A pilot study developed and trialled a new psychological treatment, named Restore & Rebuild (R&R), with UK veterans affected by moral injury – distress resulting from events violating one’s moral or ethical code.

This innovative treatment, co-designed with leading international professionals and veterans, led to significant improvements in several areas, including symptoms of depression and PTSD, as well as moral injury-related distress. R&R represents the first evidence of an effective specific treatment for moral injury in the UK. There is currently no such treatment available.

Due to the success of this pilot study, Forces in Mind Trust has awarded a further £260,000 to fund the next phase: a randomised controlled trial to more robustly evaluate the R&R treatment.

What is Moral Injury?

In a military environment, moral injury may include when Service personnel have to make decisions that affect the survival of others; when medics are not able to care for all who were harmed; failing to report an event that violates rules or ethics, or engaging in (or witnessing without intervening to prevent) acts of disproportionate violence.

However, moral injury is not exclusive to the military. Health workers and emergency services staff, for example, may also experience it; including when clinicians understand what care patients need but are unable to provide it due to constraints that are beyond their control.

People who suffer moral injuries are at increased risk of mental health conditions such as PTSD or depression. Routine PTSD treatments are less effective when someone is experiencing a moral injury.

Restore and Rebuild

The new R&R treatment allows participants to build a relationship with a therapist over 20 sessions delivered weekly.  The sessions first focus on the participants’ life experiences, as well as psychoeducation on moral injury, and involve revisiting the original morally injurious event(s). Later sessions aim to reframe their negative beliefs. Participants are also encouraged to bring a close companion along to a treatment session.

The research team is led by Dr Victoria Williamson and Professor Neil Greenberg at King’s College London, and Professor Dominic Murphy at veterans’ mental health charity, Combat Stress (also affiliated to King’s College London).

Dr Victoria Williamson, King’s College London, said: “Individuals who struggle with moral injury-related mental health difficulties can find that existing psychological therapies do not fully address the distress they experience after potentially morally injurious events. Restore & Rebuild (R&R) is a psychological treatment co-designed and developed with UK veterans and leading professionals in the field of moral injury.

“Our pilot study shows that R&R is a promising treatment for moral injury-related mental health problems and significantly improves wellbeing. In time, it may be possible to offer R&R to military veterans as well as other professionals (e.g. healthcare workers, police, journalists) who experience moral injury”.

Professor Neil Greenberg, King’s College London, said: “R&R offers real hope to military personnel who have been confronted by moral or ethically challenging situations which have negatively affected their mental health. Whilst our results are from a pilot study, so a degree of caution is required, they are very positive and we are delighted that FiMT have agreed to fund a follow on, far more definitive, study of the true impact of R&R.

“If this proves successful, we look forward to freely providing R&R to care organisations that treat veterans so they can help them move forward with their lives and continue to positively contribute to society”.

Professor Dominic Murphy, Head of Research at Combat Stress, said: “This study is one of the first of its kind to develop a new treatment for moral injury.  The results of our study are promising, and we hope to be in a position to roll out this new treatment to support more veterans in the near future.”

Michelle Alston, Chief Executive of Forces in Mind Trust, said: “Addressing any issues that stem from an individual’s time in military service is a key tenet of the Armed Forces Covenant. But treating moral injury has posed unique difficulties as there has been no UK-specific assessment scale for clinical use, and no specific treatment.

“Restore and Rebuild offers the first possibility of a UK-specific manualised treatment for moral injury-related mental health problems, which offers great potential to help those veterans affected by moral injury whilst serving.”

You can access a link to the full report here.