Restore and Rebuild (R&R) – a feasibility pilot study of a co-designed intervention for moral injury-related mental health difficulties

Figures & data

Table 1. R&R treatment session outline.

Session 1–2	Resource building	Formulation and emotional regulation strategies focused on building self-compassion.
Session 3–8	Focusing on the event	Recounting the PMIE through narrative exposure, evaluating response to the event and identifying stuck points.
Session 9–12	Moving on from the event	Cognitive re-structuring of core beliefs about self and others through exploration of key themes such as power and control, and trust.
Session 13–18	Rebuilding connections	Overcoming shame through sharing of PMIE narrative. Developing values-based goals to help re-build a valued life and improve connections with others. Exploration of barriers to recovery. Integrating self-compassion into daily life.
Session 19–20	Ending	Reviewing progress, maintaining gains and future plan, signposting if further needs are identified.

Table 2. Participant demographic information.

Index	Total sample (n = 20)
Mean age, M (SD)	45.15 (9.17)
Male, n(%)	18 (90%)
Marital status, n(%)
Single	2 (10%)
Married/living with a partner	15 (75%)
Divorced/separated	3 (15%)
Education attainment, n(%)
School until 18 years	3 (15%)
Further education	11 (55%)
Higher education (BSc)	3 (15%)
Masters/doctoral degree	3 (15%)
Branch, n(%)
British Army	14 (70%)
Royal Airforce	2 (10%)
Royal Marines/Royal Navy	4 (20%)
Length of service, M(SD)	12.65 (6.12)
Number of times deployed, M(SD)	4.55 (2.25)
Years since left the military, M(SD)	13.5 (10.69)

Table 3. Patient treatment attendance information.

Outcome	N (%)
Drop out after first session	0 (0.0%)
Number of R&R sessions attended	20 (100.0%)
1-month follow up attenders	20 (100.0%)
3-month follow up attenders	19 (95.0%)
Adverse events	0 (0.0%)

Note: Number of R&R sessions attended = there are 20 sessions in the R&R treatment manual.

Table 4. Sample outcomes at baseline, 1-month and 3-months post treatment.

Baseline	Met case criteria, n(%)	Mean score (SD)	Mean change from baseline (95% CI)	t-test P value
PTSD	19 (95.0%)	69.5 (15.3)	–	–
Alcohol misuse^a	17 (100.0%)	21.8 (2.7)	–	–
Depression	20 (100.0%)	23.65 (6.70)	–	–
MORIS^b	15 (83.3)	17.6 (6.7)	–	–
EMIS^c	n/a	56.6 (12.6)	–	–
1-month follow up
PTSD	10 (50.0%)	34.85 (19.07)	34.65 (23.6–45.71)	<0.001
Alcohol misuse^b	8 (44.4%)	12.11 (8.07)	9.07 (4.88–13.25)	0.001
Depression	13 (65.0%)	11.30 (7.36)	12.35 (7.85–16.85)	<0.001
MORIS	8 (40%)	9.35 (5.96)	8.26 (4.10–12.42)	0.001
EMIS^b	n/a	50.0 (11.47)	6.63 (−1.42 to 14.68)	0.10
3-month follow up^c
PTSD^c	4 (21.1%)	30.63 (16.70)	38.87 (28.5–49.25)	<0.001
Alcohol misuse^b	4 (22.2%)	8.66 (7.52)	12.51(8.58–16.44)	<0.001
Depression^c	8 (42.11%)	8.84 (5.04)	14.81 (10.95–18.67)	<0.001
MORIS^d	4 (25.0%)	8.56 (5.18)	9.05 (4.83–13.26)	0.001
EMIS^c	n/a	52.63 (12.34)	4.0 (−4.19 to 12.2)	0.33

Note: Total N = 20. a = data missing for 3 participants. b = data missing for 2 participants. c = data missing for 1 participant. d = data missing for 4 participants. n/a = not applicable. PTSD = measured via PCL-5 (Weathers et al., 1993). Depression = measured by PHQ-9 (Kroenke et al., 2001). Alcohol misuse = measured via AUDIT (Babor et al., 2001). MORIS = Moral Injury Scale (Williamson et al., under review). EMIS = Expressions of Moral Injury Scale (Currier et al., 2015).

Table 5. Illustrative quotations supporting themes and subthemes of thematic analysis.

