Impact of morally injurious traumatic event exposure on cognitive processing therapy outcomes among Veterans and service members

LAY SUMMARYMilitary personnel frequently report actions taken by themselves or others that violate deeply held moral beliefs, which can be experienced as a kind of moral injury. Some have questioned whether existing treatments for posttraumatic stress disorder (PTSD), such as cognitive processing therapy, are effective for those who have been exposed to a morally injurious traumatic event. These analyses demonstrate that active duty service members and Veterans seeking treatment for PTSD who reported potentially morally injurious trauma had PTSD and depression outcomes that were as good as those whose traumas were not primarily seen as morally injurious, suggesting that cognitive processing therapy is an efficacious treatment for PTSD in the context of morally injurious trauma. Introduction: Cognitive processing therapy (CPT) is recommended for the treatment of posttraumatic stress disorder (PTSD) and effective across a range of trauma types. However, some have questioned whether CPT is effective for morally injurious traumas, including perpetrating, failing to prevent, witnessing, or learning of acts that transgress moral beliefs and expectations. The aims of this analysis were to examine whether treatment-seeking active duty service members and Veterans with and without potentially morally injurious traumatic events had differences in CPT outcomes. Methods: Data were pooled from five clinical trials in which active duty service members and Veterans received CPT. Non-inferiority analyses were used to compare rates of receiving an adequate dose of treatment (i.e., eight sessions or a PTSD Checklist-5 score < 20 at the final session) and improvement in PTSD and depression symptoms. Results: More than 70% of participants received an adequate dose, and those with a potentially morally injurious trauma were no less likely to receive an adequate dose. Both those with and without a potentially morally injurious trauma experienced significant reductions in PTSD and depressive symptoms (all ps < 0.001), and reductions among those with a potentially morally injurious trauma were non-inferior to those without a morally injurious trauma. Discussion: Findings indicate that active duty military personnel and Veterans endorsing traumas primarily characterized by moral violation engage in and benefit from CPT similarly to those not endorsing such traumas. Results suggest that CPT is a good PTSD treatment option for military personnel with morally injurious trauma.