Do morally injurious experiences and index events negatively impact intensive PTSD treatment outcomes among combat veterans?

European Journal of Psychotraumatology

Philip Held, Brian J. Klassen, Victoria L. Steigerwald, Dale L. Smith, Karyna Bravo, David C. Rozek, Rebecca Van Horn & Alyson Zalta


Background: It has been suggested that current frontline posttraumatic stress disorder (PTSD) treatments are not effective for the treatment of moral injury and that individuals who have experienced morally injurious events may respond differently to treatment than those who have not. However, these claims have yet to be empirically tested.

Objective: This study evaluated the rates of morally injurious event exposure and morally injurious index trauma and their impact on PTSD (PCL-5) and depression symptom (PHQ-9) reductions during intensive PTSD treatment.

Method: Data from 161 USA military combat service members and veterans (91.3% male; mean age = 39.94 years) who participated in a 3-week Cognitive Processing Therapy (CPT)-based intensive PTSD treatment programme (ITP) was utilized. Morally injurious event exposure was established via the Moral Injury Event Scale (MIES). Index traumas were also coded by the treating clinician. Linear mixed effects regression analyses were conducted to examine if differences in average effects or trends over the course of treatment existed between veterans with morally injurious event exposure or index trauma and those without.

Results: Rates of morally injurious event exposure in this treatment sample were high (59.0%-75.2%). Morally injurious event exposure and the type of index trauma did not predict changes in symptom outcomes from the ITP and veterans reported large reductions in PTSD (d = 1.35–1.96) and depression symptoms (d = 0.95–1.24) from pre- to post-treatment. Non-inferiority analyses also demonstrated equivalence across those with and without morally injurious event exposure and index events. There were no significant gender differences.

Conclusions: The present study suggests that PTSD and depression in military veterans with morally injurious event exposure histories may be successfully treated via a 3-week CPT-based ITP.

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