Theme & sub-themes	Quote
Experiences of receiving R&R treatment
Re-evaluation of the event, in context and one’s role	Veteran: That letter writing thing for me was me getting a grip of myself and writing down stuff that I really didn’t want to write down. I really didn’t want [the therapist] or other people to hear about this because I was horrified about my own thoughts and feelings at that time. But I want to get better, so you have to, it’s just a hurdle to get over isn’t it. I knew this treatment wasn’t going to be easy, it was just like you know what [the event happened], I’ve unlocked it, it gets written down. It was by far probably the most effective thing … of all the exercises that I’ve done so far. (Male 005)
	Therapist: I think there is something really important … about allocentric versus egocentric memory processing with moral injury … . There is something … so helpful, rather than having that memory of … ‘I was directing the drone, and this is what I could smell and … see’ … Being able to look at it from an outside perspective and see the way that guy was being treated and … having to make a quick decision. There is something really important … about being able to look at it from … an outsider perspective it’s been really helpful.
	Veteran: The memories will still be in my mind, but I’ve accepted it now and know how to deal with it as far as I’m concerned. … Because they happened, simple as that, but … it’s just horrible pictures that you keep in your mind. I just blame myself for, well I did, I don’t anymore. (Male, 017)
Increased self-compassion and use of adaptive coping strategies.	Veteran: We talked a lot about perfectionism and that fear of failure … I feel less stressed [now] … I have also changed my hours … so I give myself more time … it’s partly to do with the way that you think about things, but partly to do with the recognition of actually it’s acceptable to give yourself time and therefore I could change my days. It doesn’t have to be me who is back to get the kids. My husband can do it on a certain day, so let him do it. I don’t feel like I have to do everything all the time. (Female, 015).
	Veteran: [The therapist] went through [my] average days and … [asked] when I take time for myself [for] reading which I enjoy doing. I like[to] paint, I like doing all sorts of different things, but I never fitted them in. [The therapist] was like try and fit them in. Start with 15, 20 min, half an hour … She was just encouraging me to think of myself and don’t be too hard on myself. If I’ve had a hard day there’s nothing wrong with … taking that time to rest … It was just some really good advice throughout to be fair that I’ve never really thought about. (Male, 020)
Experiencing improved social connections	Veteran: I think [the companion session] sits perfectly, you are beyond halfway through the course so obviously I’m confident by that stage with talking to [the therapist], I’ve got trust in her … I was comfortable with it, and I think the way that it was structured, the way that me and [the therapist] built a plan before we came into [the session] … so I knew how things were going and I think it worked well. The only thing I was nervous about was just reactions from my wife because there’s stuff that I’ve told nobody before … So I’ve opened up a lot more … and just talk more in depth … over the things that I think have affected me and why they’ve affected me. (Male 010)
	Therapist: What we did instead [of having a companion attend] was we used the session to write a … letter … [the veteran] had children … and they were saying ‘well if my children ask me about moral injury or my sessions in the future what would I want to tell them?’ So that’s what we covered in the session, and it was … what you’d want to include in the letter, what you wouldn’t want to include … how you want to explain what we’ve covered in the therapy. It was … almost like having the close companion there, but it was just having it in written format instead … I think the close companion session is important because it gives someone the tools to be able to explain it to someone else if they want to in a containable way.
	Veteran: [I’m] talking loads more with my wife about it. I’ve become quite passive, quite calm within stuff, I’m reacting to the children a little bit less … I am able to put that on to conversations with the kids and open up a little bit more and just be a little bit kinder to myself. I think they can see a softness within me … . Conversations are getting better, softer and more understanding since starting this [treatment], which is fantastic.
Re-evaluation of values.	Veteran: To me it’s all about making, I wouldn’t say a better me but getting myself to a place I want to be … my values standards have pretty much been set by the Army … [So] that [values] session was probably one of the strongest and most important for me especially to learn … to look at what these values and standards mean in everyday life and to be able to say ‘well actually I don’t need that value anymore’ … and to actually pick ones that you wanted to move forward with … and look at what I need now to be happy. (Male 010).
Aspects of R&R that could be improved or altered.
	Veteran: [Online] it’s convenient really … some people might find it’s not as personable, but I think it is having that person up on the screen is just as effective as being sat there face to face. I think I’d find the sessions a little bit harder maybe in person because I’d be a little bit more guarded. You potentially wouldn’t [open] up as much because of this person that I am, the person that I profess to be … and I should be not breaking down in front of people. Whereas over Teams … I’ve been able to open up a little bit more (Male, 005)
	Veteran: I don’t know whether there could have been just a bespoke [information sheet] … because when all the information is written down, it’s directed at me whereas … it would be good to have a little guide that explains to [partners] … about moral injury and explains about the treatment process and then also maybe how they can support during the treatment and look after themselves … Whereas if he had a resource that was from yourselves, and it was specific to the [R&R] course then that might be helpful. (Female, 003)
	Veteran: So, the one thing that I have struggled with is some of the paperwork … I’m slightly dyslexic and … If I wanted to do this course in the future it would be amazing if you’ve got some kind of [materials] … that somebody can click on a link and you’ve actually got the voice of your therapist. (Male 009)
	Therapist: I think in terms of working with the moral injury itself I haven’t come across anything yet which has been left out but, realistically, working with a veteran population in particular – a lot of the veterans I’m working with have multiple other PTSD events that aren’t morally injurious and they sometimes need help with those bits afterwards …  So yes, there have been bits that have been left over but they’ve been from the PTSD … presentations rather than the moral injury side of things themselves.

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Data availability statement

The data that support the findings of this study are available from the corresponding author (VW), upon reasonable request. The data are not publicly available due to privacy and ethical restrictions (i.e. containing information that could compromise the privacy of research participants).