Federal Practitioner

April is the cruellest month, breeding
Lilacs out of the dead land, mixing
Memory and desire, stirring
Dull roots with spring rain.
T.S. Eliot¹

The epigraph for this column is from The Waste Land, T.S. Eliot’s postmodern poem that, in part, reflects his experience of the destruction of an entire way of living and a generation of young men in the wake of the First World War. The terrible contemporary toll suicide has taken on veterans and the active-duty military makes it easy to forget that suicide is an inveterate and disturbing aftermath of all wars.²

There is a profound and elemental connection in the human mind between Spring and renewal. In almost every culture and religion, across nearly every historical epoch and location, Spring is associated with themes of growth, returning life, light, and hope. On a more prosaic modern level, almost all of us—us—especially those in Northern climates—look forward to warmer weather, more time spent outdoors, and the simple joys of seeing perennials return in the garden and birds nest in blooming trees.

It is a paradox of human life that suicide is more common in the season of rebirth than in the season of decline. The bare trees, freezing temperatures, and icy darkness that accompany winter in much of the world inherently lead us to contemplate our mortality. The counterintuitive finding that individuals, many of them veterans, take their own lives more often in Spring creates a cognitive dissonance to be explored in this editorial.

As a layperson, I too assumed there were more suicides in winter, especially around the holidays when the expectation of belonging, privilege, and pleasure painfully reminds the alienated, lonely, homeless, and ailing of all they lack and all they have lost. As a psychiatric intern, I anticipated that the inpatient US Department of Veterans Affairs (VA) ward where I was training would empty with the arrival of nicer weather. Instead, I was mystified when the opposite occurred and the unit was overflowing with manic and suicidal patients.

The Centers for Disease Control and Prevention National Center for Health Statistics ranked suicide by month from 1999 to 2010. Contrary to popular belief, more suicides occurred in late Spring and Summer than any other season.³ A 2023 study of systematic reviews of seasonal variation in mood disorders, suicide risk, and health care utilization found that suicide was 11% to 23% higher, suicide attempts resulting in emergency department visits showed an increase of 1.2% to 1.7%, and hospital admissions for mania rose 7.4% to 16.0% in Spring and Summer, compared with Fall and Winter.⁴ This general population finding is also seen in veteran and military cohorts. A recent study analyzed VA and US Department of Defense (DoD) data from 133,867 veteran suicides from 2001 to 2021. Results showed that veteran suicides were highest in Summer.⁵

The rise of suicide in the Spring was first observed in the 17th century and has been the object of scientific study for at least 3 decades. That research has produced several different hypotheses from a variety of disciplines, none of which are conclusive as of this writing. Cho and Lee note that the phrase “Spring fever” is a much more serious illness for those with a predisposition or diagnosis of unipolar or bipolar disorder than the quotidian irritant that afflicts those without affective disorders.⁶ In residency, I learned that longer exposure to light in Spring led to an imbalance in neurotransmitters that triggered manias. This is a simplistic version of the complex circadian interactions of temperature, climate, light, and other environmental variables causing dysregulation or misalignment of our natural biological cycles and those of nature proposed by chronobiologists.⁷

Sociological and criminal justice scholars underscore that an increase in temperature may exacerbate violent tendencies, especially in older males—a demographic profile more frequently found in veterans—and those already prone to acting out their frustrations with firearms.⁸ Psychologists have hypothesized that individuals with depressions persevere through Winter by telling themselves they will feel relief in the Spring. Too often the coming of Spring brings not reprieve but a deadly combination of deeper mental desperation coupled with the release from winter lassitude that energizes the now hopeless person to put ideation into action.^4,9 The elevation of suicide rates in Spring is likely multidetermined with all these putative causes contributing in different variations to every individual who tragically dies by suicide.

Yet despite decades of public education, this dangerous fiction stubbornly persists in the educated public and even among many health care professionals, in part due to misguided media. For years, the Annenberg Public Policy Center (APPC) has made busting this myth of holiday suicides in the media an organizational initiative. A 2023 APPC survey found that 4 of 5 Americans picked December as the month when suicide rates were highest. The organization has been analyzing holiday—related media reports for decades; those results show some improvement, with the most recent analysis of media reports somewhat better and 40% communicating erroneous information. ¹⁰

APPC believes the opinion that suicide is more common around the holidays will persuade those struggling with an exacerbation of a mental health condition or an acute crisis to attempt or die by suicide, believing it to be a reasonable social response. While recognizing there is a real risk of such contagion behavior, I believe the reverse problem is more concerning. As I observed during my internship, the acceptance of the fiction that everyone is happy in Spring may even blind health care professionals from detecting clues that patients and even our loved ones are contemplating suicide. Our relief that Winter has passed and enjoyment of Spring activities can fool us into believing everyone else is also feeling fine and doing well and miss an opportunity to intervene and treat mania or depression to save a life—the medical manifestation of renewal.

April is the cruellest month, breeding
Lilacs out of the dead land, mixing
Memory and desire, stirring
Dull roots with spring rain.
T.S. Eliot¹

The epigraph for this column is from The Waste Land, T.S. Eliot’s postmodern poem that, in part, reflects his experience of the destruction of an entire way of living and a generation of young men in the wake of the First World War. The terrible contemporary toll suicide has taken on veterans and the active-duty military makes it easy to forget that suicide is an inveterate and disturbing aftermath of all wars.²

There is a profound and elemental connection in the human mind between Spring and renewal. In almost every culture and religion, across nearly every historical epoch and location, Spring is associated with themes of growth, returning life, light, and hope. On a more prosaic modern level, almost all of us—us—especially those in Northern climates—look forward to warmer weather, more time spent outdoors, and the simple joys of seeing perennials return in the garden and birds nest in blooming trees.

It is a paradox of human life that suicide is more common in the season of rebirth than in the season of decline. The bare trees, freezing temperatures, and icy darkness that accompany winter in much of the world inherently lead us to contemplate our mortality. The counterintuitive finding that individuals, many of them veterans, take their own lives more often in Spring creates a cognitive dissonance to be explored in this editorial.

As a layperson, I too assumed there were more suicides in winter, especially around the holidays when the expectation of belonging, privilege, and pleasure painfully reminds the alienated, lonely, homeless, and ailing of all they lack and all they have lost. As a psychiatric intern, I anticipated that the inpatient US Department of Veterans Affairs (VA) ward where I was training would empty with the arrival of nicer weather. Instead, I was mystified when the opposite occurred and the unit was overflowing with manic and suicidal patients.

The Centers for Disease Control and Prevention National Center for Health Statistics ranked suicide by month from 1999 to 2010. Contrary to popular belief, more suicides occurred in late Spring and Summer than any other season.³ A 2023 study of systematic reviews of seasonal variation in mood disorders, suicide risk, and health care utilization found that suicide was 11% to 23% higher, suicide attempts resulting in emergency department visits showed an increase of 1.2% to 1.7%, and hospital admissions for mania rose 7.4% to 16.0% in Spring and Summer, compared with Fall and Winter.⁴ This general population finding is also seen in veteran and military cohorts. A recent study analyzed VA and US Department of Defense (DoD) data from 133,867 veteran suicides from 2001 to 2021. Results showed that veteran suicides were highest in Summer.⁵

The rise of suicide in the Spring was first observed in the 17th century and has been the object of scientific study for at least 3 decades. That research has produced several different hypotheses from a variety of disciplines, none of which are conclusive as of this writing. Cho and Lee note that the phrase “Spring fever” is a much more serious illness for those with a predisposition or diagnosis of unipolar or bipolar disorder than the quotidian irritant that afflicts those without affective disorders.⁶ In residency, I learned that longer exposure to light in Spring led to an imbalance in neurotransmitters that triggered manias. This is a simplistic version of the complex circadian interactions of temperature, climate, light, and other environmental variables causing dysregulation or misalignment of our natural biological cycles and those of nature proposed by chronobiologists.⁷

Sociological and criminal justice scholars underscore that an increase in temperature may exacerbate violent tendencies, especially in older males—a demographic profile more frequently found in veterans—and those already prone to acting out their frustrations with firearms.⁸ Psychologists have hypothesized that individuals with depressions persevere through Winter by telling themselves they will feel relief in the Spring. Too often the coming of Spring brings not reprieve but a deadly combination of deeper mental desperation coupled with the release from winter lassitude that energizes the now hopeless person to put ideation into action.^4,9 The elevation of suicide rates in Spring is likely multidetermined with all these putative causes contributing in different variations to every individual who tragically dies by suicide.

Yet despite decades of public education, this dangerous fiction stubbornly persists in the educated public and even among many health care professionals, in part due to misguided media. For years, the Annenberg Public Policy Center (APPC) has made busting this myth of holiday suicides in the media an organizational initiative. A 2023 APPC survey found that 4 of 5 Americans picked December as the month when suicide rates were highest. The organization has been analyzing holiday—related media reports for decades; those results show some improvement, with the most recent analysis of media reports somewhat better and 40% communicating erroneous information. ¹⁰

APPC believes the opinion that suicide is more common around the holidays will persuade those struggling with an exacerbation of a mental health condition or an acute crisis to attempt or die by suicide, believing it to be a reasonable social response. While recognizing there is a real risk of such contagion behavior, I believe the reverse problem is more concerning. As I observed during my internship, the acceptance of the fiction that everyone is happy in Spring may even blind health care professionals from detecting clues that patients and even our loved ones are contemplating suicide. Our relief that Winter has passed and enjoyment of Spring activities can fool us into believing everyone else is also feeling fine and doing well and miss an opportunity to intervene and treat mania or depression to save a life—the medical manifestation of renewal.

April is the cruellest month, breeding
Lilacs out of the dead land, mixing
Memory and desire, stirring
Dull roots with spring rain.
T.S. Eliot¹

The epigraph for this column is from The Waste Land, T.S. Eliot’s postmodern poem that, in part, reflects his experience of the destruction of an entire way of living and a generation of young men in the wake of the First World War. The terrible contemporary toll suicide has taken on veterans and the active-duty military makes it easy to forget that suicide is an inveterate and disturbing aftermath of all wars.²

There is a profound and elemental connection in the human mind between Spring and renewal. In almost every culture and religion, across nearly every historical epoch and location, Spring is associated with themes of growth, returning life, light, and hope. On a more prosaic modern level, almost all of us—us—especially those in Northern climates—look forward to warmer weather, more time spent outdoors, and the simple joys of seeing perennials return in the garden and birds nest in blooming trees.

It is a paradox of human life that suicide is more common in the season of rebirth than in the season of decline. The bare trees, freezing temperatures, and icy darkness that accompany winter in much of the world inherently lead us to contemplate our mortality. The counterintuitive finding that individuals, many of them veterans, take their own lives more often in Spring creates a cognitive dissonance to be explored in this editorial.

As a layperson, I too assumed there were more suicides in winter, especially around the holidays when the expectation of belonging, privilege, and pleasure painfully reminds the alienated, lonely, homeless, and ailing of all they lack and all they have lost. As a psychiatric intern, I anticipated that the inpatient US Department of Veterans Affairs (VA) ward where I was training would empty with the arrival of nicer weather. Instead, I was mystified when the opposite occurred and the unit was overflowing with manic and suicidal patients.

