Service Members often describe their worst military-based traumas as the confrontation with unresolvable moral dilemmas that rattle their fundamental sense of self. Moral Injury is the debilitating syndrome that indexes the psychiatric and functional impairment associated with these military-based traumas. The objective of this study is to improve the measurement of the moral injury construct by evaluating two moral injury event questionnaires (i.e., Moral Injury Events Scale [MIES]1 and Moral Injury Questionnaire-Military Version [MIQM]2) and refining these instruments by creating new measures of moral injury events and mechanisms using items from the MIES and MIQM. This study will conduct secondary analysis on data from two longitudinal parent studies: a Department of Veterans Affairs (VA) Veterans Integrated Service Network 17 Center of Excellence (CoE) study of Iraq and Afghanistan War Veterans (N = ~500) and a Department of Defense (DoD) Walter Army Institute of Research (WRAIR) study of active duty Soldiers (N = ~800). Data on the MIES and MIQM, along with a set of theoretically relevant predictors and outcomes, are being collected at two time points approximately eight months apart in the Veteran and Soldier samples, and will be ready to analyze by spring 2017 and spring 2018 for the Soldier and Veteran samples, respectively. This objective will be accomplished by pursuing three specific aims: 1) the occurrence of moral injury events and mechanisms will be assessed using item- level analysis of the MIES and MIQM; 2) the dimensionality of the MIES, MIQM, and new refined measures that disaggregate moral injury event and mechanism items on both measures will be tested using expert review, exploratory factor analysis, confirmatory factor analysis, and graded response (item response theory) analysis. The reliability and construct validity of the MIES, MIQM, and new measures of moral injury events and mechanisms will be evaluated using correlational coefficients, multiple regressions, and structural equation models. 3) Empirically driven recommendations for assessing moral injury events and mechanisms will be developed and disseminated throughout the VA and DoD. This Career Development Award -1 (CDA-1) will provide Dr. Frankfurt with the support needed to move her towards her career goal of being an independent VA clinical research scientist with a focus in military trauma-related sequelae including moral injury and aim to improve post-deployment reintegration. To achieve this goal, Dr. Frankfurt?s training plan includes VA psychology leadership training and professional development training. Specific training goals for the proposed CDA-1 include: (1) Mentorship in psychometrics, assessment, and measurement construction; (2) Mentorship in advanced interdisciplinary clinical and theoretical domains relevant to moral injury; and (3) Mentorship in project administration, grantsmanship, and research in the VA and DoD, and how to conduct research in these two different yet connected organizations. In addition to these training goals, Dr. Frankfurt also aims to become a VA psychology leader to advocate for innovative, integrative evidence-based care. Given her research and clinical background in the field of trauma psychology, this CDA-1 project is a natural extension of her prior work. This project will continue her previous work on psychosocial functioning and moral injury following combat trauma and extend it into the field of postdeployment rehabilitation and recovery. This CDA-1 training plan includes mentorship from VA and DoD experts in the fields of moral injury (Dr. Brett Litz), assessment (Dr. Michael Russell), survey and DoD research (Dr. Lyndon Riviere), and non-VA expert in psychometrics (Dr. Brett Donnellan). This CDA-1 will also provide mentored support for Dr. Frankfurt to prepare a Career Development Award-2 application for a project to develop an evidence-based guide and trainings on treating moral injury for VA providers.

Public Health Relevance

This CDA-1 project is expected to develop measures that can be used to identify the impact of moral injury events on Veterans? postdeployment rehabilitation and recovery. Moral injury is the harm that results from actions Veterans did or did not take during service, and involves significant guilt, shame, and rage. This project is expected to determine if moral injury events have a significant impact on reintegration and, thus, whether moral injury needs to be addressed in the rehabilitation context. The proposed study will evaluate and attempt to refine two existing measures of moral injury events and provide empirically driven recommendations on moral injury assessment to VA providers. Fundamental issues with moral injury measurement need to be remedied to move forward research on moral injury interventions. For the VA researchers and providers, this project will contribute greatly to improving recovery and reintegration by identifying moral injury as a potentially novel target of intervention.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (IK1)
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Career Development Program - Panel II (RRD9)
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Olin Teague Veterans Center
United States
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Frankfurt, Sheila B; DeBeer, Bryann B; Morissette, Sandra B et al. (2018) Mechanisms of Moral Injury Following Military Sexual Trauma and Combat in Post-9/11 U.S. War Veterans. Front Psychiatry 9:520