IntroductionBackground and Significance

War zones are distinguished by the potential for engaging in and becoming traumatized by actions taken or not taken that seem to involve moral violations and to result in significant suffering, harm, or death. War zones are rife with moral complexity, and some combat events are disturbing because they involve acting or being treated in morally transgressive ways rather than, or in addition to, surviving life-threatening events; these have been labeled potentially morally injurious events (PMIEs) to distinguish them from the prototypical life threat–based traumas defined in “Criterion A” of the posttraumatic stress disorder (PTSD) diagnosis []. Examples of PMIEs include killing either combatants or noncombatants, participating in or failing to prevent excessive violence, or being unable to intervene on behalf of others’ suffering. The prevalence of PMIEs likely varies by branch, unit, military occupational specialty, and era. However, approximately 40%‐60% of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) combat infantry soldiers and marines reported killing enemy combatants, and approximately 10%‐30% reported killing noncombatants; a minority of veterans report engaging in or witnessing excessive violence or atrocities [-].

PMIEs must be understood in the war zone context in which combat events may be simultaneously transgressive and life-threatening. The likelihood of reporting high-magnitude PMIEs such as killing or engaging in excessive violence is strongly associated with the intensity of combat [], and more so than known trauma risk factors such as adverse childhood events []. Vietnam and OIF and OEF veterans describe how being overcome by grief, anger, and a desire for retribution for lost unit members had motivated their excessive violence [,]. Similarly, deployed service members were more likely to report mistreating noncombatants if they also reported that a member of their unit had become a casualty, if they had handled dead bodies or human remains, or if they were angry []. Thus, it is important to recognize that PMIEs may be considered an expected part of participating in intense combat and not due to personal characteristics of the veteran. Although combat exposure appears to be associated with reporting PMIEs, not all combat veterans experience PMIEs. Relatedly, PMIEs do not necessarily entail lasting harm, but there is accumulating evidence that PMIEs have a higher conditional probability of resulting in lasting harm.

In general, PMIEs in combat are associated with worse behavioral and functional outcomes, over and above the known impact of general combat exposures [,]. Putative PMIEs, like killing and exposure to or participating in excessive violence, are consistently associated with the increased likelihood of mental disorders like more serious PTSD, depression, substance abuse, and functional impairment, even after accounting for the known contribution of life-threatening combat experiences. Reporting PMIEs increases the liability of known risk factors for suicide, such as PTSD and depression. Thus, for some veterans, it seems there is something incrementally toxic about actions taken in combat that resulted in actual or perceived harm to another person.

PMIEs are proposed to result in a complex trauma syndrome characterized by chronic reexperiencing, avoidance and numbing, entrenched guilt, shame, rage and despair, isolation and severing of social ties, self-harm and, in extremis, suicide; this putative syndrome has been labeled moral injury []. In distinction to life threat–based combat trauma; PMIEs that involved actions the service member or veteran took were associated with more trauma-related guilt, reexperiencing symptoms, negative thoughts about oneself, self-blame, and sadness, whereas PMIEs that involved witnessing others’ transgressions were associated with more betrayal, humiliation, and engaging in physically assaultive events []. See for a model of PMIE-related impact.

‎Figure 1. Model depicting the proposed bidirectional impact of potentially morally injurious events. PTSD: posttraumatic stress disorder.

However, there is no consensus around the boundaries of the moral injury syndrome or how it is distinguished from PTSD. Major questions about the construct validity of moral injury remain unanswered. There is no paradigmatic way of defining moral injury as an outcome, and causal frameworks for moral injury are largely untested and speculative []. Litz et al [] proposed the first conceptual model of moral injury; many variations of this definition have been circulated, and there is little guidance on how to synthesize these varied definitions. Because moral injury is typically conceptualized as a complex trauma syndrome, it is unknown whether the idea of moral injury has incremental clinical or explanatory validity over established psychiatric diagnoses such as PTSD and depression. Relatedly, there is no field-wide agreement about whether moral injury is a syndrome, a diagnosis, or a subtype of PTSD. Attempts to distinguish moral injury from PTSD have generally relied on straw-man notions of PTSD and moral injury or have used methodologically flawed empirical strategies to disaggregate them []. In sum, the notion of moral injury is like a bead of mercury; it appears stable and unitary but when pressed, skitters apart.