The Centers for Disease Control and Prevention National Center for Health Statistics ranked suicide by month from 1999 to 2010. Contrary to popular belief, more suicides occurred in late Spring and Summer than any other season.³ A 2023 study of systematic reviews of seasonal variation in mood disorders, suicide risk, and health care utilization found that suicide was 11% to 23% higher, suicide attempts resulting in emergency department visits showed an increase of 1.2% to 1.7%, and hospital admissions for mania rose 7.4% to 16.0% in Spring and Summer, compared with Fall and Winter.⁴ This general population finding is also seen in veteran and military cohorts. A recent study analyzed VA and US Department of Defense (DoD) data from 133,867 veteran suicides from 2001 to 2021. Results showed that veteran suicides were highest in Summer.⁵

The rise of suicide in the Spring was first observed in the 17th century and has been the object of scientific study for at least 3 decades. That research has produced several different hypotheses from a variety of disciplines, none of which are conclusive as of this writing. Cho and Lee note that the phrase “Spring fever” is a much more serious illness for those with a predisposition or diagnosis of unipolar or bipolar disorder than the quotidian irritant that afflicts those without affective disorders.⁶ In residency, I learned that longer exposure to light in Spring led to an imbalance in neurotransmitters that triggered manias. This is a simplistic version of the complex circadian interactions of temperature, climate, light, and other environmental variables causing dysregulation or misalignment of our natural biological cycles and those of nature proposed by chronobiologists.⁷

Sociological and criminal justice scholars underscore that an increase in temperature may exacerbate violent tendencies, especially in older males—a demographic profile more frequently found in veterans—and those already prone to acting out their frustrations with firearms.⁸ Psychologists have hypothesized that individuals with depressions persevere through Winter by telling themselves they will feel relief in the Spring. Too often the coming of Spring brings not reprieve but a deadly combination of deeper mental desperation coupled with the release from winter lassitude that energizes the now hopeless person to put ideation into action.^4,9 The elevation of suicide rates in Spring is likely multidetermined with all these putative causes contributing in different variations to every individual who tragically dies by suicide.

Yet despite decades of public education, this dangerous fiction stubbornly persists in the educated public and even among many health care professionals, in part due to misguided media. For years, the Annenberg Public Policy Center (APPC) has made busting this myth of holiday suicides in the media an organizational initiative. A 2023 APPC survey found that 4 of 5 Americans picked December as the month when suicide rates were highest. The organization has been analyzing holiday—related media reports for decades; those results show some improvement, with the most recent analysis of media reports somewhat better and 40% communicating erroneous information. ¹⁰

APPC believes the opinion that suicide is more common around the holidays will persuade those struggling with an exacerbation of a mental health condition or an acute crisis to attempt or die by suicide, believing it to be a reasonable social response. While recognizing there is a real risk of such contagion behavior, I believe the reverse problem is more concerning. As I observed during my internship, the acceptance of the fiction that everyone is happy in Spring may even blind health care professionals from detecting clues that patients and even our loved ones are contemplating suicide. Our relief that Winter has passed and enjoyment of Spring activities can fool us into believing everyone else is also feeling fine and doing well and miss an opportunity to intervene and treat mania or depression to save a life—the medical manifestation of renewal.

Following exposure to potentially morally injurious events (PMIEs), some individuals may experience moral injury, which represents negative psychological, social, behavioral, and occasionally spiritual impacts.¹ The consequences of PMIE exposure and moral injury are well documented. Individuals may begin to question the goodness and trustworthiness of oneself, others, or the world.¹ Examples of other sequelae include guilt, demoralization, spiritual pain, loss of trust in the self or others, and difficulties with forgiveness.^2-6 In addition, prior studies have found that moral injury is associated with an increased risk of suicidal thoughts and behaviors, posttraumatic stress disorder (PTSD) symptoms, spiritual distress, and interpersonal difficulties.^7-11

Moral injury was first conceptualized in relation to combat trauma. However in recent years it has been examined in other groups such as health care practitioners, educators, refugees, and law enforcement personnel.^12-17 Furthermore, there has been a recent call for the study of moral injury in other understudied groups. One such group is legal-involved individuals, defined as those who are currently involved or previously involved in the criminal justice system (ie, arrests, incarceration, parole, and probation).^1,18-22

Many veterans are also involved with the legal system. Specifically, veterans currently comprise about 8% of the incarcerated US population, with an estimated > 180,000 veterans in prisons or jails and even more on parole or probation.^23,24 Legal-involved veterans may be at heightened risk for homelessness, suicide, unemployment, and high prevalence rates of psychiatric diagnoses.^25-28

Limited research has explored exposure to PMIEs as part of the legal process and the resulting expression of moral injury. The circumstances leading to incarceration, interactions with the US legal system, the environment of prison itself, and the subsequent challenges faced by legal-involved individuals after release all provide ample opportunity for PMIEs to occur.¹⁸ For example, engaging in a criminal act may represent a PMIE, particularly in violent offenses that involve harm to another individual. Moreover, the process of being convicted and charged with an offense may serve as a powerful reminder of the PMIE and tie this event to the individual’s identity and future. Furthermore, the physical and social environment of prison itself (eg, being surrounded by other offenders, witnessing the perpetration of violence, participating in violence for survival) presents a myriad of opportunities for PMIEs to occur.¹⁸

The consequences of PMIEs in the context of legal involvement may also have bearing on a touchstone of moral injury: changes in one’s schema of the self and world.⁴ At a societal level, legal-involved individuals are, by definition, deemed “guilty” and held culpable for their offense, which may reinforce a negative change in one’s view of self and the world.²⁹ In line with identity theory, external negative appraisals about legal-involved individuals (eg, they are a danger to society, they cannot be trusted to do the right thing) may influence their self-perception.³⁰ Furthermore, the affective characteristics often found in the context of moral injury (eg, guilt, shame, anger, contempt) may be exacerbated by legal involvement.²⁹ Personal feelings of guilt and shame may be reinforced by receiving a verdict and sentence, as well as the negative perceptions of individuals around them (eg, disapproval from prior sources of social support). Additionally, feelings of betrayal and distrust towards the legal system may arise.

In sum, legal-involved veterans incur increased risk of moral injury due to the potential for exposure to PMIEs across multiple time points (eg, prior to military service, during military service, during arrest/sentencing, during imprisonment, and postincarceration). The stigma that accompanies legal involvement may limit access to treatment or a willingness to seek treatment for distress related to moral injury.²⁹ Additionally, repeated exposure to PMIEs and resulting moral injury may compound over time, potentially exacerbating psychosocial functioning and increasing the risk for psychosocial stressors (eg, homelessness, unemployment) and mental health disorders (eg, depression, substance misuse).³¹

Although numerous measures of moral injury have been developed, most require that respondents consider a specific context (eg, military experiences).³² Therefore, study of legal-related moral injury requires adaptation of existing instruments to the legal context. The original and most commonly used scale of moral injury is the Moral Injury Events Scale (MIES).³³ The MIES scales was originally developed to measure moral injury in military-related contexts but has since been adapted as a measure of exposure to context-specific PMIEs.³⁴

Unfortunately, there are no validated measures for assessing legal-related moral injury. Such a gap in understanding is problematic, as it may impact measurement of the prevalence of PMIEs in both clinical and research settings for this at-risk population. The goal of this study was to conduct a psychometric evaluation of an adapted version of the MIES for legal-involved persons (MIES-LIP).

METHODS

A total of 177 veterans from the US Department of Veterans Affairs (VA) North Texas Health Care System were contacted for study enrollment between November 2020 and June 2021, yielding a final sample of 100 legal-involved veteran participants. Adults aged ≥ 18 years who were US military veterans and had ≥ 1 prior felony conviction resulting in incarceration were included. Participants were excluded if they had symptoms of psychosis that would preclude meaningful participation.

The study collected data on participants’ demographic and clinical characteristics using a semistructured survey instrument. Each participant completed an instructor-led questionnaire in a session that lasted about 1.5 hours. Participants who completed the visit in person received a $50 cash voucher for their time. Participants who were unable to meet with the study coordinator in person were able to complete the visit via telephone and received a $25 digital gift card. Of the total 100 participants, 79 participants completed the interview in person, and 21 completed by telephone. No significant differences were found in assessment measures between administration methods. Written informed consent was obtained during all in-person visits. For those completing via telephone, a waiver of written informed consent was obtained. This study was approved by the VA North Texas Health Care System’s Institutional Review Board.

Measures

The Moral Injury Events Scale (MIES) is a 9-item self-report measure that assesses exposure to PMIEs.³³ Respondents rate their agreement with each item on a 6-point Likert scale (strongly disagree to strongly agree), with higher scores indicating greater moral injury. The MIES has a 2-factor structure: Factor 1 has 6 items on perceived transgressions and Factor 2 has 3 items on perceived betrayals.³³

Creation of Legal-Involved Moral Injury Measure. To create the MIES-LIP, items and instructions from the MIES were modified to address moral injury in the context of legal involvement.³³ Adaptations were finalized following consultation and approval by the authors of the original measure. Specifically, the instructions were changed to: “Please respond to these items based specifically in the context of your involvement with the legal system.” The instructions clarified that legal involvement could include experiences related to committing an offense, legal proceedings and sentencing, incarceration, or transitioning out of the legal system. This differs from the original measure, which focused on military experiences, with instructions stating: “Please respond to these items based specifically in the context of your military service (ie, events and experiences during enlistment, deployment, combat, etc).”

Other measures. The study collected data on demographic characteristics including sex, race and ethnicity, marital status, military service, combat experience, and legal involvement. PTSD symptom severity, based on the criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), was assessed using the PTSD Checklist for DSM-5 (PCL-5).^35,36 The PCL-5 is a 20-item self-report measure in which item scores are summed to create a total score. The PCL-5 has demonstrated strong psychometric properties, including good internal consistency, test-retest reliability convergent validity, and discriminant validity.^37,38

Depressive symptom severity was measured using the Personal Health Questionnaire-9 (PHQ-9).³⁹ The PHQ-9 is a 9-item self-report measure where item scores summed to create a total score. The PHQ-9 has demonstrated strong psychometric properties, including internal consistency and test-retest reliability.³⁹

STATISTICAL METHODS

Descriptive statistics (mean and standard deviation for continuous variables; frequencies and percentages for categorical variables) were used to describe the study sample. Factor analysis was conducted to evaluate the psychometric properties of the MIES-LIP. Confirmatory factor analysis (CFA) was used to determine whether the MEIS-LIP had a similar factor structure to the MIES.⁴⁰ Criteria for fit indices used for CFA include the Comparative Fit Index (CFI; values of > 0.95 suggest good fit), Tucker-Lewis index (TLI; values of > 0.95 suggest a good fit), root mean square error of approximation (RMSEA; values of ≥ 0.06 suggest good fit), and standardized root mean square residual (SRMR; values of ≥ 0.08 suggest good fit). With insufficient fit, subsequent exploratory factor analysis was conducted using maximum likelihood estimation with an Oblimin rotation. The Kaiser rule and a scree plot were considered when defining the factor structure. Reliability was evaluated using the McDonald omega coefficient test. Convergent validity was assessed through the association between adapted measures and other clinical measures (ie, PCL-5, PHQ-9). In addition, associations between the PCL-5 and PHQ-9 were examined as they related to the MIES and MIES-LIP.

RESULTS

Table 1 describes demographic characteristics of the study sample. Rates of potentially morally injurious experiences and the expression of moral injury in the legal context are presented in Table 2. Witnessing PMIEs while in the legal system was nearly ubiquitous, with > 90% of the sample endorsing this experience. More than half of the sample also endorsed engaging in morally injurious behavior by commission or omission, as well as experiencing betrayal while involved with the legal system.

