Mindful Self Compassion for Combat Deployed Veterans With Moral Injury and Co-occurring PTSD-SUD

PTSD-SUD is particularly common following combat exposure, affecting a rapidly increasing
number of U.S. military Veterans. The co-occurrence of these disorders presents added
challenges to the VA treatment delivery system, presently in need of effective integrated
treatments. Veterans with PTSD-SUD experience more severe symptomatology, increased risk of
suicidality, poorer quality of life, and poorer response to existing treatments than Veterans
with either disorder alone. Furthermore, PTSD-SUD prevents Veterans from reintegrating into
society and is associated with occupational and social dysfunction. These findings underscore
the need to effectively and efficiently address comorbidity and the complex array of problems
with which Veterans present to treatment.

One approach is to develop interventions that target mechanisms thought to underlie multiple
highly prevalent disorders, such as guilt related to traumatic experiences. Combat Veterans
often report experiencing moral injury defined as perpetrating, failing to prevent, or
witnessing acts that violate the values they live by in their civilian lives. Veterans who
negatively appraise their actions or inaction during combat may experience guilt, a common
posttraumatic reaction. Moral injury suggests the inability to contextualize or justify
actions and the unsuccessful accommodation of those morally challenging experiences into
pre-existing moral schemas, resulting in guilt and shame. Posttraumatic guilt has been
implicated as a risk factor for the development and maintenance of several forms of
psychopathology including PTSD, SUD, depression, and suicidality. However, to date,
treatments for posttraumatic psychological health issues have been primarily disorder
specific, with a focus largely on symptom reduction. Therefore, greater understanding of
modifiable factors that influence functional impairment and PTSD-SUD is needed to enhance
treatment efforts.

Mindful Self Compassion (MSC) combines the skills of mindfulness and self-compassion,
providing self-soothing skills to respond to difficult thoughts and feelings (including
guilt) via meditation. Self-compassion (SC) emphasizes kindness towards one's self, a feeling
of connectedness with others, and mindful awareness of distressing experiences. Furthermore,
because SC is negatively associated with self-criticism, rumination, thought suppression,
anxiety, and depression, and positively associated with healthy psychological functioning, it
is well suited to addressing posttraumatic psychopathology, shame, and guilt.

This proposal will begin to address a gap in the field's knowledge about MSC, and its role in
the treatment of co-occurring disorders in Veterans with moral injury. The investigators will
evaluate changes in self-compassion, post-traumatic guilt, shame, PTSD and substance use
symptom severity. In addition to symptom reduction, the investigators will focus on
functional outcomes (e.g., quality of life, suicidality). Participants will complete
assessments at baseline, post-treatment, and 1-month follow-up. This project will allow us to
1) determine the feasibility of recruitment, 2) determine the acceptability of MSC, 3)
provide preliminary evidence of the effects of MSC, and 4) refine study procedures and make
adaptations to MSC based upon experience gained in the pilot in preparation for a fully
powered RCT to test the effectiveness of MSC.

Inclusion Criteria:

- moral injury as captured by at least one "strongly agree" response on the Moral Injury
Events Scale

- diagnosis of PTSD (within the last 30 days) confirmed by the Clinician Administered
PTSD Scale (CAPS) with a total symptom score of 44 or more

- diagnosis of a substance use disorder confirmed by the Structured Clinical Interview
for DSM-5 Section E (SCID-E)

- willing and able to provide informed consent

- not currently receiving trauma-focused treatment

Exclusion Criteria:

- individuals with an acute psychotic disorder or acute psychotic symptoms are not
eligible if their symptoms are unstable and if they are not well connected with
appropriate mental health services

- patients with a psychiatric hospitalization or suicide attempt within the past month
will be excluded

- currently receiving trauma-focused treatment, e.g., (PE, CPT, CBT for PTSD)

- Patients currently enrolled in trauma-focused treatment may be enrolled when they
have completed the treatment if they remain interested and continue to have PTSD

- individuals with life-threatening or unstable medical illness. Diagnoses of mild
cognitive impairment (e.g. mTBI) and other anxiety and depressive disorders will not
be excluded because of their high comorbidity with PTSD and SUD