This project will focus on developing a treatment manual that will be designed to target the lasting and varied multidimensional impact of PMIEs, rather than targeting a vague notion of the moral injury concept. Preliminary studies supporting this project have used qualitative interview methods with service members and veterans to generate reliable domains of PMIE-related impact. These domains include alterations in self-perception and identity; alterations in one’s moral thinking; alterations in feelings of social connectedness and changes in social behavior; alterations in expectations regarding security and trust; self-harming and self-sabotaging behavior; profound emotional aftermath such as anger, guilt, disgust, and shame; and alterations in beliefs about life meaning and purpose []. These data reflect service members’ and veterans’ phenomenological perspectives of the impact of PMIEs and will inform treatment development efforts. Given that moral injury is a complex trauma syndrome, we will focus treatment on PMIE-related impacts on functional impairment and quality of life.

Existing PTSD treatments may inadequately address the morally injurious aspects of combat trauma because they were developed for civilian trauma contexts. These treatments were developed for single-incident victimization-based trauma exposures such as adult sexual assault or surviving a terrorist attack. The US Department of Veterans Affairs’ (VA’s) trauma-focused treatments of choice typically use one of two change strategies: (1) identifying irrational or inappropriate trauma-related attributions, such as erroneously assuming responsibility for one’s trauma, challenging these cognitive distortions, and replacing them with purportedly more accurate thoughts (cognitive processing therapy [CPT]); or (2) repeated imaginal or in vivo exposure to trauma reminders with the aim of extinguishing or habituating to overgeneralized trauma-related stress reactions (prolonged exposure [PE]). See for a description of therapy activities. The idea of PMIEs may help explain why evidence-based PTSD treatments developed in civilian trauma contexts that are effective in those contexts (CPT and PE) are significantly less effective in service member and veteran populations []. For example, approximately 70% of service members and veterans who complete PE or CPT do not report clinically significant symptom change or lose their PTSD diagnosis [-]. These evidence-based approaches may have limited applicability to war zone PMIEs because of the following reasons:

These approaches require patients to select one “worst and presently most distressing” trauma to treat in therapy. Adult civilian traumas are presumed to be a single incident in an otherwise non–life-threatening context; however, combat deployment is a chronically dangerous endeavor, and veterans confront many life-threatening situations as occupational hazards. Thus, we suspect these approaches do not reflect the reality of veterans’ war zone experiences because they presume that combat traumas, including PMIEs, are isolated and rare events and thus do not allow for PMIE-related alterations in self-perception and identity or moral thinking.Cognitive-behavioral trauma therapies such as CPT involve identifying faulty trauma-related assumptions of blame and ameliorating those assumptions. Because evidence-based PTSD therapies were developed to treat life threat–based or victimization-based experiences, trauma-related guilt and shame are presumed irrational and indications of internalized victim-blaming. However, in the war zone context, veterans’ beliefs about their responsibility for the consequences of their actions may be accurate. Importantly, it is contrary to military training, cultural values, and norms to suggest that blame, responsibility, or culpability is an illusory construction. Military doctrine instructs that service members are responsible for even unintended secondary- and third-degree consequences of their actions; this needs to be calculated into trauma processing. Additionally, qualitative research with veterans has found that some veterans feel guilt not just because of what they did, but also because at the time they enjoyed carrying out violent acts []. Guilt, shame, and anger may not be an irrational response to PMIEs but an appropriate one and a sign of an intact conscience and meaning-making system. In the principal investigator (PI; SO)’s prior ad hoc therapy group, veterans spurned the idea of losing their sense of blame and responsibility. We may speculate that veterans’ sense of blame and responsibility (and associated guilt and shame) helped them rebuild a sense of order and justice out of war zone chaos; they intellectually recognized they were not solely to blame, but cognitive appeals to reason did not meet their strong affective sense of culpability.Additionally, there is little evidence or theoretical support to suggest that guilt, shame, sadness, or rage abate following repeated exposure to avoided trauma-related stimuli (as in PE).PE and CPT are not well-suited for group treatment, which is a cost-saving way to treat veterans and may provide veterans opportunity for exposure to corrective experiences stemming from discussion and feedback from other veterans who share their experiences. There is a group CPT protocol; however, it does not include group-based trauma processing and proscribes direct disclosure of combat traumas. In sum, the theoretical and cultural relevance of existing trauma-focused treatments for combat-related PMIEs may be curtailed.Table 1. Brief description of existing posttraumatic stress disorder (PTSD) and potentially morally injurious event (PMIE)–focused treatments.TreatmentFormatTargetChange agentsPMIE disclosedGoalPEIndividualSingle traumaExposure and extinction of trauma-related stimuliYesReduce PTSD symptomsCPTIndividual or groupSingle traumaCognitive restructuringNoReduce PTSD symptomsACT for MIIndividual or groupMoral painBehavioral activation, acceptance of moral painNoIncrease functioningImpact of killingIndividual; yoked to PE or CPTSingle killing traumaCognitive restructuringYesReduce PTSD and improve functioningAdaptive disclosureIndividualSingle PMIEDisclosure and imaginal dialogueYesReduce PTSD symptoms and improve functioning