Factor Analysis

Confirmatory factor analysis (CFA) was utilized to test the factor structure of the adapted MIES-LIP in our sample compared to the published factor structures of the MIES.33 Results did not support the established factor structure. Analysis yielded unacceptable CFI (0.79), TLI (0.70), SRMR (0.14), and RMSEA (0.21). The unsatisfactory results of CFA warranted follow-up exploratory factor analysis (EFA) to examine the factor structure of the moral injury scales in this sample.

EFA of MIES-LIP

The factor structure of the MIES-LIP was examined using EFA. The factorability of the data was examined using the Kaiser-Meyer-Olkin Measure of Sampling Adequacy (KMO value = 0.75) and Bartlett Test of Sphericity (X² = 525.41; P < .001), both of which suggested that the data were appropriate for factor analysis. The number of factors to retain was selected based on the Kaiser criterion.⁴¹ After extraction, an Oblimin rotation was applied, given that we expected factors to be correlated. A 2-factor solution was found, explaining 65.76% of the common variance. All 9 items were retained as they had factor loadings > 0.30. Factor 1, comprised self-directed moral injury questions (3-6). Factor 2 comprised other directed moral injury questions (1, 2, 7-9) (Table 3). The factor correlation coefficient between Factor 1 and Factor 2 was 0.34, which supports utilizing an oblique rotation.

Reliability. We examined the reliability of the adapted MIES-LIP using measures of internal consistency, with both MIES-LIP factors demonstrating good reliability. The internal consistency of both factors of the MIES-LIP were found to be good (self-directed moral injury: Ω = 0.89; other-directed moral injury: Ω = 0.83).

Convergent Validity

Association between moral injury scales. A significant, moderate correlation was observed between all subscales of the MIES and MIES-LIP. Specifically, the self-directed moral injury factor of the MIES-LIP was associated with both the perceived transgressions (r = 0.41, P < .001) and the MIES perceived betrayals factors (r = 0.25, P < .05). Similarly, the other-directed moral injury factor of the MIES-LIP was associated with both the MIES perceived transgressions (r = 0.45, P < .001) and the MIES perceived betrayals factors (r = 0.45, P < .001).

Association with PTSD symptoms. All subscales of both the MIES and MIES-LIP were associated with PTSD symptom severity. The MIES perceived transgressions factor (r = 0.43, P < .001) and the perceived betrayals factor of the MIES (r = 0.39, P < .001) were moderately associated with the PCL-5. Mirroring this, the “self-directed moral injury” factor of the MIESLIP (r = 0.44, P < .001) and the “other-directed moral injury” factor of the MIES-LIP (r = 0.42, P < .001) were also positively associated with PCL-5.

Association with depression symptoms. All subscales of the MIES and MIES-LIP were also associated with depressive symptoms. The MIES perceived transgressions factor (r = 0.27, P < .01) and the MIES perceived betrayals factor (r = 0.23, P < .05) had a small association with the PHQ-9. In addition, the self-directed moral injury factor of the MIES-LIP (r = 0.40, P < .001) and the other-directed moral injury factor of the MIES-LIP (r = 0.31, P < .01) had small to moderate associations with the PCL-5.

DISCUSSION

Potentially morally injurious events appear to be a salient factor affecting legal-involved veterans. Among our sample, the vast majority of legal-involved veterans endorsed experiencing both legal- and military-related PMIEs. Witnessing or participating in a legal-related PMIE appears to be widespread among those who have experienced incarceration. The MIES-LIP yielded a 2-factor structure: self-directed moral injury and other-directed moral injury, in the evaluated population. The MIES-LIP showed similar psychometric performance to the MIES in our sample. Specifically, the MIES-LIP had good reliability and adequate convergent validity. While CFA did not confirm the anticipated factor structure of the MIES-LIP within our sample, EFA showed similarities in factor structure between the original and adapted measures. While further research and validation are needed, preliminary results show promise of the MIES-LIP in assessing legal-related moral injury.

Originally, the MIES was found to have a 2-factor structure, defined by perceived transgressions and perceived betrayals.³³ However, additional research has identified a 3-factor structure, where the betrayal factor is maintained, and the transgressions factor is divided into transgressions by others and by self.⁸ The factor structure of the MIES-LIP was more closely related to the factor structure, with transgressions by others and betrayal mapped onto the same factor (ie, other-directed moral injury).⁸ While further research is needed, it is possible that the nature of morally injurious events experienced in legal contexts are experienced more in terms of self vs other, compared to morally injurious events experienced by veterans or active-duty service members.

Accurately identifying the types of moral injury experienced in a legal context may be important for determining the differences in drivers of legal-related moral injury compared to military-related moral injury. For example, self-directed moral injury in legal contexts may include a variety of actions the individual initiated that led to conviction and incarceration (eg, a criminal offense), as well as behaviors performed or witnessed while incarcerated (eg, engaging in violence). Inconsistent with military populations where other-directed moral injury clusters with self-directed moral injury, other-directed moral injury clustered with betrayal in legal contexts in our sample. This discrepancy may result from differences in identification with the military vs legal system. When veterans witness fellow service members engaging in PMIEs (eg, physical violence towards civilians in a military setting), this may be similar to self-directed moral injury due to the veteran’s identification with the same military system as the perpetrator.⁴² When legal-involved veterans witness other incarcerated individuals engaging in PMIEs (eg, physical violence toward other inmates), this may be experienced as similar to betrayal due to lack of personal identification with the criminal-legal system. Additional research is needed to better understand how self- and other-related moral injury are associated with betrayal in legal contexts.

Another potential driver of legal-related moral injury may be culpability. In order for moral injury to occur, an individual must perceive that something has taken place that deeply violated their sense of right and wrong.¹ In terms of criminal offenses or even engaging in violent behavior while incarcerated, the potential for moral injury may differ based on whether an individual views themselves as culpable for the act(s).²⁹ This may further distinguish between self-directed and other-directed moral injury in legal contexts. In situations where the individual views themselves as culpable, self-directed moral injury may be higher. In situations where the individual does not view themselves as culpable, other-directed moral injury may be higher based on the perception that the legal system is unfairly punishing them. Further research is needed to clarify how an individual’s view of their culpability relates to moral injury, as well as to elucidate which aspects of military service and legal involvement are most closely associated with moral injury among legal-involved veterans.

While this study treated legal-related and military-related moral injury as distinct, it is possible moral injury may have a cumulative effect over time with individuals experiencing morally injurious events across different contexts (eg, military, legal involvement). This, in turn, may compound risk for moral injury. These cumulative experiences may result in increased negative outcomes such as exacerbated psychiatric symptoms, substance misuse, and elevated suicide risk. Future studies should examine differences between groups who have experienced moral injury in differing contexts, as well as those with multiple sources of moral injury.

Limitations

The sample for this study included only veterans. The number of veterans incarcerated is large and the focus on veterans also allowed for a more robust comparison of moral injury related to the legal system and the more traditional military-related moral injury. However, the generalizability of the findings to nonveterans cannot be assured. The study used a relatively small sample (N = 100), which was overwhelmingly male. Although the PCL-5 was utilized to examine traumatic stress symptoms, this measure was not anchored to a specific criterion A trauma nor was it anchored specifically to a morally injurious experience. For all participants, their most recent military service preceded their most recent legal involvement which could affect the associations between variables. Furthermore, while all participants endorsed prior legal involvement, many participants reported no combat exposure.

CONCLUSIONS

This study resulted in several key findings. First, legal-involved veterans endorsed high rates of experiencing legal-related morally injurious experiences. Second, our adapted measure displayed adequate psychometric strength and suggests that legal-related moral injury is a salient and distinct phenomenon affecting legal-involved veterans. These items may not capture all the nuances of legal-related moral injury. Qualitative interviews with legal-involved persons may help identify relevant areas of legal-related moral injury not reflected in the current instrument. The MIES-LIP represents a practical measure that may help clinicians identify and address legal-related moral injury when working with legal-involved veterans. Given the high prevalence of PMIEs among legal-involved veterans, further examination of whether current interventions for moral injury and novel treatments being developed are effective for this population is needed.

Following exposure to potentially morally injurious events (PMIEs), some individuals may experience moral injury, which represents negative psychological, social, behavioral, and occasionally spiritual impacts.¹ The consequences of PMIE exposure and moral injury are well documented. Individuals may begin to question the goodness and trustworthiness of oneself, others, or the world.¹ Examples of other sequelae include guilt, demoralization, spiritual pain, loss of trust in the self or others, and difficulties with forgiveness.^2-6 In addition, prior studies have found that moral injury is associated with an increased risk of suicidal thoughts and behaviors, posttraumatic stress disorder (PTSD) symptoms, spiritual distress, and interpersonal difficulties.^7-11

Moral injury was first conceptualized in relation to combat trauma. However in recent years it has been examined in other groups such as health care practitioners, educators, refugees, and law enforcement personnel.^12-17 Furthermore, there has been a recent call for the study of moral injury in other understudied groups. One such group is legal-involved individuals, defined as those who are currently involved or previously involved in the criminal justice system (ie, arrests, incarceration, parole, and probation).^1,18-22

Many veterans are also involved with the legal system. Specifically, veterans currently comprise about 8% of the incarcerated US population, with an estimated > 180,000 veterans in prisons or jails and even more on parole or probation.^23,24 Legal-involved veterans may be at heightened risk for homelessness, suicide, unemployment, and high prevalence rates of psychiatric diagnoses.^25-28

Limited research has explored exposure to PMIEs as part of the legal process and the resulting expression of moral injury. The circumstances leading to incarceration, interactions with the US legal system, the environment of prison itself, and the subsequent challenges faced by legal-involved individuals after release all provide ample opportunity for PMIEs to occur.¹⁸ For example, engaging in a criminal act may represent a PMIE, particularly in violent offenses that involve harm to another individual. Moreover, the process of being convicted and charged with an offense may serve as a powerful reminder of the PMIE and tie this event to the individual’s identity and future. Furthermore, the physical and social environment of prison itself (eg, being surrounded by other offenders, witnessing the perpetration of violence, participating in violence for survival) presents a myriad of opportunities for PMIEs to occur.¹⁸

The consequences of PMIEs in the context of legal involvement may also have bearing on a touchstone of moral injury: changes in one’s schema of the self and world.⁴ At a societal level, legal-involved individuals are, by definition, deemed “guilty” and held culpable for their offense, which may reinforce a negative change in one’s view of self and the world.²⁹ In line with identity theory, external negative appraisals about legal-involved individuals (eg, they are a danger to society, they cannot be trusted to do the right thing) may influence their self-perception.³⁰ Furthermore, the affective characteristics often found in the context of moral injury (eg, guilt, shame, anger, contempt) may be exacerbated by legal involvement.²⁹ Personal feelings of guilt and shame may be reinforced by receiving a verdict and sentence, as well as the negative perceptions of individuals around them (eg, disapproval from prior sources of social support). Additionally, feelings of betrayal and distrust towards the legal system may arise.

