Toward a dual process model of moral injury and traumatic illness.

Moral injury has emerged as a topic of significant research and clinical interest over the last decade. However, much work remains to be done to comprehensively define the moral injury construct, with implications for understanding the etiology and maintenance of moral injury, its symptoms, associations with and distinctions from traumatic illness, and treatment approaches. We provide a brief overview of the existing moral injury literature and introduce a novel dual process model (DPM) of moral injury and traumatic illness. The DPM posits an event exposure which may satisfy DSM-5 posttraumatic stress disorder (PTSD) criterion A, potential morally injurious event (PMIE) criteria, or both, followed by individual role appraisal as a perpetrator through action or inaction, a witness, a victim, or a combination of the these. Role appraisal influences symptoms and processes across biological, psychological, behavioral, social, spiritual/religious, as well as values, character, and identity domains to support a label of traumatic illness, moral injury, or both. The DPM provides a flexible analytical framework for evaluating symptoms associated with moral injury and traumatic stress and has important implications for treatment. The most thoroughly reviewed evidence-based interventions for traumatic stress hinge on exposure and habituation mechanisms to manage dysregulation of fear and memory systems, but these mechanisms often do not address core domains of moral injury identified in the DPM, including spiritual, religious, values, character, and identity domains as these exist largely outside of the putative fear network. We provide brief vignettes to illustrate the practical application of the DPM and argue that adjunct and stand-alone approaches which address values and character domains, leveraging principles of Stoicism, non-judgment of experience, acceptance, and values-oriented action, are more likely than traditional trauma treatment approaches to positively affect moral injury symptoms.

Comparing the training effectiveness of virtual reality and role play among future mental health providers.

OBJECTIVE: The present study compares the effectiveness of a standardized peer-to-peer role play (RP) and a virtual client-trainer (VC-T) in training graduate-level students in the development of interviewing and clinical skills related to working with the military population. The study examines each training modality in six areas: (a) self-efficacy, (b) initial engagement, (c) recognizing and responding to symptoms of posttraumatic stress disorder, (d) recognizing and responding to symptoms of suicide, (e) military cultural competence, and (f) overall competence. METHOD: A quasi-experimental nonequivalent groups study design was used. The sample comprised students enrolled in a graduate-level program (RP = 61; VC-T = 75). Participants completed pretest measures, attended training, and completed posttest measures. RESULTS: Broadly, the findings revealed that RP and the VC-T are equally effective in increasing trainees' self-efficacy, recognition and response to posttraumatic stress disorder symptoms, recognition and response to suicide symptoms, military cultural competence, and overall competence. These results suggest that regardless of training modality, trainees demonstrated increased clinical skills and competencies needed for working with the military population. CONCLUSIONS: The results suggest that both RP and the VC-T are equally effective, which opens the possibilities of implementing the VC-T as a training tool that has greater reach compared with RP. As more graduate programs offer an online version of their traditional on-ground coursework, the VC-T is an opportunity to have 1 training platform for both on-ground and online students. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Symptom Severity, Self-efficacy and Treatment-Seeking for Mental Health Among US Iraq/Afghanistan Military Veterans.

Military veterans have high rates of mental health problems, yet the majority do not seek treatment. Understanding treatment-seeking in this population is important. This study investigated if symptom severity and self-efficacy are associated with treatment-seeking among US Iraq/Afghanistan veterans. Survey data from 525 veterans meeting clinical criteria for PTSD and depression were included of which, 54.4% had sought treatment in the past 12 months. Multivariate logistic regression analysis indicated that high symptom severity was associated with treatment seeking, whereas high self-efficacy was associated with a decreased likelihood to seek treatment. Self-efficacy could be an underlying mechanism of treatment seeking decisions.

Implementing the Knowledge Assessment of CPT Critical Skills (KACCS) Scale.

Cognitive processing therapy (CPT) has been endorsed as an evidence-based therapy for PTSD. It is currently being implemented within the Veterans Health Administration (VA) as a manualized, trauma-focused psychotherapy in line with recommendations from the most recent VA/DOD Clinical Practice Guideline for the management of PTSD. While research on CPT implementation has focused on individual factors that facilitate or hinder adoption, little is known on whether trainees retain core concepts of CPT. The present research addresses this gap in the literature by conducting a validation study of the Knowledge Assessment of CPT Critical Skills (KACCS) Scale among known user groups of CPT (no experience, immediate user, expert user) and, subsequently, an implementation study of the KACCS Scale among clinician trainees participating in an online CPT training. The validation study found that the KACCS Scale can discriminate among various CPT user groups (no experience, intermediate, expert), while the implementation study found that the KACCS Scale provides specific information on core concepts that have been learned at the end of training. The KACCS Scale could benefit from further validation studies and, subsequently, be added to the current CPT instrumentation to monitor learning and retention of core concepts at various training periods (initial workshop, consultation, booster workshop).

Well-being and suicidal ideation of secondary school students from military families.