aPMIE: potentially morally injurious event.

bPE: prolonged exposure.

cPTSD: posttraumatic stress disorder.

dCPT: cognitive processing therapy.

eACT: acceptance and commitment therapy.

fMI: moral injury.

Interventions that purport to directly target PMIEs are being developed and tested in the VA. These include acceptance and commitment therapy for moral injury (ACT-MI) [], adaptive disclosure (AD) [], and the impact of killing (IOK) intervention []. See for a description of therapy activities. However, nascent PMIE-focused therapies may be limited because (1) there is no consensus definition of moral injury or gold-standard outcome measures; (2) IOK and AD are constrained in the type or number of PMIEs treated; (3) neither ACT-MI, IOK, nor AD are designed for PMIE processing in a group context; (4) ACT-MI, IOK, and AD have limited efficacy evidence.

There is no consensus definition of moral injury as an outcome and no gold-standard treatment outcome measure. Not surprisingly, different therapeutic strategies that purport to treat PMIEs often use divergent definitions of moral injury, and, to date, any formal approach is limited by a lack of a treatment-valid outcome measure of moral injury. For example, ACT-MI therapy narrowly formulates moral injury as maladaptive attempts to manage moral pain following events that violate one’s morals, including others’ actions that victimized the veteran []. These strategies used to manage distress and suffering are also core causal constructs and targets in ACT, regardless of the condition being treated. So, the narrow definition of moral injury used by ACT-MI appears to be primarily the result of the theoretical framework of a treatment, rather than a well-rounded way of defining moral injury. A problem with this narrow definition is that it assumes that meta-cognitive strategies that people use to manage moral emotions are in every case a result of strategic attempts at controlling the experience. It assumes that if these meta-cognitive strategies are reduced, moral emotions will abate, which are unaddressed empirical questions. In addition, conceptually the narrow targeting of ways of coping with moral emotions leaves out a variety of other well-described core features of moral injury (being treated as or perceiving the self as an “other,” social withdrawal, etc). AD is designed in part to treat moral injury but defines moral injury by virtue of the traumatic insult (the worst and presently most distressing event) and measures the efficacy of the approach in functioning and PTSD terms.

PMIE-focused therapies target a limited set of PMIEs. IOK and AD target PTSD and functional impairment secondary to war-related PMIEs. The IOK intervention intentionally limits its focus to PTSD symptoms associated with killing in combat and is meant to be adjunctive to PE or CPT. AD does not limit the therapy focus to a single type of PMIE; however, AD requires that a veteran choose one military event as presently most distressing and haunting at the time of this writing, and the aftermath of this event is the initial focus of treatment. Veterans must make a forced choice of a single “worst” combat event to focus on in therapy, which may be frustrating and invalidating for some veterans.