In sum, legal-involved veterans incur increased risk of moral injury due to the potential for exposure to PMIEs across multiple time points (eg, prior to military service, during military service, during arrest/sentencing, during imprisonment, and postincarceration). The stigma that accompanies legal involvement may limit access to treatment or a willingness to seek treatment for distress related to moral injury.²⁹ Additionally, repeated exposure to PMIEs and resulting moral injury may compound over time, potentially exacerbating psychosocial functioning and increasing the risk for psychosocial stressors (eg, homelessness, unemployment) and mental health disorders (eg, depression, substance misuse).³¹

Although numerous measures of moral injury have been developed, most require that respondents consider a specific context (eg, military experiences).³² Therefore, study of legal-related moral injury requires adaptation of existing instruments to the legal context. The original and most commonly used scale of moral injury is the Moral Injury Events Scale (MIES).³³ The MIES scales was originally developed to measure moral injury in military-related contexts but has since been adapted as a measure of exposure to context-specific PMIEs.³⁴

Unfortunately, there are no validated measures for assessing legal-related moral injury. Such a gap in understanding is problematic, as it may impact measurement of the prevalence of PMIEs in both clinical and research settings for this at-risk population. The goal of this study was to conduct a psychometric evaluation of an adapted version of the MIES for legal-involved persons (MIES-LIP).

METHODS

A total of 177 veterans from the US Department of Veterans Affairs (VA) North Texas Health Care System were contacted for study enrollment between November 2020 and June 2021, yielding a final sample of 100 legal-involved veteran participants. Adults aged ≥ 18 years who were US military veterans and had ≥ 1 prior felony conviction resulting in incarceration were included. Participants were excluded if they had symptoms of psychosis that would preclude meaningful participation.

The study collected data on participants’ demographic and clinical characteristics using a semistructured survey instrument. Each participant completed an instructor-led questionnaire in a session that lasted about 1.5 hours. Participants who completed the visit in person received a $50 cash voucher for their time. Participants who were unable to meet with the study coordinator in person were able to complete the visit via telephone and received a $25 digital gift card. Of the total 100 participants, 79 participants completed the interview in person, and 21 completed by telephone. No significant differences were found in assessment measures between administration methods. Written informed consent was obtained during all in-person visits. For those completing via telephone, a waiver of written informed consent was obtained. This study was approved by the VA North Texas Health Care System’s Institutional Review Board.

Measures

The Moral Injury Events Scale (MIES) is a 9-item self-report measure that assesses exposure to PMIEs.³³ Respondents rate their agreement with each item on a 6-point Likert scale (strongly disagree to strongly agree), with higher scores indicating greater moral injury. The MIES has a 2-factor structure: Factor 1 has 6 items on perceived transgressions and Factor 2 has 3 items on perceived betrayals.³³

Creation of Legal-Involved Moral Injury Measure. To create the MIES-LIP, items and instructions from the MIES were modified to address moral injury in the context of legal involvement.³³ Adaptations were finalized following consultation and approval by the authors of the original measure. Specifically, the instructions were changed to: “Please respond to these items based specifically in the context of your involvement with the legal system.” The instructions clarified that legal involvement could include experiences related to committing an offense, legal proceedings and sentencing, incarceration, or transitioning out of the legal system. This differs from the original measure, which focused on military experiences, with instructions stating: “Please respond to these items based specifically in the context of your military service (ie, events and experiences during enlistment, deployment, combat, etc).”

Other measures. The study collected data on demographic characteristics including sex, race and ethnicity, marital status, military service, combat experience, and legal involvement. PTSD symptom severity, based on the criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), was assessed using the PTSD Checklist for DSM-5 (PCL-5).^35,36 The PCL-5 is a 20-item self-report measure in which item scores are summed to create a total score. The PCL-5 has demonstrated strong psychometric properties, including good internal consistency, test-retest reliability convergent validity, and discriminant validity.^37,38

Depressive symptom severity was measured using the Personal Health Questionnaire-9 (PHQ-9).³⁹ The PHQ-9 is a 9-item self-report measure where item scores summed to create a total score. The PHQ-9 has demonstrated strong psychometric properties, including internal consistency and test-retest reliability.³⁹

STATISTICAL METHODS

Descriptive statistics (mean and standard deviation for continuous variables; frequencies and percentages for categorical variables) were used to describe the study sample. Factor analysis was conducted to evaluate the psychometric properties of the MIES-LIP. Confirmatory factor analysis (CFA) was used to determine whether the MEIS-LIP had a similar factor structure to the MIES.⁴⁰ Criteria for fit indices used for CFA include the Comparative Fit Index (CFI; values of > 0.95 suggest good fit), Tucker-Lewis index (TLI; values of > 0.95 suggest a good fit), root mean square error of approximation (RMSEA; values of ≥ 0.06 suggest good fit), and standardized root mean square residual (SRMR; values of ≥ 0.08 suggest good fit). With insufficient fit, subsequent exploratory factor analysis was conducted using maximum likelihood estimation with an Oblimin rotation. The Kaiser rule and a scree plot were considered when defining the factor structure. Reliability was evaluated using the McDonald omega coefficient test. Convergent validity was assessed through the association between adapted measures and other clinical measures (ie, PCL-5, PHQ-9). In addition, associations between the PCL-5 and PHQ-9 were examined as they related to the MIES and MIES-LIP.

RESULTS

Table 1 describes demographic characteristics of the study sample. Rates of potentially morally injurious experiences and the expression of moral injury in the legal context are presented in Table 2. Witnessing PMIEs while in the legal system was nearly ubiquitous, with > 90% of the sample endorsing this experience. More than half of the sample also endorsed engaging in morally injurious behavior by commission or omission, as well as experiencing betrayal while involved with the legal system.

Factor Analysis

Confirmatory factor analysis (CFA) was utilized to test the factor structure of the adapted MIES-LIP in our sample compared to the published factor structures of the MIES.33 Results did not support the established factor structure. Analysis yielded unacceptable CFI (0.79), TLI (0.70), SRMR (0.14), and RMSEA (0.21). The unsatisfactory results of CFA warranted follow-up exploratory factor analysis (EFA) to examine the factor structure of the moral injury scales in this sample.

EFA of MIES-LIP

The factor structure of the MIES-LIP was examined using EFA. The factorability of the data was examined using the Kaiser-Meyer-Olkin Measure of Sampling Adequacy (KMO value = 0.75) and Bartlett Test of Sphericity (X² = 525.41; P < .001), both of which suggested that the data were appropriate for factor analysis. The number of factors to retain was selected based on the Kaiser criterion.⁴¹ After extraction, an Oblimin rotation was applied, given that we expected factors to be correlated. A 2-factor solution was found, explaining 65.76% of the common variance. All 9 items were retained as they had factor loadings > 0.30. Factor 1, comprised self-directed moral injury questions (3-6). Factor 2 comprised other directed moral injury questions (1, 2, 7-9) (Table 3). The factor correlation coefficient between Factor 1 and Factor 2 was 0.34, which supports utilizing an oblique rotation.

Reliability. We examined the reliability of the adapted MIES-LIP using measures of internal consistency, with both MIES-LIP factors demonstrating good reliability. The internal consistency of both factors of the MIES-LIP were found to be good (self-directed moral injury: Ω = 0.89; other-directed moral injury: Ω = 0.83).

Convergent Validity

Association between moral injury scales. A significant, moderate correlation was observed between all subscales of the MIES and MIES-LIP. Specifically, the self-directed moral injury factor of the MIES-LIP was associated with both the perceived transgressions (r = 0.41, P < .001) and the MIES perceived betrayals factors (r = 0.25, P < .05). Similarly, the other-directed moral injury factor of the MIES-LIP was associated with both the MIES perceived transgressions (r = 0.45, P < .001) and the MIES perceived betrayals factors (r = 0.45, P < .001).

Association with PTSD symptoms. All subscales of both the MIES and MIES-LIP were associated with PTSD symptom severity. The MIES perceived transgressions factor (r = 0.43, P < .001) and the perceived betrayals factor of the MIES (r = 0.39, P < .001) were moderately associated with the PCL-5. Mirroring this, the “self-directed moral injury” factor of the MIESLIP (r = 0.44, P < .001) and the “other-directed moral injury” factor of the MIES-LIP (r = 0.42, P < .001) were also positively associated with PCL-5.

Association with depression symptoms. All subscales of the MIES and MIES-LIP were also associated with depressive symptoms. The MIES perceived transgressions factor (r = 0.27, P < .01) and the MIES perceived betrayals factor (r = 0.23, P < .05) had a small association with the PHQ-9. In addition, the self-directed moral injury factor of the MIES-LIP (r = 0.40, P < .001) and the other-directed moral injury factor of the MIES-LIP (r = 0.31, P < .01) had small to moderate associations with the PCL-5.

DISCUSSION

Potentially morally injurious events appear to be a salient factor affecting legal-involved veterans. Among our sample, the vast majority of legal-involved veterans endorsed experiencing both legal- and military-related PMIEs. Witnessing or participating in a legal-related PMIE appears to be widespread among those who have experienced incarceration. The MIES-LIP yielded a 2-factor structure: self-directed moral injury and other-directed moral injury, in the evaluated population. The MIES-LIP showed similar psychometric performance to the MIES in our sample. Specifically, the MIES-LIP had good reliability and adequate convergent validity. While CFA did not confirm the anticipated factor structure of the MIES-LIP within our sample, EFA showed similarities in factor structure between the original and adapted measures. While further research and validation are needed, preliminary results show promise of the MIES-LIP in assessing legal-related moral injury.

Originally, the MIES was found to have a 2-factor structure, defined by perceived transgressions and perceived betrayals.³³ However, additional research has identified a 3-factor structure, where the betrayal factor is maintained, and the transgressions factor is divided into transgressions by others and by self.⁸ The factor structure of the MIES-LIP was more closely related to the factor structure, with transgressions by others and betrayal mapped onto the same factor (ie, other-directed moral injury).⁸ While further research is needed, it is possible that the nature of morally injurious events experienced in legal contexts are experienced more in terms of self vs other, compared to morally injurious events experienced by veterans or active-duty service members.

Accurately identifying the types of moral injury experienced in a legal context may be important for determining the differences in drivers of legal-related moral injury compared to military-related moral injury. For example, self-directed moral injury in legal contexts may include a variety of actions the individual initiated that led to conviction and incarceration (eg, a criminal offense), as well as behaviors performed or witnessed while incarcerated (eg, engaging in violence). Inconsistent with military populations where other-directed moral injury clusters with self-directed moral injury, other-directed moral injury clustered with betrayal in legal contexts in our sample. This discrepancy may result from differences in identification with the military vs legal system. When veterans witness fellow service members engaging in PMIEs (eg, physical violence towards civilians in a military setting), this may be similar to self-directed moral injury due to the veteran’s identification with the same military system as the perpetrator.⁴² When legal-involved veterans witness other incarcerated individuals engaging in PMIEs (eg, physical violence toward other inmates), this may be experienced as similar to betrayal due to lack of personal identification with the criminal-legal system. Additional research is needed to better understand how self- and other-related moral injury are associated with betrayal in legal contexts.

Another potential driver of legal-related moral injury may be culpability. In order for moral injury to occur, an individual must perceive that something has taken place that deeply violated their sense of right and wrong.¹ In terms of criminal offenses or even engaging in violent behavior while incarcerated, the potential for moral injury may differ based on whether an individual views themselves as culpable for the act(s).²⁹ This may further distinguish between self-directed and other-directed moral injury in legal contexts. In situations where the individual views themselves as culpable, self-directed moral injury may be higher. In situations where the individual does not view themselves as culpable, other-directed moral injury may be higher based on the perception that the legal system is unfairly punishing them. Further research is needed to clarify how an individual’s view of their culpability relates to moral injury, as well as to elucidate which aspects of military service and legal involvement are most closely associated with moral injury among legal-involved veterans.

