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

暴露于道德伤害事件的战区退伍军人经常遇到许多困难， 功能这些退伍军人经常报告自杀的想法和行为，药物滥用， 抑郁症和创伤后应激障碍，以及恢复有价值生活的问题（例如，灵性修炼、亲密关系）. 1 -7 尽管道德伤害具有跨诊断的性质，但没有专门针对道德伤害的跨诊断 干预措施。现有的干预措施往往侧重于治疗创伤后应激障碍造成的精神伤害。 除了强调创伤后应激障碍，这些干预措施的目标信念与道德伤害的因果关系 10 -12强调改变与痛苦有关的信念， 道德伤害可能不会最佳地促进功能恢复，因为道德侵犯造成的道德痛苦可能 正当的由于三分之一的战区退伍军人赞同暴露于道德伤害事件， 可以在VHA中有效传播的干预措施，以促进功能恢复。 干预必须同时解决道德情绪并促进价值观一致的行为 这些情绪。 接受和承诺治疗精神伤害（ACT-MI）是一种基于恢复的， 心理社会治疗非常适合退伍军人认可的功能相关的困难 15 ACT教授技能，帮助退伍军人以不同的方式与痛苦的想法，情绪，冲动， 40 ACT不是专注于减轻症状，而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价值观一致的活动， 即使在痛苦的存在下。特别是在退伍军人群体中，ACT已被证明 有效治疗自杀意念和抑郁症，因此，已被“推出”作为一个基于证据的 VHA中抑郁症的心理治疗。59 -60 ACT-MI根据ACT的原则运作， 关注道德情感的社会功能。13 -14 ACT-MI是唯一的精神伤害干预， 基于社会功能主义，它声称道德情感（例如，羞耻，骄傲）服务于进化 因此，学会以不同的方式与道德情感互动， 复苏在ACT-MI中，使用基于组的干预来促进在体内暴露于道德情感， 价值观的背景。拟议的两组随机对照初步研究将评估 ACT-MI和活性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。入组的退伍军人将被随机分配至：（a）当前中心治疗（PCT） 或（B）ACT-MI，两者均由12个90分钟的小组会议组成。 本研究的具体目的是：（1）评价ACT-MI干预的可接受性， 退伍军人经历与精神伤害相关的功能障碍，（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必要的样本量 功效研究除了选定的NIH患者外，还将测量经验证量表的性能 78所有参与者将完成一项基线， ACT-MI完成后1个月和3个月的评估、治疗后和随访评估，或 便士两组受试者还将完成治疗后评估， 干预这项拟议中的研究代表了一系列可能产生复苏的研究中至关重要的第一步- 为退伍军人中的精神伤害进行有针对性的、有医疗支持的干预。ACT-MI的目标 直接与康复研究和发展的目标，以改善退伍军人的功能，增加 社区康复，并促进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.