No PMIE-focused therapies or any recommended PTSD treatments support veterans’ disclosing and processing their PMIEs with each other facilitated by a group leader. Existing PMIE-focused therapies (ie, ACT-MI, AD, and IOK) do not provide social contexts that allow veterans to share and process their PMIEs and war zone experiences with other veterans. Additionally, the VA/Department of Defense (DoD) PTSD Clinical Practice Guidelines do not recommend any group treatments wherein veterans can disclose and process their traumas with each other []. VA clinicians have likely developed local group therapies to provide these therapeutic experiences, but there are no treatment manuals or clinical guidelines to support these practices. In fact, there is surprisingly little research on group treatments for PTSD, either in or outside the VA, despite its frequent use and interest to veterans []. For example, in a rigorous national survey of Iraq and Afghanistan veterans’ treatment interests, nearly 40% of veterans expressed an interest in group therapy []. Veterans in the PI’s informal ad hoc psychotherapy group informally reported that the group was one of the first opportunities to speak about their combat traumas in therapy with other veterans. We suspect that by not providing veterans with treatment groups in which they can share their PMIEs, veterans may not have any opportunity, in or outside therapy, to share their most troubling experiences with the only other people who they perceive will “get it.” Veterans informally reported that they have never told anyone about their experiences because they do not talk about their PMIEs in other therapy groups, and informal or social reunions with comrades or former units are not spaces to share disturbing and haunting memories. As they note, veterans mostly hang out with other veterans, but they avoid talking about their PMIEs. The VA could be unintentionally communicating to both veterans and providers that these experiences cannot be put into words or should not be shared. Without training and support, providers may feel unprepared to directly discuss these events [].

Because of the potential limitations of existing PMIE- and PTSD-focused treatments, we believe that veterans will benefit from a group treatment that provides an opportunity for disclosing PMIEs with other veterans, processing the strong affects associated with these events, accepting the reality of being changed by and the universal human impact of PMIEs, and directly addressing alterations in meaning and purpose.

We will develop a usable, feasible, learnable, and effective manual guided by best practices from implementation science. Treatment design (ie, form and function) is a central but often underappreciated determinant of treatment effectiveness. Speculatively, design issues may account for why therapies that are efficacious in tightly controlled clinical trial settings falter when applied in real-world settings; for instance, manuals may be difficult to learn or implement or have a poor fit within a delivery context. We plan to use 2 cutting-edge treatment development strategies from implementation science to develop our therapy manual: the user-centered design framework and the stage model for treatment manual development.

The user-centered design framework organizes the process of developing evidence-based treatments into 4 stages, that is, Discover, Design and Build, and Test (DDBT). See for the DDBT model, based on Lyon et al []. The user-centered design framework provides functional guidance for involving end users and stakeholders in every stage of treatment design, from initial idea development to final implementation strategies. In practice, the application of these methods substantially increases the likelihood of creating a treatment that can be rapidly and efficiently learned and used by providers because it accommodates feedback from clinicians and patients. Because user-centered design intentionally canvasses both patients and providers, it results in a treatment that is acceptable and feasible for both types of users and addresses clinical system and setting needs and potential constraints.

‎Figure 2. The Discover, Design and Built, and Test (DDBT) model forms the basis of this Career Development Award-2 research plan.

The goal of a treatment manual is to provide a description of a therapy and instructions for therapists on implementing it. However, the manual needs to include different types of information and levels of detail depending on the stage of treatment development. Therapists in a pilot trial have different needs than a therapist in ongoing regular clinical practice. The stage model for treatment manual development outlines what a treatment manual should include for a pilot trial (vs an efficacy trial or ongoing clinical care) []. Treatment manuals for pilot trials should include preliminary specification of techniques, goals, format, and active ingredients; these manuals are written in such a way that they can be iteratively revised and refined following the pilot test and future efficacy or effectiveness trials. The stage model for treatment manual development specifies seven chapters that a pilot test manual should include (1) an overview, description, and rationale of the treatment; (2) conception of the disorder or problem; (3) treatment goals; (4) contrast to other approaches; (5) specification of defining interventions; (6) session content; and (7) general format.

As part of her clinical responsibilities, the PI informally developed a group psychotherapy to redress the limitations of existing treatments. This group was based on relational dynamic theory. The Relational School of Psychoanalysis grew out of a series of books and papers by Mitchell [] first published in the 1980s. The Relational School emphasizes the role of relationships with others, real and imagined, in constructing mental life including mental disorders and distress. Working with Vietnam veterans and survivors of other traumatic events in adult life, GB (coinvestigator) developed a theory of adult-onset trauma embedded within the relational tradition. Under the circumstances, this work is seen as applicable in the PMIE context [].