BACKGROUND: The mental health of children is a primary public health concern; adolescents of military personnel may be at increased risk of experiencing poorer well-being overall and depressive symptoms specifically. These adolescents experience individual and intrafamilial stressors of parental deployment and reintegration, which are directly and indirectly associated with internalizing behaviors. PURPOSE: The present study sought to better understand the influence of parental military connectedness and parental deployment on adolescent mental health. METHODS: Data from the 2011 California Healthy Kids Survey examined feeling sad or hopeless, suicidal ideation, well-being, and depressive symptoms by military connectedness in a subsample (n = 14,299) of seventh-, ninth-, and 11th-grade California adolescents. Cross-classification tables and multiple logistic regression analyses were used. RESULTS: More than 13% of the sample had a parent or sibling in the military. Those with military connections were more likely to report depressive symptoms and suicidal ideation. Controlling for grade, gender, and race/ethnicity, reporting any familial deployment compared with no deployments was associated with increasing odds of experiencing sadness or hopelessness, depressive symptoms, and suicidal ideation. CONCLUSIONS: Findings emphasize the increased risk of mental health issues among youth with parents (and siblings) in the military. Although deployment-related mental health stressors are less likely during peace, during times of war there is a need for increased screening in primary care and school settings. Systematic referral systems and collaboration with community-based mental health centers will bolster screening and services.

Prevalence and correlates of victimization and weapon carrying among military- and nonmilitary-connected youth in Southern California.

OBJECTIVES: The present analysis sought to explore the normative rates and correlates of school victimization and weapon carrying among military-connected and nonmilitary-connected youth in public schools in Southern California. METHODS: Data are from a sub-sample of the 2011 California Healthy Kids Survey (N=14,512). Items to assess victimization and weapon carrying were separated into three categories: physical acts (e.g., being pushed or shoved), nonphysical acts (e.g., having rumors spread about them) and weapon carrying. RESULTS: The bivariate results indicate that youth with a military-connected parent had higher rates of physical victimization (56.8%), nonphysical victimization (68.1%), and weapon carrying (14.4%) compared to those with siblings serving (55.2%, 65.2%, and 11.4%, respectively) and nonmilitary-connected (50.3%, 61.6%, and 8.9%, respectively) youth. Having a parent in the military increased the odds of weapon carrying by 29% (Odds Ratio=1.29, 95% confidence interval=1.02-1.65). Changing schools and a larger number of family member deployments in the past 10years were associated with significant increases in the likelihood of victimization and weapon carrying. CONCLUSIONS: The results of this analysis warrant a focus on school supports for youth experiencing parental military service, multiple relocations and deployments of a family member.

Substance use among military-connected youth: the California Healthy Kids Survey.

BACKGROUND: Young people in military-connected families may be exposed to deleterious stressors, related to family member deployment, that have been associated with externalizing behaviors such as substance use. Substance use predisposes youth to myriad health and social problems across the life span. PURPOSE: This study examined the prevalence and correlates of lifetime and recent substance use in a normative sample of youth who were either connected or not connected to the military. METHODS: Data are from a subsample of the 2011 California Healthy Kids Survey (N=14,149). Items in the present analyses included present familial military affiliation (no one, parent, sibling); number of deployments (none, one, two or more); gender; grade; and race/ethnicity. Substance use items assessed whether the youth reported lifetime use of alcohol, tobacco, marijuana, other drugs, or prescription drugs; and recent (past 30 days) use of alcohol, tobacco, marijuana, and other drugs. RESULTS: Multivariate analysis conducted in 2012 revealed that an increase in the number of deployments was associated with a higher likelihood of lifetime and recent use, with the exception of lifetime smoking. CONCLUSIONS: These results indicate that experiences associated with deployment of a family member may increase the likelihood of substance use.

A tri-ethnic examination of symptom expression on the positive and negative syndrome scale in schizophrenia spectrum disorders.

This study examined differences in symptom expression as measured by the Positive and Negative Syndrome Scale (PANSS [Schizophr. Bull. 13 (1987) 261]) in a tri-ethnic sample of persons diagnosed with schizophrenia. We hypothesized that ethnic differences would be more apparent in Positive Scale symptoms than in Negative and General Scale symptoms of the PANSS. The sample of 351 persons receiving services in community-based mental health clinics came from the initial phase of the San Diego site of the Schizophrenia Care and Assessment Program (SCAP), a longitudinal naturalistic study on the course of schizophrenia treatment. Participants were 88 African-Americans, 198 Euro-Americans, and 65 Latinos. Baseline PANSS scale scores and individual items were analyzed using Multivariate Analysis of Covariance procedures to examine symptoms by ethnic group and living situation while controlling for income, education, and age. There were no significant ethnic differences on the scale scores. At the item level of analysis, significant ethnic group differences were found in Hallucinatory Behavior, Suspiciousness, Excitement, and for Somatic Concerns. The cultural implications for the ethnic differences in each symptom behavior and the need for further research on symptom expression from an ethnographic perspective are discussed.