES facilitators; one conducted the first ES intervention; the second conducted the second intervention. The first ES facilitator was a study investigator and participated in MMMI and ES development; the second facilitator was experienced in delivering programs to military veterans.
MMMI. We introduced mindfulness and instructed participants through a series of brief exercises and home practice to help veterans notice what is happening in their body and mind in the moment, gently redirecting the mind to the breath or chosen object as necessary, and bringing awareness to how they typically respond to thoughts and experiences. Initial exercises focused on what mindfulness is, applied mindfulness in everyday activities (e.g., mindful walking), and encouraged participants to become aware of thoughts, emotions, and sensations, without trying to avoid or change them. We alternated mindfulness exercises with moral injury discussion, progressively making veterans aware of how thoughts/emotions/sensations are related to moral injury experiences and how related symptoms can be managed in a nonjudging, compassionate manner. Beginning in session three, instruction and activities focused on compassion toward others/self, reducing blame, condemnation, and increasing acceptance.
ES. Moral injury content was identical in both groups (e.g., explanation of moral injury, discussion of how moral injury may be related to mental health and substance use). In place of mindfulness exercises, themes were relevant to moral injury and included management of stress and moral emotions, exercise, self-care, peer support, boundaries, sleep, and implementing and maintaining new wellness practices. The facilitator led the discussion of didactic material designed to encourage peer support and self-awareness as group members reflected on their strengths and existing supports, and challenges and barriers to engaging in wellness practices. For a detailed description of program development, and session objectives, and content, see Author (2022).
Survey Measures
After completing the online meeting, four weeks prior to the start of the programs, participants received a unique secure survey link (i.e., baseline survey) that lasted approximately 25 minutes to complete. Following the last session, participants were sent a survey link and had four weeks to complete a final survey (i.e., post-intervention survey). Participants received $30 for completing the baseline survey and $50 for completing the post intervention survey. An in-depth description of the program development, study methodology, and a full list of the measures can be found in Author et al. (2022).
Program Satisfaction. Based on Kirkpatrick’s model (Kirkpatrick & Kirkpatrick, 2016), we evaluated four aspects of program satisfaction: reactions (“How satisfied are you with the training program you attended”; 3 items), attitudes/learning/knowledge (“How well do you feel you understand moral injury?”; 3 items), behavior (“How much have you put what you learned into practice?”; 3 items) and return on investment (“How much has this program benefitted you?”; 1 item). Items were rated on a 5-point scale (1-5; unique response options to each item) and higher scores indicate greater satisfaction.
Moral Injury. Given discrepancies in the literature regarding an operational definition of moral injury, moral injury was assessed using four distinct measures of moral injury. Participants completed the 17-item Expressions of Moral Injury Scale – Military Version (EMIS-M; Currier et al. 2018, 2020). Measured on a 5-point response scale (1 =strongly disagree , 5 = strongly agree , items are divided into two domains: 1) self-directed symptoms (9 items, e.g., “I am an unforgiveable person”) and 2) other-directed symptoms (8 items, e.g., “I feel anger over being betrayed”). Participants also completed the 10-item Moral Injury Symptom Scale – Military Version Short Form (MISS-M-SF; Koenig et al., 2018). Measured on a 10-point response scale (1 = strongly disagree , 10 = strongly agree ), a total score was calculated by summing up responses across the items (e.g., “I feel guilt over failing to save the life of someone in war”). Participants also completed the 8-item Moral Paradox Scale (MP; Fleming, 2021). Measured on a 5-point scale (1 = strongly disagree , 5 =strongly agree ), a total score was calculated by summing up responses across the items (e.g., “The world makes much less sense to me since my military experience”). Finally, participants also completed the 14-item Moral Injury Outcome Scale (MIOS; Litz et al. 2022). Measured on a 5-point scale (1 = strongly disagree , 5 =strongly agree ), the MIOS assesses moral injury broadly (i.e., a total score) and two specific domains: shame-related experiences (“I blame myself”) and trust-violation-related outcomes (e.g., “I lost trust in others”). Moreover, the MIOS includes 7 additional items (summed for a total score) adapted from the Brief Inventory of Psychosocial Functioning (Kleiman et al., 2020) to assess impaired functioning due to moral injury across differing life domains (e.g., family relationships, work, friendships).