Adult-onset trauma is viewed as a result of catastrophic disruptions to the familiar senses of the self; for example, the senses of time and agency become dysregulated, but in particular the affective self is flooded with feelings such as fear, guilt, and shame that disrupt self-perception and destroy a previous experience of a cohesive and continuous identity from pre- to posttrauma. Equally significant, the ability to feel connected to others and the sense of relatedness are undermined. A principle of relational dynamic therapy is that specific constellations of memories, emotions, situations, and relationships hold key meanings about earlier events, in this instance, about combat. We suggest this conceptualization aligns with service members’ and veterans’ reports of the impact of PMIEs [].

The goal of relational dynamic trauma therapy is to help veterans identify connections between their present symptoms and their experiences in combat and their PMIEs, their present life stressors and relationships, and the historical factors that carry person-specific meaning to their trauma or PMIEs. These explorations take place in the presence of attuned and sympathetic others, who can resonate with the experience and the affect being expressed. Symptom reduction occurs through increasing the patient’s capacity to consciously reflect on their experiences and develop an integrated self-awareness of the various factors that affect their mental states. The result is greater self-reflection, less avoidance, and greater adaptive incorporation of life experiences and their aftermath and meanings into one’s inner world. The mechanisms of change in dynamic therapy include identifying and helping patients to understand the emotional and behavioral antecedents to their symptoms; developing an awareness and exploring the meaning of psychological conflicts around strong affects such as aggression, dependency, vulnerability, and caring that are associated with their PMIEs; identifying the unconscious (automatic) and nonverbal behaviors with which veterans manage their conflicts; and proposing hypotheses about the meaning that relates these aspects of the veteran’s experiences of themselves. Over and above all, this work is undertaken in the presence of others who can validate without judging the individual experiences being reviewed; this is of paramount importance in relational dynamic treatment with patients who have been traumatized [].

Broadly speaking, dynamic therapies effectively target psychosocial and interpersonal functioning, independent of psychiatric labels [], including depression, grief, and anxiety [,]. Although few controlled trials have tested the impact of dynamic therapies on PTSD, a critical literature review suggested that dynamic approaches may be particularly suited to target the impact of trauma on crucial areas of interpersonal functioning, self-esteem, and affect tolerance []. The mechanisms of change in relational dynamic trauma therapy have been found effective in other therapy contexts. For instance, increases in insight or self-awareness are associated with improved interpersonal functioning and symptom severity []. The therapist’s facilitation of the patient’s affective experience and expression are positively associated with psychotherapy outcomes []. Increases in patients’ abilities to understand themselves and others in terms of mental states and subjective experiences are also associated with improved functioning []. Relational dynamic therapies are, by theory and in practice, not diagnostically bound or symptom-focused and thus may be a good fit in the rehabilitation model of recovery.

Study Aims and Hypotheses

This project will develop a depth-oriented group psychotherapy for morally injured combat veterans. The research plan will use modern user-centered design methods that continuously gather user experiences during treatment development, with the goal of increased effectiveness and usability []. User feedback will be synthesized with formative feedback from a clinical expert panel. This objective will be accomplished by pursuing these specific aims.

Aim 1

Discover user needs and preferences as well as treatment-engagement barriers and facilitators from the perspectives of PMIE-impacted veterans and VA trauma clinicians (ie, mental health providers and chaplains).

Aim 2

Design a treatment manual and refine it using feedback from veterans, trauma clinicians, and an expert clinical advisory board.

Aim 3

Conduct 2 rapid prototyping open trials (ie, tangibly testing treatment approaches using a prototype manual) with PMIE-impacted veterans (N=12), and iteratively revise the manual based on veteran, provider, and clinical expert panel feedback, with the following hypothesis: “The treatment manual will meet usability, feasibility, learnability, and acceptability criteria.”

