Despite the use of evidence-based psychotherapies for posttraumatic stress disorder (PTSD), many Veterans report continued symptoms and impairment after treatment. Additionally, there is evidence to suggest those treatments are less effective for moral injury (MI) distress?experiencing severe guilt, shame, and anger about witnessing or performing an act that violates one?s deeply held values. Current treatments are also limited as they do not directly facilitate building positive resources to enhance social functioning. Given the prevalence of trauma distress and limitations to existing treatments, novel approaches are needed to (1) target both PTSD and MI and (2) directly impact psychosocial growth and functional recovery. Research indicates that positive psychology interventions effectively enhance well-being through cultivating positive emotions. Moral elevation (hereafter ?elevation?)?a distinct, positive emotional state described as feeling moved by others? virtuous actions?may be relevant to PTSD and MI recovery because it encourages social engagement and serves as a template for interpreting the world in a healthier way. Additionally, preliminary results from a pilot study showed promising evidence that elevation was negatively correlated with PTSD avoidance symptoms and MI. Therefore, the goal of this proposed study is to conduct a pilot trial of a web-based elevation intervention to determine if such an intervention is a feasible and acceptable therapeutic approach for Operations Enduring Freedom, Iraqi Freedom, and New Dawn Veterans. [This study will also assess the feasibility of randomization, retention, and completion of a no-treatment condition (i.e., comparison group) in preparation for future randomized controlled trials (RCTs).] The sample will include [24] Veterans [(12 per group)] who experience at least one morally injurious event and with a current diagnosis of PTSD. The online elevation intervention consists of two exercises per week for one month, totaling eight sessions. Sessions will include watching validated videos that elicit elevation and recalling moments when one experienced elevation in daily life, paired with journaling about one?s reactions to witnessed virtuous behavior. Participants [in the intervention condition] will also be presented with a brief goal to be completed prior to the next session to facilitate greater social engagement. [Participants randomized to the no-treatment condition will access the same online portal twice per week, but will not be exposed to any intervention components.] All participants will complete brief self-report measures at each online session. All participants will also complete self-report measures at baseline and 1-month follow-up that will assess PTSD symptoms, MI distress, prosocial behavior, and quality of social relationships. At the follow-up assessment, participants randomized to the intervention condition will complete an individual qualitative interview with a member of the study team to assess acceptability and satisfaction with the intervention and proposed methodology, which will be coded and analyzed to inform future clinical trials. To supplement self-report measures, all participants will invite a significant other (e.g., spouse, close friend) to complete measures based on observations of the Veteran?s behavior and social functioning at baseline and 1-month follow-up. Feasibility of recruitment, retention, and completion of the intervention will be analyzed by tracking the number of participants retained at each stage of the study, as well as the number of sessions completed in the intervention. Results from this study will be used to develop an RCT with a larger sample size to determine the efficacy of an elevation intervention and assess whether this novel approach leads to unique beneficial outcomes regarding PTSD and MI distress.

Public Health Relevance

Given the prevalence of PTSD and moral injury in combat Veterans and the limitations to current treatments, novel approaches are needed to target both PTSD and moral injury and directly impact psychosocial growth and functional recovery. One potential way to address this critical need is through moral elevation?a positive emotional state described as feeling uplifted and inspired by others? virtuous actions. This study will pilot a web-based moral elevation intervention with OEF/OIF/OND Veterans who experienced a morally injurious event and with a PTSD diagnosis. If Veterans are willing and able to complete an online moral elevation intervention and it has beneficial effects, then moral elevation could be feasibly utilized as a tool to reverse the negative effects of trauma and facilitate recovery. Data from this study will be used to develop larger clinical trials to test if this intervention significantly improves PTSD symptoms and moral injury distress and enhances social functioning.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (I21)
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Rehabilitation Research and Development SPiRE Program (RRDS)
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Olin Teague Veterans Center
United States
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