Thriving in the Midst of Moral Pain: The Acceptability and Feasibility of Acceptance and Commitment Therapy for Moral Injury (ACT-MI) Among Warzone Veterans
| Status: | Not yet recruiting |
|---|---|
| Conditions: | Hospital |
| Therapuetic Areas: | Other |
| Healthy: | No |
| Age Range: | 18 - 89 |
| Updated: | 12/6/2018 |
| Start Date: | January 2, 2019 |
| End Date: | December 31, 2021 |
| Contact: | Lauren Borges, PhD |
| Email: | lauren.borges2@va.gov |
| Phone: | (314) 566-4118 |
The need for moral injury interventions is increasingly being recognized as a domain in
Veteran care that must be addressed. Consequences of exposure to morally injurious events
include risk for suicide, substance abuse, and refractory symptoms of PTSD and depression.
Exposure to morally injurious events is also highly prevalent among Veterans. Thus,
interventions addressing moral injury are crucial to helping Veterans build meaningful lives.
Psychotherapies explicitly targeting moral injury and functional recovery associated with
this construct are limited in VHA. The proposed study serves as a first step in addressing
this gap in the literature through the development of a recovery-oriented, evidence-based
treatment approach for moral injury among warzone Veterans who report functional impairments
related to moral emotions. The proposed pilot study will evaluate the acceptability of this
intervention and the feasibility of the design for a future study to test the treatment's
capacity to improve patients' functioning.
Veteran care that must be addressed. Consequences of exposure to morally injurious events
include risk for suicide, substance abuse, and refractory symptoms of PTSD and depression.
Exposure to morally injurious events is also highly prevalent among Veterans. Thus,
interventions addressing moral injury are crucial to helping Veterans build meaningful lives.
Psychotherapies explicitly targeting moral injury and functional recovery associated with
this construct are limited in VHA. The proposed study serves as a first step in addressing
this gap in the literature through the development of a recovery-oriented, evidence-based
treatment approach for moral injury among warzone Veterans who report functional impairments
related to moral emotions. The proposed pilot study will evaluate the acceptability of this
intervention and the feasibility of the design for a future study to test the treatment's
capacity to improve patients' functioning.
Warzone Veterans exposed to morally injurious events frequently experience numerous
difficulties in functioning. These Veterans often report suicidal ideation and behavior,
substance abuse, symptoms of depression and PTSD, and problems in resuming valued living
(e.g., spiritual practice, close relationships). Despite the transdiagnostic nature of moral
injury, there are no moral injury-specific transdiagnostic interventions. Existing
interventions tend to be focused on treating moral injury in the context of PTSD. In addition
to an emphasis on PTSD, these interventions target beliefs associated with moral injury as
causal factors in the development and maintenance of suffering. An emphasis on altering
beliefs associated with moral injury may not optimally facilitate functional recovery as
moral pain from moral violations may be justified. As one third of warzone Veterans endorse
exposure to morally injurious events, it is vital to develop interventions that can be
efficiently disseminated in VHA to facilitate functional recovery. The ideal intervention
must simultaneously address moral emotions and promote values consistent behavior in the face
of these emotions.
Acceptance and Commitment Therapy for moral injury (ACT-MI) is a recovery-based, psychosocial
treatment ideally suited for Veterans endorsing difficulties in functioning related to moral
injury. ACT teaches skills to help Veterans relate differently to painful thoughts, emotions,
urges, and sensations. Rather than focusing on symptom reduction, ACT is an evidence-based
intervention that directly targets functional recovery by assisting Veterans in identifying
and engaging in values-consistent behavior even in the presence of distress. In Veteran
populations specifically, ACT has been demonstrated effective in treating suicidal ideation
and depression and as a result, has been "rolled-out" as an evidence based psychotherapy for
depression within VHA. ACT-MI operates on the principles of ACT, with an explicit focus on
the social functions of moral emotions. ACT-MI is the only intervention for moral injury that
is based on social functionalism which purports that moral emotions (e.g., shame, pride)
serve evolutionary purposes essential to group survival. Thus learning to interact with moral
emotions differently is crucial to recovery. In ACT-MI, a group-based intervention is used to
facilitate in-vivo exposure to moral emotions in the context of values. The proposed two arm
randomized controlled pilot study will evaluate the acceptability of ACT-MI and an active
control treatment, and determine the feasibility of the randomized controlled trial design
for a future full-scale efficacy study. To accomplish this goal the investigators will
continue to refine ACT-MI. Veterans enrolled will be randomized to: (a) Present Centered
Therapy (PCT) or (b) ACT-MI, both of which will consist of 12, 90-minute group sessions. The
specific aims of this study are to: (1) Evaluate the acceptability of the ACT-MI intervention
for Veterans experiencing impairment in functioning associated with moral injury, (2)
Determine the feasibility of the efficacy study design, and to (3) Select measures and
calculate the necessary sample size for a future efficacy study. The performance of validated
scales will be measured, in addition to selected NIH Patient Reported Outcomes Measurement
Information System modules. All participants will complete a baseline assessment, post
treatment, and follow-up assessment one and three months after completion of ACT-MI or PCT.