MethodsStudy Design and Overview

This study design is a multiphase mixed methods treatment development project that involves (1) interviewing veterans and clinicians (Aim 1); (2) writing a treatment manual (Aim 2); and (3) open pilot testing the treatment manual in 2 successive psychotherapy groups (Aim 3). This project will use the user-centered DDBT framework to generate a treatment manual to treat the lasting and varied multidimensional functional impairments associated with high-magnitude PMIEs in a group psychotherapy context. We plan for approximately 50 Central Texas Veterans Healthcare System (CTVHCS) veterans to complete study activities: up to 38 veterans will complete Aim 1 interviews, and approximately 12 veterans will complete Aim 3 group psychotherapy pilot trials and associated assessments. See for the timeline of study activities. See for a data summary.

Table 2. Gantt table of study activities and timeline.Gantt tableYear 1Year 2Year 3Year 4Year 5Quarter12341234123412341234Aim 1: Discover user needs as well as treatment barriers and facilitators from the perspectives of PMIE-impacted transitioning veterans and VA providers.Interview PMIE-exposed veterans (n=20)✓✓✓✓Interview VA trauma clinicians (n=20)✓✓✓✓Interview past participants of PI’s therapy group (n=18)✓✓✓✓Qualitative data analysis✓✓✓✓Aim 2: Design and build a treatment manual based on Aim 1 findings, clinician feedback, and depth-oriented relational dynamic research and practice.Design and build a group therapy to treat PMIE-related functional and social impairments✓✓✓✓✓✓✓✓Reinterview VA trauma clinicians for feedback (n=20)✓✓Clinical expert review panel convenes✓✓✓✓Pilot trial startup procedures (eg, clinic coordination)✓Aim 3: test the treatment manual via iterative open pilot trials with PMIE-impacted veterans.First open pilot✓✓✓✓Interventionist training (2 interventionists)✓Recruitment, screening, and consent (n=6)✓Treatment and supervision (2 interventionists)✓✓Data collection, analysis, and interpretation✓✓✓✓Clinical expert panel reviews treatment manual✓Treatment manual revision✓✓Second open pilot✓✓✓✓Recruitment, screening, and consent (n=6)✓Treatment and supervision (2 interventionists)✓✓Data collection, analysis, and interpretation✓✓✓✓Revision of treatment manual✓✓✓✓Develop a fidelity and competency scale✓✓Clinical expert panel reviews manual and new scale✓

aPMIE: potentially morally injurious event.

bVA: Department of Veterans Affairs.

cPI: principal investigator

Table 3. Summary of data collection and analysis.User-centered design phase, participants, and roleMethod and timing of assessmentVariables and topicsAnalysis planStudy aimQualitative dataDiscoverVeterans: potential future usersOne-time, one hour semistructured interviewNeedsPreferences (eg, group vs individual)Barriers and facilitators to participationRapid qualitative analysisClinicians and potential future users——Veterans: former users—ExperiencesPreferencesAreas for improvement—
Design and buildClinical expert review panelBiannual semistructured focus group, in Years 1‐3TechniquesGoalsFormatActive ingredientsClinicians and potential future usersThink aloud review of treatment manual, via one-time one-hour semistructured interviewUsability issuesFuture contextTestVeterans and pilot trial participantsOne-time, one-hour semistructured interviewClinicians and InterventionistsFeedback during supervisionUsabilityLearnabilityAcceptabilityQuantitative dataVeterans and pilot trial participants
Planned versus actual recruitmentNumber of completed sessionsNumber of dropoutsSelf-report measures completed 1-month and 6-month posttreatmentClinical measurePilot trial primary outcomes:UsabilityFeasibilityAcceptability
Pilot trial exploratory clinical outcomesDescriptive statistics:MeanSD95% CIsStandardized mean change, for exploratory clinical outcomes

aNot applicable.

Aim 1 Overview: Discover User Needs

The goal of Aim 1 is to discover user needs as well as potential barriers, facilitators, and structures of treatment from stakeholder perspectives. This process will involve user-centered interviews with (1) PMIE-impaired veterans in CTVHCS, (2) a national sample of VA trauma clinicians, and (3) previous participants in SO’s moral injury therapy group, a diverse set of VA mental health providers. The goal is to generate data on acceptability- and usability-related issues that will guide treatment development. These data will guide the design of the treatment manual in Aim 2.

