Thriving in the Midst of Moral Pain: The Acceptability and Feasibility of Acceptance and Commitment Therapy for Moral Injury (ACT-MI) Among Warzone Veterans

面对道德伤害事件的战区退伍军人经常在 功能正常。这些退伍军人经常报告有自杀念头和行为，药物滥用，症状 抑郁症和创伤后应激障碍，以及在恢复有价值的生活方面的问题(例如，修行、亲密关系)1-7 尽管精神伤害具有跨诊断性质，但并不存在特定于精神伤害的跨诊断 干预措施。现有干预措施往往侧重于在创伤后应激障碍背景下治疗精神伤害。10-11 除了强调创伤后应激障碍，这些干预措施还针对与精神伤害相关的信仰作为原因 发展和维持痛苦的因素。10-12强调改变与以下有关的信念 精神伤害可能不会像道德侵犯带来的精神痛苦那样最佳地促进功能恢复 这是正当的。随着三分之一的战区退伍军人支持暴露在道德伤害的事件中，发展 可在VHA中有效传播以促进功能恢复的干预措施。8-9理想情况 干预必须同时解决道德情绪和促进价值观在面对一致的行为 这些情绪。 精神伤害接受与承诺疗法(ACT-MI)是一种以康复为基础的 心理社会治疗非常适合支持功能相关困难的退伍军人 15 ACT教授技能，帮助退伍军人以不同的方式处理痛苦的想法，情绪，冲动， 而不是集中在减轻症状上，ACT是一种基于证据的干预措施， 通过帮助退伍军人识别和参与一致的价值观，直接针对功能恢复 即使在悲痛的情况下也会表现出行为。特别是在退伍军人群体中，ACT已经被证明 在治疗自杀意念和抑郁症方面很有效，因此，作为一项证据，已经推出了 VHA.59-60ACT-MI中抑郁症的心理治疗遵循ACT的原则，具有明确的 关注道德情感的社会功能。13-14 ACT-MI是对道德伤害的唯一干预，即 基于社会功能主义，该理论声称道德情感(例如，羞耻、骄傲)为进化服务 目标对群体生存至关重要。15因此，学会以不同的方式与道德情感互动对于 恢复。在ACT-MI中，基于群体的干预被用来促进在体内暴露于道德情绪在 价值观的背景。拟议的两个ARM随机对照试验研究将评估 ACT-MI和主动对照治疗的可接受性，并确定 未来全面疗效研究的随机对照试验设计。为了实现这一目标，我们 将继续完善ACT-MI。入选的退伍军人将被随机分为：(A)当前中心疗法(PCT) 或(B)ACT-MI，这两个项目都将包括12个90分钟的小组会议。 本研究的具体目的是：(1)评价ACT-MI干预的可接受性 退伍军人遭遇精神损伤相关的功能障碍，(2)确定可行性 有效性研究设计，以及(3)选择措施并计算未来所需的样本量 功效研究。除了选定的NIH患者外，还将测量经过验证的量表的性能 报告成果衡量信息系统模块。78所有参与者都将完成基线 ACT-MI或ACT-MI完成后1个月和3个月的评估、治疗后和随访评估 %。两组的参与者还将完成治疗后对 干预。这项拟议的研究代表着可能产生复苏的一系列研究的关键的第一步- 退伍军人精神伤害的定向、经验性干预。ACT-MI的目标 直接与康复研究和开发的目标保持一致，以改善退伍军人的功能，增加 重新融入社区，促进以退伍军人为中心的护理。

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).1-7 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.10-11 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.10-12 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.8-9 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.15 ACT teaches skills to help Veterans relate differently to painful thoughts, emotions, urges, and sensations.40 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.59-60 ACT-MI operates on the principles of ACT, with an explicit focus on the social functions of moral emotions.13-14 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.15 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 we 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.78 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.