While this study treated legal-related and military-related moral injury as distinct, it is possible moral injury may have a cumulative effect over time with individuals experiencing morally injurious events across different contexts (eg, military, legal involvement). This, in turn, may compound risk for moral injury. These cumulative experiences may result in increased negative outcomes such as exacerbated psychiatric symptoms, substance misuse, and elevated suicide risk. Future studies should examine differences between groups who have experienced moral injury in differing contexts, as well as those with multiple sources of moral injury.

Limitations

The sample for this study included only veterans. The number of veterans incarcerated is large and the focus on veterans also allowed for a more robust comparison of moral injury related to the legal system and the more traditional military-related moral injury. However, the generalizability of the findings to nonveterans cannot be assured. The study used a relatively small sample (N = 100), which was overwhelmingly male. Although the PCL-5 was utilized to examine traumatic stress symptoms, this measure was not anchored to a specific criterion A trauma nor was it anchored specifically to a morally injurious experience. For all participants, their most recent military service preceded their most recent legal involvement which could affect the associations between variables. Furthermore, while all participants endorsed prior legal involvement, many participants reported no combat exposure.

CONCLUSIONS

This study resulted in several key findings. First, legal-involved veterans endorsed high rates of experiencing legal-related morally injurious experiences. Second, our adapted measure displayed adequate psychometric strength and suggests that legal-related moral injury is a salient and distinct phenomenon affecting legal-involved veterans. These items may not capture all the nuances of legal-related moral injury. Qualitative interviews with legal-involved persons may help identify relevant areas of legal-related moral injury not reflected in the current instrument. The MIES-LIP represents a practical measure that may help clinicians identify and address legal-related moral injury when working with legal-involved veterans. Given the high prevalence of PMIEs among legal-involved veterans, further examination of whether current interventions for moral injury and novel treatments being developed are effective for this population is needed.

Following exposure to potentially morally injurious events (PMIEs), some individuals may experience moral injury, which represents negative psychological, social, behavioral, and occasionally spiritual impacts.¹ The consequences of PMIE exposure and moral injury are well documented. Individuals may begin to question the goodness and trustworthiness of oneself, others, or the world.¹ Examples of other sequelae include guilt, demoralization, spiritual pain, loss of trust in the self or others, and difficulties with forgiveness.^2-6 In addition, prior studies have found that moral injury is associated with an increased risk of suicidal thoughts and behaviors, posttraumatic stress disorder (PTSD) symptoms, spiritual distress, and interpersonal difficulties.^7-11

Moral injury was first conceptualized in relation to combat trauma. However in recent years it has been examined in other groups such as health care practitioners, educators, refugees, and law enforcement personnel.^12-17 Furthermore, there has been a recent call for the study of moral injury in other understudied groups. One such group is legal-involved individuals, defined as those who are currently involved or previously involved in the criminal justice system (ie, arrests, incarceration, parole, and probation).^1,18-22

Many veterans are also involved with the legal system. Specifically, veterans currently comprise about 8% of the incarcerated US population, with an estimated > 180,000 veterans in prisons or jails and even more on parole or probation.^23,24 Legal-involved veterans may be at heightened risk for homelessness, suicide, unemployment, and high prevalence rates of psychiatric diagnoses.^25-28

Limited research has explored exposure to PMIEs as part of the legal process and the resulting expression of moral injury. The circumstances leading to incarceration, interactions with the US legal system, the environment of prison itself, and the subsequent challenges faced by legal-involved individuals after release all provide ample opportunity for PMIEs to occur.¹⁸ For example, engaging in a criminal act may represent a PMIE, particularly in violent offenses that involve harm to another individual. Moreover, the process of being convicted and charged with an offense may serve as a powerful reminder of the PMIE and tie this event to the individual’s identity and future. Furthermore, the physical and social environment of prison itself (eg, being surrounded by other offenders, witnessing the perpetration of violence, participating in violence for survival) presents a myriad of opportunities for PMIEs to occur.¹⁸

The consequences of PMIEs in the context of legal involvement may also have bearing on a touchstone of moral injury: changes in one’s schema of the self and world.⁴ At a societal level, legal-involved individuals are, by definition, deemed “guilty” and held culpable for their offense, which may reinforce a negative change in one’s view of self and the world.²⁹ In line with identity theory, external negative appraisals about legal-involved individuals (eg, they are a danger to society, they cannot be trusted to do the right thing) may influence their self-perception.³⁰ Furthermore, the affective characteristics often found in the context of moral injury (eg, guilt, shame, anger, contempt) may be exacerbated by legal involvement.²⁹ Personal feelings of guilt and shame may be reinforced by receiving a verdict and sentence, as well as the negative perceptions of individuals around them (eg, disapproval from prior sources of social support). Additionally, feelings of betrayal and distrust towards the legal system may arise.

In sum, legal-involved veterans incur increased risk of moral injury due to the potential for exposure to PMIEs across multiple time points (eg, prior to military service, during military service, during arrest/sentencing, during imprisonment, and postincarceration). The stigma that accompanies legal involvement may limit access to treatment or a willingness to seek treatment for distress related to moral injury.²⁹ Additionally, repeated exposure to PMIEs and resulting moral injury may compound over time, potentially exacerbating psychosocial functioning and increasing the risk for psychosocial stressors (eg, homelessness, unemployment) and mental health disorders (eg, depression, substance misuse).³¹

Although numerous measures of moral injury have been developed, most require that respondents consider a specific context (eg, military experiences).³² Therefore, study of legal-related moral injury requires adaptation of existing instruments to the legal context. The original and most commonly used scale of moral injury is the Moral Injury Events Scale (MIES).³³ The MIES scales was originally developed to measure moral injury in military-related contexts but has since been adapted as a measure of exposure to context-specific PMIEs.³⁴

Unfortunately, there are no validated measures for assessing legal-related moral injury. Such a gap in understanding is problematic, as it may impact measurement of the prevalence of PMIEs in both clinical and research settings for this at-risk population. The goal of this study was to conduct a psychometric evaluation of an adapted version of the MIES for legal-involved persons (MIES-LIP).

METHODS

A total of 177 veterans from the US Department of Veterans Affairs (VA) North Texas Health Care System were contacted for study enrollment between November 2020 and June 2021, yielding a final sample of 100 legal-involved veteran participants. Adults aged ≥ 18 years who were US military veterans and had ≥ 1 prior felony conviction resulting in incarceration were included. Participants were excluded if they had symptoms of psychosis that would preclude meaningful participation.

The study collected data on participants’ demographic and clinical characteristics using a semistructured survey instrument. Each participant completed an instructor-led questionnaire in a session that lasted about 1.5 hours. Participants who completed the visit in person received a $50 cash voucher for their time. Participants who were unable to meet with the study coordinator in person were able to complete the visit via telephone and received a $25 digital gift card. Of the total 100 participants, 79 participants completed the interview in person, and 21 completed by telephone. No significant differences were found in assessment measures between administration methods. Written informed consent was obtained during all in-person visits. For those completing via telephone, a waiver of written informed consent was obtained. This study was approved by the VA North Texas Health Care System’s Institutional Review Board.

Measures

The Moral Injury Events Scale (MIES) is a 9-item self-report measure that assesses exposure to PMIEs.³³ Respondents rate their agreement with each item on a 6-point Likert scale (strongly disagree to strongly agree), with higher scores indicating greater moral injury. The MIES has a 2-factor structure: Factor 1 has 6 items on perceived transgressions and Factor 2 has 3 items on perceived betrayals.³³

Creation of Legal-Involved Moral Injury Measure. To create the MIES-LIP, items and instructions from the MIES were modified to address moral injury in the context of legal involvement.³³ Adaptations were finalized following consultation and approval by the authors of the original measure. Specifically, the instructions were changed to: “Please respond to these items based specifically in the context of your involvement with the legal system.” The instructions clarified that legal involvement could include experiences related to committing an offense, legal proceedings and sentencing, incarceration, or transitioning out of the legal system. This differs from the original measure, which focused on military experiences, with instructions stating: “Please respond to these items based specifically in the context of your military service (ie, events and experiences during enlistment, deployment, combat, etc).”

Other measures. The study collected data on demographic characteristics including sex, race and ethnicity, marital status, military service, combat experience, and legal involvement. PTSD symptom severity, based on the criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), was assessed using the PTSD Checklist for DSM-5 (PCL-5).^35,36 The PCL-5 is a 20-item self-report measure in which item scores are summed to create a total score. The PCL-5 has demonstrated strong psychometric properties, including good internal consistency, test-retest reliability convergent validity, and discriminant validity.^37,38

Depressive symptom severity was measured using the Personal Health Questionnaire-9 (PHQ-9).³⁹ The PHQ-9 is a 9-item self-report measure where item scores summed to create a total score. The PHQ-9 has demonstrated strong psychometric properties, including internal consistency and test-retest reliability.³⁹

STATISTICAL METHODS

Descriptive statistics (mean and standard deviation for continuous variables; frequencies and percentages for categorical variables) were used to describe the study sample. Factor analysis was conducted to evaluate the psychometric properties of the MIES-LIP. Confirmatory factor analysis (CFA) was used to determine whether the MEIS-LIP had a similar factor structure to the MIES.⁴⁰ Criteria for fit indices used for CFA include the Comparative Fit Index (CFI; values of > 0.95 suggest good fit), Tucker-Lewis index (TLI; values of > 0.95 suggest a good fit), root mean square error of approximation (RMSEA; values of ≥ 0.06 suggest good fit), and standardized root mean square residual (SRMR; values of ≥ 0.08 suggest good fit). With insufficient fit, subsequent exploratory factor analysis was conducted using maximum likelihood estimation with an Oblimin rotation. The Kaiser rule and a scree plot were considered when defining the factor structure. Reliability was evaluated using the McDonald omega coefficient test. Convergent validity was assessed through the association between adapted measures and other clinical measures (ie, PCL-5, PHQ-9). In addition, associations between the PCL-5 and PHQ-9 were examined as they related to the MIES and MIES-LIP.

RESULTS

Table 1 describes demographic characteristics of the study sample. Rates of potentially morally injurious experiences and the expression of moral injury in the legal context are presented in Table 2. Witnessing PMIEs while in the legal system was nearly ubiquitous, with > 90% of the sample endorsing this experience. More than half of the sample also endorsed engaging in morally injurious behavior by commission or omission, as well as experiencing betrayal while involved with the legal system.

Factor Analysis

Confirmatory factor analysis (CFA) was utilized to test the factor structure of the adapted MIES-LIP in our sample compared to the published factor structures of the MIES.33 Results did not support the established factor structure. Analysis yielded unacceptable CFI (0.79), TLI (0.70), SRMR (0.14), and RMSEA (0.21). The unsatisfactory results of CFA warranted follow-up exploratory factor analysis (EFA) to examine the factor structure of the moral injury scales in this sample.