Participants in both groups will also complete a post-treatment assessment on the
acceptability of the intervention. The proposed study represents a crucial first step in a
line of research likely to yield a recovery oriented, empirically-supported intervention for
moral injury among Veterans. The objectives of ACT-MI directly align with Rehabilitation
Research and Development's goal to improve Veteran functioning, increase community
reintegration, and to facilitate Veteran centered care.
difficulties in functioning. These Veterans often report suicidal ideation and behavior,
substance abuse, symptoms of depression and PTSD, and problems in resuming valued living
(e.g., spiritual practice, close relationships). Despite the transdiagnostic nature of moral
injury, there are no moral injury-specific transdiagnostic interventions. Existing
interventions tend to be focused on treating moral injury in the context of PTSD. In addition
to an emphasis on PTSD, these interventions target beliefs associated with moral injury as
causal factors in the development and maintenance of suffering. An emphasis on altering
beliefs associated with moral injury may not optimally facilitate functional recovery as
moral pain from moral violations may be justified. As one third of warzone Veterans endorse
exposure to morally injurious events, it is vital to develop interventions that can be
efficiently disseminated in VHA to facilitate functional recovery. The ideal intervention
must simultaneously address moral emotions and promote values consistent behavior in the face
of these emotions.
Acceptance and Commitment Therapy for moral injury (ACT-MI) is a recovery-based, psychosocial
treatment ideally suited for Veterans endorsing difficulties in functioning related to moral
injury. ACT teaches skills to help Veterans relate differently to painful thoughts, emotions,
urges, and sensations. Rather than focusing on symptom reduction, ACT is an evidence-based
intervention that directly targets functional recovery by assisting Veterans in identifying
and engaging in values-consistent behavior even in the presence of distress. In Veteran
populations specifically, ACT has been demonstrated effective in treating suicidal ideation
and depression and as a result, has been "rolled-out" as an evidence based psychotherapy for
depression within VHA. ACT-MI operates on the principles of ACT, with an explicit focus on
the social functions of moral emotions. ACT-MI is the only intervention for moral injury that
is based on social functionalism which purports that moral emotions (e.g., shame, pride)
serve evolutionary purposes essential to group survival. Thus learning to interact with moral
emotions differently is crucial to recovery. In ACT-MI, a group-based intervention is used to
facilitate in-vivo exposure to moral emotions in the context of values. The proposed two arm
randomized controlled pilot study will evaluate the acceptability of ACT-MI and an active
control treatment, and determine the feasibility of the randomized controlled trial design
for a future full-scale efficacy study. To accomplish this goal the investigators will
continue to refine ACT-MI. Veterans enrolled will be randomized to: (a) Present Centered
Therapy (PCT) or (b) ACT-MI, both of which will consist of 12, 90-minute group sessions. The
specific aims of this study are to: (1) Evaluate the acceptability of the ACT-MI intervention
for Veterans experiencing impairment in functioning associated with moral injury, (2)
Determine the feasibility of the efficacy study design, and to (3) Select measures and
calculate the necessary sample size for a future efficacy study. The performance of validated
scales will be measured, in addition to selected NIH Patient Reported Outcomes Measurement
Information System modules. All participants will complete a baseline assessment, post
treatment, and follow-up assessment one and three months after completion of ACT-MI or PCT.
Participants in both groups will also complete a post-treatment assessment on the
acceptability of the intervention. The proposed study represents a crucial first step in a
line of research likely to yield a recovery oriented, empirically-supported intervention for
moral injury among Veterans. The objectives of ACT-MI directly align with Rehabilitation
Research and Development's goal to improve Veteran functioning, increase community
reintegration, and to facilitate Veteran centered care.
Inclusion Criteria:
- Eligible for VHA care
- Has been deployed to a warzone
- Has experienced a morally injurious event which continues to interfere with
functioning
- Willing to be randomized and participate in either of the two conditions
Exclusion Criteria:
- Inability to provide informed consent
- Inability to complete study measures, e.g.:
- due to significant acute intoxication/withdrawal symptoms
- mania
- psychosis
- aggression
- catatonia
- cognitive impairment
- Imminent suicide risk
- Membership in a vulnerable population, e.g.:
- pregnant women
- History of significant violence towards VA staff
- Participation in another psychotherapy research study
- Current participation in an EBP for a condition related to moral injury
We found this trial at
1
site
Aurora, Colorado 80045
Principal Investigator: Lauren Borges, PhD
Phone: 303-399-8020
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