Aim 1 Interviews With PMIE-Impaired Veterans (n=20)Participants

We will interview up to 20 US combat veterans enrolled in CTVHCS who report exposure to high-magnitude PMIEs and distress or functional impairment associated with the PMIE exposure (n=20).

Study Setting

Veterans will be recruited from CTVHCS. CTVHCS serves one of the largest veteran communities in the United States, as most veterans settle in and around the Fort Hood area following separation. For example, in 2014, approximately 125,000 veterans settled in Austin and the surrounding counties. Interviews will be conducted either in person or via an institutional review board (IRB)–approved teleconference.

Recruitment

We will use three strategies for recruiting participants.

Direct outreach to potentially eligible veterans: the names and contact information for potentially eligible veterans will be extracted from the VA Corporate Data Warehouse (CDW) via an approved Data Access Request Tracker (DART) request. CDW data requests will be limited to male and female, English-speaking veterans aged 18 years or older, enrolled in CTVHCS, and with a service record of combat deployments. Study staff will contact these veterans via postal mail with information about the study that includes a preaddressed, stamped postcard that they may return to opt out of receiving further contact about the study or express their interest in receiving a phone call from the investigator about the study. Staff will contact veterans that have not opted out and those who expressed interest in receiving more information via a VA office telephone or VA-issued, password-protected, and encrypted cellular phone 2 weeks after sending a study information letter to ask about their interest in the study.Self-referral based on advertisements: a study brochure for participants will be placed in waiting rooms and with providers at CTVHCS hospitals and clinics.Clinician referral: study staff will present the study aims and inclusion and exclusion criteria to CTVHCS providers in staff meetings and solicit referrals for the study. Study staff may send emails with study information to staff and may also contact staff via secure platforms (eg, encrypted VA email). Providers will be instructed to receive verbal permission from veterans to be contacted by study staff by phone and to document this in the veteran’s electronic medical record prior to sharing the veteran’s contact information with study staff.Pre-Eligibility Screening

A trained study staffer will prescreen interested veterans for basic eligibility requirements: whether they served at least one combat deployment or received combat hazard pay; whether they are willing to answer questionnaires about distressing combat experiences, including morally injurious events, as part of eligibility screening; and whether they are willing to return study forms. Prescreening takes approximately 10 minutes.

Consent, Eligibility Screening, and Compensation

If veterans pass prescreening criteria, they will be scheduled for an informed consent and eligibility screening appointment. The potential participant will complete the informed consent prior to completing eligibility measures due to the sensitive content of these measures. To assess eligibility, participants will complete the event screener and brief Inventory of Psychosocial Functioning (b-IPF) [] from the Moral Injury Outcome Scale (MIOS) [], the Sheehan Disability Scale (SDS) [], the Columbia-Suicide Severity Rating Scale (C-SSRS) [], and the Montreal Cognitive Assessment (MoCA) []. See for study measures. They will also be asked about their alcohol and substance use and dependence. The informed consent and eligibility screening will take approximately 45‐60 minutes. If participants provide consent and are eligible, then they will complete the full MIOS measure; if veterans are not eligible, we will not administer these items to reduce participant burden. At the end of the informed consent and eligibility screening, veterans will be scheduled for a one-hour interview with members of the study team. Veterans will be compensated US $30 after completing this one-hour interview. Veterans who decline to participate in the study but report an interest in mental health treatment will receive appropriate referrals.

Table 4. Table of veteran participant study measures.Measurement informationStudy aim 1: samplesStudy aim 3Purpose and measureConstructSample 1Sample 3Time pointsBaseline1month PG6 months PGEligibility (Aim 1, sample 1 and 3); descriptive (Aim 1, Sample 3)MIOS event screenerPMIE exposure✓✓✓✓Eligibility, descriptive (Aim 1), exploratory outcome (Aim 3)SDSFunctional impairment✓✓✓✓b-IPF, in MIOSPsychosocial functioning✓✓✓✓✓Eligibility and safetyC-SSRSSuicide risk✓✓✓✓✓EligibilityMoCACognitive impairment✓✓Primary outcome (Aim 3)AIM