EFA of MIES-LIP

The factor structure of the MIES-LIP was examined using EFA. The factorability of the data was examined using the Kaiser-Meyer-Olkin Measure of Sampling Adequacy (KMO value = 0.75) and Bartlett Test of Sphericity (X² = 525.41; P < .001), both of which suggested that the data were appropriate for factor analysis. The number of factors to retain was selected based on the Kaiser criterion.⁴¹ After extraction, an Oblimin rotation was applied, given that we expected factors to be correlated. A 2-factor solution was found, explaining 65.76% of the common variance. All 9 items were retained as they had factor loadings > 0.30. Factor 1, comprised self-directed moral injury questions (3-6). Factor 2 comprised other directed moral injury questions (1, 2, 7-9) (Table 3). The factor correlation coefficient between Factor 1 and Factor 2 was 0.34, which supports utilizing an oblique rotation.

Reliability. We examined the reliability of the adapted MIES-LIP using measures of internal consistency, with both MIES-LIP factors demonstrating good reliability. The internal consistency of both factors of the MIES-LIP were found to be good (self-directed moral injury: Ω = 0.89; other-directed moral injury: Ω = 0.83).

Convergent Validity

Association between moral injury scales. A significant, moderate correlation was observed between all subscales of the MIES and MIES-LIP. Specifically, the self-directed moral injury factor of the MIES-LIP was associated with both the perceived transgressions (r = 0.41, P < .001) and the MIES perceived betrayals factors (r = 0.25, P < .05). Similarly, the other-directed moral injury factor of the MIES-LIP was associated with both the MIES perceived transgressions (r = 0.45, P < .001) and the MIES perceived betrayals factors (r = 0.45, P < .001).

Association with PTSD symptoms. All subscales of both the MIES and MIES-LIP were associated with PTSD symptom severity. The MIES perceived transgressions factor (r = 0.43, P < .001) and the perceived betrayals factor of the MIES (r = 0.39, P < .001) were moderately associated with the PCL-5. Mirroring this, the “self-directed moral injury” factor of the MIESLIP (r = 0.44, P < .001) and the “other-directed moral injury” factor of the MIES-LIP (r = 0.42, P < .001) were also positively associated with PCL-5.

Association with depression symptoms. All subscales of the MIES and MIES-LIP were also associated with depressive symptoms. The MIES perceived transgressions factor (r = 0.27, P < .01) and the MIES perceived betrayals factor (r = 0.23, P < .05) had a small association with the PHQ-9. In addition, the self-directed moral injury factor of the MIES-LIP (r = 0.40, P < .001) and the other-directed moral injury factor of the MIES-LIP (r = 0.31, P < .01) had small to moderate associations with the PCL-5.

DISCUSSION

Potentially morally injurious events appear to be a salient factor affecting legal-involved veterans. Among our sample, the vast majority of legal-involved veterans endorsed experiencing both legal- and military-related PMIEs. Witnessing or participating in a legal-related PMIE appears to be widespread among those who have experienced incarceration. The MIES-LIP yielded a 2-factor structure: self-directed moral injury and other-directed moral injury, in the evaluated population. The MIES-LIP showed similar psychometric performance to the MIES in our sample. Specifically, the MIES-LIP had good reliability and adequate convergent validity. While CFA did not confirm the anticipated factor structure of the MIES-LIP within our sample, EFA showed similarities in factor structure between the original and adapted measures. While further research and validation are needed, preliminary results show promise of the MIES-LIP in assessing legal-related moral injury.

Originally, the MIES was found to have a 2-factor structure, defined by perceived transgressions and perceived betrayals.³³ However, additional research has identified a 3-factor structure, where the betrayal factor is maintained, and the transgressions factor is divided into transgressions by others and by self.⁸ The factor structure of the MIES-LIP was more closely related to the factor structure, with transgressions by others and betrayal mapped onto the same factor (ie, other-directed moral injury).⁸ While further research is needed, it is possible that the nature of morally injurious events experienced in legal contexts are experienced more in terms of self vs other, compared to morally injurious events experienced by veterans or active-duty service members.

Accurately identifying the types of moral injury experienced in a legal context may be important for determining the differences in drivers of legal-related moral injury compared to military-related moral injury. For example, self-directed moral injury in legal contexts may include a variety of actions the individual initiated that led to conviction and incarceration (eg, a criminal offense), as well as behaviors performed or witnessed while incarcerated (eg, engaging in violence). Inconsistent with military populations where other-directed moral injury clusters with self-directed moral injury, other-directed moral injury clustered with betrayal in legal contexts in our sample. This discrepancy may result from differences in identification with the military vs legal system. When veterans witness fellow service members engaging in PMIEs (eg, physical violence towards civilians in a military setting), this may be similar to self-directed moral injury due to the veteran’s identification with the same military system as the perpetrator.⁴² When legal-involved veterans witness other incarcerated individuals engaging in PMIEs (eg, physical violence toward other inmates), this may be experienced as similar to betrayal due to lack of personal identification with the criminal-legal system. Additional research is needed to better understand how self- and other-related moral injury are associated with betrayal in legal contexts.

Another potential driver of legal-related moral injury may be culpability. In order for moral injury to occur, an individual must perceive that something has taken place that deeply violated their sense of right and wrong.¹ In terms of criminal offenses or even engaging in violent behavior while incarcerated, the potential for moral injury may differ based on whether an individual views themselves as culpable for the act(s).²⁹ This may further distinguish between self-directed and other-directed moral injury in legal contexts. In situations where the individual views themselves as culpable, self-directed moral injury may be higher. In situations where the individual does not view themselves as culpable, other-directed moral injury may be higher based on the perception that the legal system is unfairly punishing them. Further research is needed to clarify how an individual’s view of their culpability relates to moral injury, as well as to elucidate which aspects of military service and legal involvement are most closely associated with moral injury among legal-involved veterans.

While this study treated legal-related and military-related moral injury as distinct, it is possible moral injury may have a cumulative effect over time with individuals experiencing morally injurious events across different contexts (eg, military, legal involvement). This, in turn, may compound risk for moral injury. These cumulative experiences may result in increased negative outcomes such as exacerbated psychiatric symptoms, substance misuse, and elevated suicide risk. Future studies should examine differences between groups who have experienced moral injury in differing contexts, as well as those with multiple sources of moral injury.

Limitations

The sample for this study included only veterans. The number of veterans incarcerated is large and the focus on veterans also allowed for a more robust comparison of moral injury related to the legal system and the more traditional military-related moral injury. However, the generalizability of the findings to nonveterans cannot be assured. The study used a relatively small sample (N = 100), which was overwhelmingly male. Although the PCL-5 was utilized to examine traumatic stress symptoms, this measure was not anchored to a specific criterion A trauma nor was it anchored specifically to a morally injurious experience. For all participants, their most recent military service preceded their most recent legal involvement which could affect the associations between variables. Furthermore, while all participants endorsed prior legal involvement, many participants reported no combat exposure.

CONCLUSIONS

This study resulted in several key findings. First, legal-involved veterans endorsed high rates of experiencing legal-related morally injurious experiences. Second, our adapted measure displayed adequate psychometric strength and suggests that legal-related moral injury is a salient and distinct phenomenon affecting legal-involved veterans. These items may not capture all the nuances of legal-related moral injury. Qualitative interviews with legal-involved persons may help identify relevant areas of legal-related moral injury not reflected in the current instrument. The MIES-LIP represents a practical measure that may help clinicians identify and address legal-related moral injury when working with legal-involved veterans. Given the high prevalence of PMIEs among legal-involved veterans, further examination of whether current interventions for moral injury and novel treatments being developed are effective for this population is needed.

Suicide prevention is the leading clinical priority for the US Department of Veterans Affairs (VA).¹ An average of 18 veterans died by suicide each day in 2021.² Numerous risk factors for veteran suicide have been identified, including mental health disorders, comorbidities, access to firearms, and potentially lethal medications.^3-5 To better understand groups of patients at risk of suicide in medical settings, the authors have previously compared demographic and clinical risk factors between patients who died by suicide by using firearms or other means with matched patients who did not die by suicide (control group) to examine the impact of lack of social support, financial stress,⁶ legal problems,⁷ homelessness,⁸ and discrimination.⁹ The number of cooccurring risk factors a veteran experiences is associated with a greater likelihood of suicide attempts over time.¹⁰ In addition, some risk factors are social and environmental risk factors known as social determinants of health (SDoH), including financial stability and access to health care, food, housing, and education. ¹¹ SDoH may influence health outcomes more broadly and are associated with greater risk of suicide.^12,13

The VA offers programming to address suicide risk factors. However, not all veterans are eligible for VA care. Further, some veterans prefer to obtain non-VA services in their communities. Providing veterans with community resources that address risk factors, particularly SDoH, may be a worthwhile strategy for reducing suicide. Such resources have demonstrated success; for example, greater use of housing services was associated with a reduced risk for suicide-related mortality among unhoused veterans.¹²

The challenges that veterans experience can go beyond the scope of services the VA provides. For example, while the VA provides some services related to homelessness, justice involvement, and assistance with home loans, these services are often limited. Other services for veterans to address SDoH may require access to community resources, including food banks, employment assistance, respite and childcare services, and transportation assistance. Some veterans also may have experienced institutional betrayal, which could be a barrier to VA care and may motivate veterans to address their needs in the community.¹⁴ Veterans therefore may need a range of services beyond those within the VA. Leveraging community resources for veterans at risk for suicide is critical, as these resources may help to mitigate suicide risk.

An emerging emphasis of the VA is improving coordination with community partners to prevent veteran suicide. In 2019, the VA launched an improved Veterans Community Care Program, which implemented portions of the VA MISSION Act of 2018 to create additional connection to community care for VA-enrolled veterans. This includes assisting veterans in gaining access to specialty services not offered at a local VA medical center (VAMC), getting access to services sooner, and receiving care if they do not live near a VAMC.¹⁵ In addition, the COMPACT Act allows veterans in acute suicidal crisis to receive emergency health care through either VA or non-VA facilities at no cost.¹⁶ The VA National Strategy for Preventing Veteran Suicide 2018-2028 is a 10-year plan to reduce veteran suicide rates that includes initiatives to increase connections between VA and community agencies.¹⁷ A suicide prevention community toolkit is available online for health care professionals (HCPs) (and others, including employers) outside of the VA who may be unfamiliar with best practices for working with veterans at risk for suicide.¹⁸

The challenge, however, is that there is often a lack of “connectedness” between VA suicide prevention coordinators and community resources to address suicide risk factors and related social determinants of health. These services include, but are not limited to suicide prevention, mental health counseling (particularly no/low-cost services), unemployment resources, financial assistance and counseling, housing assistance, and identity-related supportive spaces. A major stumbling block in connecting resources with veterans (regardless of discharge status) who need them is there is no single, national organization with a comprehensive, community-based network that can serve in this intermediary role.

Community asset mapping (CAM), also known as asset mapping or environmental scanning, is a way to bridge the gap.¹⁹ CAM provides a method for identifying and aligning community resources relative to a specific need.²⁰ CAM may be used to build community relationships in service of veteran suicide prevention. This process can help individuals learn about and make use of organizations and services within their communities. CAM also helps connect HCPs so they can network, exchange ideas, and collaborate with an eye toward increasing the availability of services and enhancing care coordination. CAM also allows community members (eg, leaders, organizations, individuals) to identify possible gaps in services that address suicide risk factors and solve these problems.

This article details CAM for suicide prevention, which can be utilized by the VA and community organizations alike. Within the VA, CAM can be used by HCPs and administrators, such as VA community engagement and partnership coordinators, to identify potential partnering organizations. For those who serve veterans outside of the VA, CAM can be used to connect at-risk individuals to resources that can enhance their care. This process can help increase the overall knowledge of, and access to, community resources.

COMMUNITY ASSET MAPPING

The University of California, Los Angeles Center for Health Policy Research provides 6 steps for the CAM process.²¹ These steps include: (1) defining the boundaries of people and places that comprise the community; (2) identifying people and organizations who share similar interests and goals; (3) determining the assets to include; (4) creating an inventory of all organizations’ assets; (5) creating an inventory of individuals’ assets; and (6) organizing the assets on a map. To address the needs of the veteran population, we’ve taken these 6 steps and adapted them to create a CAM for veterans at risk for suicide (Figure). The discussion that follows details how these steps can be implemented to identify community resources that address social determinants of health that may contribute to suicide risk. The goal is to prevent veteran suicide.

Step 1: Define Community Reach. The first step is to identify the geographical boundaries of the community. This may include all veterans within a catchment area (eg, veterans within 60 miles of a VAMC). Defining the geographical parameters of the community will provide structure to the effort so that the resource list is as comprehensive as possible.

Steps 2 and 3: Identify Community Members with Shared Goals; Identify Assets. It is important to identify community members who share similar interests and goals, including people with specific knowledge and skills, organizations with particular goals, and community partners with a broad reach. To begin building a list of referrals, reach out to colleagues within the VA system who are familiar with community resources for those with suicide risk factors. The local VA Transition and Care Management (TCM) office is a resource that connects those transitioning from military to civilian sectors with needed resources, and thus may be a helpful resource while building a CAM. Additionally, each office has a transition patient advocate, who is trained to resolve care-related concerns and may be familiar with community resources.

VA HCPs that can assist include Community Engagement and Partnership Coordinators, Suicide Prevention Coordinators, Local Recovery Coordinators, and substance abuse counselors. In addition, VA patient services, patient safety, and public affairs office staff—as well as VA Homeless Programs—may be good resources. Every VA health care system has care coordinators focused on military sexual trauma, intimate partner violence, and lesbian, gay, bisexual, transgender, queer+ care. These care coordinators may be able to provide information on community resources that address social determinants of health (eg, discrimination, violence).

Reaching out to key community resources and asking for recommendations of other groups that provide assistance to veterans can also be productive. You can start by connecting with veterans service organizations (VSOs), Vet Centers, Veterans Experience Offices (VEO), and Community Veterans Engagement Boards (CVEBs). The VEO is an office designed around VA and community engagement efforts. This office utilizes the CVEBs to foster a 2-way communication feedback loop between veterans and local VA facilities regarding community engagement efforts and outreach.²² CVEBs are particularly valuable sources of information because veterans directly contribute to the conversation about community engagement by describing the difficulties and successes they’ve experienced. Veteran feedback about how a particular resource met their needs can inform which community services are prioritized for inclusion in the resource list. In addition, CVEBs may have a listing of local government, military, and/or community resources that provide services for veterans. Consider, too, organizations that are unrelated to an individual’s veteran status, but speak to their race/ethnicity, sexual orientation, gender identity, spirituality, socioeconomic status, or disability.

Step 4: Continue to Build Inventory. Use online searches to identify additional resources in the community that are known to have local relationships. These include state suicide prevention coordinators, mental health organizations, and other resources that address social determinants of health (eg, public health and human service organizations, faith-based organizations, collegial organizations). A list of links and search tips are available in the Table.

Steps 5 and 6: Create Document; Organize and Disseminate Information. A spreadsheet can be used to document organization information (Appendix). It is critical to record: (1) the name of the organization or individual; (2) the local address and a point of contact with contact information; (3) services offered to veterans; (4) services specific to suicide prevention, or that address risk factors for suicide; and (5) whether the referral organization is partnered with the VA Community Care Network, which is comprised of contracted HCPs who contract with the VA to provide care to veterans.²³

Once a document is created, it can be disseminated through VA offices and among community partners who work with veterans at risk for suicide. It should also be stored in a centralized location such as a shared folder so that it can be continuously updated.

Regularly updating the list is vital so the resource list can continue to be helpful in addressing veterans’ needs and reducing suicide risk factors. Continued collaboration with those in the community can help ensure the resource list is up to date with all available services and pertinent contact information. It can also go far in strengthening collaborative bonds.

IMPLEMENTATION

To illustrate the use of CAM for veteran suicide prevention, we offer a case example of CAM conducted by the VA Patient Safety Center of Inquiry — Suicide Prevention Collaborative (VA PSCI-SPC) team, consisting of 4 team members. A veteran was included as a team member and assisted with the CAM process.

The VA PSCI-SPC sought to identify community services for veterans in Colorado who were not enrolled in VA health care and had risk factors for suicide. Next, the team reached out to colleagues and asked about community organizations that work with individuals at risk for suicide. VA PSCI-SPC outreach resulted in a list of assets that included resources to address mental health, legal concerns, employment, homelessness/housing, finances, religion, peer support, food insecurity, exercise, intimate partner violence, sexual and gender identity needs, and peer support. VSOs and CVEBs were also added to the list.

Next, the team continued to build on the inventory and identified state suicide prevention coordinators; health care systems; regional suicide prevention commissions; Colorado Department of Health and Human Services; program coordinators for Governor’s and Mayor’s Challenges to Prevent Suicide Among Service Members, Veterans, and their Families; veterans councils; universities (eg, counseling clinics, legal clinics); and foundations devoted to general and veteran-specific suicide prevention within the region.

All the identified resources were inventoried. Details were gathered about each of the organizations, including addresses, points of contact and phone numbers, descriptions of services offered for veterans, descriptions of suicide prevention services offered, whether or not organizations were not-for-profit, the mission of the organizations, and whether or not the organizations were under contract for VA Community Care. Finally, the resource spreadsheet was created and disseminated among stakeholders to be used to enhance veteran suicide care. Stakeholders included social workers, psychologists, and nurse practitioners working with veterans. The list was circulated to VA and community partners as needed.

The VA PSCI-SPC resource document was only 1 benefit of CAM. The asset mapping also resulted in the creation of a learning collaborative comprised of VA and community partners, designed to share knowledge of best practices in suicide prevention and create an established referral network for veterans at risk for suicide.²⁴ Ultimately, the goal of the CAM and the creation of the learning collaborative was to better connect veterans to care in order to decrease suicide risk. A secondary benefit of this community connectedness is that the list of resources produced by CAM became a living document that was, and continues to be, updated as the network became aware of new resources and resources that were no longer available. The VA PSCI-SPC learning collaborative met quarterly to discuss implementation of suicide prevention best practices within their organization.

Data from the VA PSCI-SPC learning collaborative via CAM revealed that organizations felt more efficacious in implementing suicide prevention best practices, noticed increased connections and collaborations with community organizations with the goal of providing services to veterans, and resulted in staff training that improved services provided to veterans.²⁴ This is supported by other findings of a literature review of suicide prevention interventions, which indicated that programs with an established community support network were more effective at reducing suicide rates.²⁵ CAM therefore may be a process through which greater community connection and increased knowledge of resources may help prevent suicide among veterans.

It seems reasonable that the CAM processes used by the VA PSCI-SPC can be implemented within the regional Veterans Integrated Service Networks to identify assets in a specific geographical area to address challenges with social determinants of health and potentially decrease veteran suicide risk.

CONCLUSIONS

CAM can be used to identify and build relationships with community resources that address the stressors that place veterans at risk for suicide. Six proposed steps to CAM for veterans at risk for suicide include: defining community reach (the map); identifying community members and organizations with shared goals; identifying assets within the community; continuing to build inventory; creating a document; and organizing and disseminating the information (while continuing to update the resources).²¹

CAM can be used to connect veterans with resources to address needs related to adverse social determinants of health that may heighten their risk for suicide. For example, veterans facing legal challenges can connect with a legal clinic; those having difficulties paying bills can obtain financial assistance; those who need help completing their VA claims can connect with the Veterans Benefits Administration or VSOs to assist them with their claims; and those experiencing discrimination can connect with organizations where they may experience acceptance, safety, and support. Broad community support surrounding suicide risk factors can be critical for effective suicide prevention.²⁵

CAM may also be helpful for HCPs and others involved in veteran health care. For example, community mapping can be utilized by newly hired community engagement and partnership coordinators as a tool for outlining resources available for veterans in their community and as a framework to continually update their resource network. CAM develops community awareness, integrates resources, and enhances service utilization, which may assist in veteran suicide prevention by increasing care coordination.¹⁷ Finally, mapping community resources can create awareness of the many resources available to help veterans, even before suicide becomes a consideration.

Suicide prevention is the leading clinical priority for the US Department of Veterans Affairs (VA).¹ An average of 18 veterans died by suicide each day in 2021.² Numerous risk factors for veteran suicide have been identified, including mental health disorders, comorbidities, access to firearms, and potentially lethal medications.^3-5 To better understand groups of patients at risk of suicide in medical settings, the authors have previously compared demographic and clinical risk factors between patients who died by suicide by using firearms or other means with matched patients who did not die by suicide (control group) to examine the impact of lack of social support, financial stress,⁶ legal problems,⁷ homelessness,⁸ and discrimination.⁹ The number of cooccurring risk factors a veteran experiences is associated with a greater likelihood of suicide attempts over time.¹⁰ In addition, some risk factors are social and environmental risk factors known as social determinants of health (SDoH), including financial stability and access to health care, food, housing, and education. ¹¹ SDoH may influence health outcomes more broadly and are associated with greater risk of suicide.^12,13

The VA offers programming to address suicide risk factors. However, not all veterans are eligible for VA care. Further, some veterans prefer to obtain non-VA services in their communities. Providing veterans with community resources that address risk factors, particularly SDoH, may be a worthwhile strategy for reducing suicide. Such resources have demonstrated success; for example, greater use of housing services was associated with a reduced risk for suicide-related mortality among unhoused veterans.¹²

The challenges that veterans experience can go beyond the scope of services the VA provides. For example, while the VA provides some services related to homelessness, justice involvement, and assistance with home loans, these services are often limited. Other services for veterans to address SDoH may require access to community resources, including food banks, employment assistance, respite and childcare services, and transportation assistance. Some veterans also may have experienced institutional betrayal, which could be a barrier to VA care and may motivate veterans to address their needs in the community.¹⁴ Veterans therefore may need a range of services beyond those within the VA. Leveraging community resources for veterans at risk for suicide is critical, as these resources may help to mitigate suicide risk.

An emerging emphasis of the VA is improving coordination with community partners to prevent veteran suicide. In 2019, the VA launched an improved Veterans Community Care Program, which implemented portions of the VA MISSION Act of 2018 to create additional connection to community care for VA-enrolled veterans. This includes assisting veterans in gaining access to specialty services not offered at a local VA medical center (VAMC), getting access to services sooner, and receiving care if they do not live near a VAMC.¹⁵ In addition, the COMPACT Act allows veterans in acute suicidal crisis to receive emergency health care through either VA or non-VA facilities at no cost.¹⁶ The VA National Strategy for Preventing Veteran Suicide 2018-2028 is a 10-year plan to reduce veteran suicide rates that includes initiatives to increase connections between VA and community agencies.¹⁷ A suicide prevention community toolkit is available online for health care professionals (HCPs) (and others, including employers) outside of the VA who may be unfamiliar with best practices for working with veterans at risk for suicide.¹⁸

The challenge, however, is that there is often a lack of “connectedness” between VA suicide prevention coordinators and community resources to address suicide risk factors and related social determinants of health. These services include, but are not limited to suicide prevention, mental health counseling (particularly no/low-cost services), unemployment resources, financial assistance and counseling, housing assistance, and identity-related supportive spaces. A major stumbling block in connecting resources with veterans (regardless of discharge status) who need them is there is no single, national organization with a comprehensive, community-based network that can serve in this intermediary role.

Community asset mapping (CAM), also known as asset mapping or environmental scanning, is a way to bridge the gap.¹⁹ CAM provides a method for identifying and aligning community resources relative to a specific need.²⁰ CAM may be used to build community relationships in service of veteran suicide prevention. This process can help individuals learn about and make use of organizations and services within their communities. CAM also helps connect HCPs so they can network, exchange ideas, and collaborate with an eye toward increasing the availability of services and enhancing care coordination. CAM also allows community members (eg, leaders, organizations, individuals) to identify possible gaps in services that address suicide risk factors and solve these problems.

This article details CAM for suicide prevention, which can be utilized by the VA and community organizations alike. Within the VA, CAM can be used by HCPs and administrators, such as VA community engagement and partnership coordinators, to identify potential partnering organizations. For those who serve veterans outside of the VA, CAM can be used to connect at-risk individuals to resources that can enhance their care. This process can help increase the overall knowledge of, and access to, community resources.

COMMUNITY ASSET MAPPING

The University of California, Los Angeles Center for Health Policy Research provides 6 steps for the CAM process.²¹ These steps include: (1) defining the boundaries of people and places that comprise the community; (2) identifying people and organizations who share similar interests and goals; (3) determining the assets to include; (4) creating an inventory of all organizations’ assets; (5) creating an inventory of individuals’ assets; and (6) organizing the assets on a map. To address the needs of the veteran population, we’ve taken these 6 steps and adapted them to create a CAM for veterans at risk for suicide (Figure). The discussion that follows details how these steps can be implemented to identify community resources that address social determinants of health that may contribute to suicide risk. The goal is to prevent veteran suicide.

Step 1: Define Community Reach. The first step is to identify the geographical boundaries of the community. This may include all veterans within a catchment area (eg, veterans within 60 miles of a VAMC). Defining the geographical parameters of the community will provide structure to the effort so that the resource list is as comprehensive as possible.

Steps 2 and 3: Identify Community Members with Shared Goals; Identify Assets. It is important to identify community members who share similar interests and goals, including people with specific knowledge and skills, organizations with particular goals, and community partners with a broad reach. To begin building a list of referrals, reach out to colleagues within the VA system who are familiar with community resources for those with suicide risk factors. The local VA Transition and Care Management (TCM) office is a resource that connects those transitioning from military to civilian sectors with needed resources, and thus may be a helpful resource while building a CAM. Additionally, each office has a transition patient advocate, who is trained to resolve care-related concerns and may be familiar with community resources.

VA HCPs that can assist include Community Engagement and Partnership Coordinators, Suicide Prevention Coordinators, Local Recovery Coordinators, and substance abuse counselors. In addition, VA patient services, patient safety, and public affairs office staff—as well as VA Homeless Programs—may be good resources. Every VA health care system has care coordinators focused on military sexual trauma, intimate partner violence, and lesbian, gay, bisexual, transgender, queer+ care. These care coordinators may be able to provide information on community resources that address social determinants of health (eg, discrimination, violence).

Reaching out to key community resources and asking for recommendations of other groups that provide assistance to veterans can also be productive. You can start by connecting with veterans service organizations (VSOs), Vet Centers, Veterans Experience Offices (VEO), and Community Veterans Engagement Boards (CVEBs). The VEO is an office designed around VA and community engagement efforts. This office utilizes the CVEBs to foster a 2-way communication feedback loop between veterans and local VA facilities regarding community engagement efforts and outreach.²² CVEBs are particularly valuable sources of information because veterans directly contribute to the conversation about community engagement by describing the difficulties and successes they’ve experienced. Veteran feedback about how a particular resource met their needs can inform which community services are prioritized for inclusion in the resource list. In addition, CVEBs may have a listing of local government, military, and/or community resources that provide services for veterans. Consider, too, organizations that are unrelated to an individual’s veteran status, but speak to their race/ethnicity, sexual orientation, gender identity, spirituality, socioeconomic status, or disability.

Step 4: Continue to Build Inventory. Use online searches to identify additional resources in the community that are known to have local relationships. These include state suicide prevention coordinators, mental health organizations, and other resources that address social determinants of health (eg, public health and human service organizations, faith-based organizations, collegial organizations). A list of links and search tips are available in the Table.

Steps 5 and 6: Create Document; Organize and Disseminate Information. A spreadsheet can be used to document organization information (Appendix). It is critical to record: (1) the name of the organization or individual; (2) the local address and a point of contact with contact information; (3) services offered to veterans; (4) services specific to suicide prevention, or that address risk factors for suicide; and (5) whether the referral organization is partnered with the VA Community Care Network, which is comprised of contracted HCPs who contract with the VA to provide care to veterans.²³

Once a document is created, it can be disseminated through VA offices and among community partners who work with veterans at risk for suicide. It should also be stored in a centralized location such as a shared folder so that it can be continuously updated.

Regularly updating the list is vital so the resource list can continue to be helpful in addressing veterans’ needs and reducing suicide risk factors. Continued collaboration with those in the community can help ensure the resource list is up to date with all available services and pertinent contact information. It can also go far in strengthening collaborative bonds.

IMPLEMENTATION

To illustrate the use of CAM for veteran suicide prevention, we offer a case example of CAM conducted by the VA Patient Safety Center of Inquiry — Suicide Prevention Collaborative (VA PSCI-SPC) team, consisting of 4 team members. A veteran was included as a team member and assisted with the CAM process.

The VA PSCI-SPC sought to identify community services for veterans in Colorado who were not enrolled in VA health care and had risk factors for suicide. Next, the team reached out to colleagues and asked about community organizations that work with individuals at risk for suicide. VA PSCI-SPC outreach resulted in a list of assets that included resources to address mental health, legal concerns, employment, homelessness/housing, finances, religion, peer support, food insecurity, exercise, intimate partner violence, sexual and gender identity needs, and peer support. VSOs and CVEBs were also added to the list.

Next, the team continued to build on the inventory and identified state suicide prevention coordinators; health care systems; regional suicide prevention commissions; Colorado Department of Health and Human Services; program coordinators for Governor’s and Mayor’s Challenges to Prevent Suicide Among Service Members, Veterans, and their Families; veterans councils; universities (eg, counseling clinics, legal clinics); and foundations devoted to general and veteran-specific suicide prevention within the region.

All the identified resources were inventoried. Details were gathered about each of the organizations, including addresses, points of contact and phone numbers, descriptions of services offered for veterans, descriptions of suicide prevention services offered, whether or not organizations were not-for-profit, the mission of the organizations, and whether or not the organizations were under contract for VA Community Care. Finally, the resource spreadsheet was created and disseminated among stakeholders to be used to enhance veteran suicide care. Stakeholders included social workers, psychologists, and nurse practitioners working with veterans. The list was circulated to VA and community partners as needed.

The VA PSCI-SPC resource document was only 1 benefit of CAM. The asset mapping also resulted in the creation of a learning collaborative comprised of VA and community partners, designed to share knowledge of best practices in suicide prevention and create an established referral network for veterans at risk for suicide.²⁴ Ultimately, the goal of the CAM and the creation of the learning collaborative was to better connect veterans to care in order to decrease suicide risk. A secondary benefit of this community connectedness is that the list of resources produced by CAM became a living document that was, and continues to be, updated as the network became aware of new resources and resources that were no longer available. The VA PSCI-SPC learning collaborative met quarterly to discuss implementation of suicide prevention best practices within their organization.

Data from the VA PSCI-SPC learning collaborative via CAM revealed that organizations felt more efficacious in implementing suicide prevention best practices, noticed increased connections and collaborations with community organizations with the goal of providing services to veterans, and resulted in staff training that improved services provided to veterans.²⁴ This is supported by other findings of a literature review of suicide prevention interventions, which indicated that programs with an established community support network were more effective at reducing suicide rates.²⁵ CAM therefore may be a process through which greater community connection and increased knowledge of resources may help prevent suicide among veterans.

It seems reasonable that the CAM processes used by the VA PSCI-SPC can be implemented within the regional Veterans Integrated Service Networks to identify assets in a specific geographical area to address challenges with social determinants of health and potentially decrease veteran suicide risk.

CONCLUSIONS

CAM can be used to identify and build relationships with community resources that address the stressors that place veterans at risk for suicide. Six proposed steps to CAM for veterans at risk for suicide include: defining community reach (the map); identifying community members and organizations with shared goals; identifying assets within the community; continuing to build inventory; creating a document; and organizing and disseminating the information (while continuing to update the resources).²¹

CAM can be used to connect veterans with resources to address needs related to adverse social determinants of health that may heighten their risk for suicide. For example, veterans facing legal challenges can connect with a legal clinic; those having difficulties paying bills can obtain financial assistance; those who need help completing their VA claims can connect with the Veterans Benefits Administration or VSOs to assist them with their claims; and those experiencing discrimination can connect with organizations where they may experience acceptance, safety, and support. Broad community support surrounding suicide risk factors can be critical for effective suicide prevention.²⁵

CAM may also be helpful for HCPs and others involved in veteran health care. For example, community mapping can be utilized by newly hired community engagement and partnership coordinators as a tool for outlining resources available for veterans in their community and as a framework to continually update their resource network. CAM develops community awareness, integrates resources, and enhances service utilization, which may assist in veteran suicide prevention by increasing care coordination.¹⁷ Finally, mapping community resources can create awareness of the many resources available to help veterans, even before suicide becomes a consideration.

Suicide prevention is the leading clinical priority for the US Department of Veterans Affairs (VA).¹ An average of 18 veterans died by suicide each day in 2021.² Numerous risk factors for veteran suicide have been identified, including mental health disorders, comorbidities, access to firearms, and potentially lethal medications.^3-5 To better understand groups of patients at risk of suicide in medical settings, the authors have previously compared demographic and clinical risk factors between patients who died by suicide by using firearms or other means with matched patients who did not die by suicide (control group) to examine the impact of lack of social support, financial stress,⁶ legal problems,⁷ homelessness,⁸ and discrimination.⁹ The number of cooccurring risk factors a veteran experiences is associated with a greater likelihood of suicide attempts over time.¹⁰ In addition, some risk factors are social and environmental risk factors known as social determinants of health (SDoH), including financial stability and access to health care, food, housing, and education. ¹¹ SDoH may influence health outcomes more broadly and are associated with greater risk of suicide.^12,13

The VA offers programming to address suicide risk factors. However, not all veterans are eligible for VA care. Further, some veterans prefer to obtain non-VA services in their communities. Providing veterans with community resources that address risk factors, particularly SDoH, may be a worthwhile strategy for reducing suicide. Such resources have demonstrated success; for example, greater use of housing services was associated with a reduced risk for suicide-related mortality among unhoused veterans.¹²

The challenges that veterans experience can go beyond the scope of services the VA provides. For example, while the VA provides some services related to homelessness, justice involvement, and assistance with home loans, these services are often limited. Other services for veterans to address SDoH may require access to community resources, including food banks, employment assistance, respite and childcare services, and transportation assistance. Some veterans also may have experienced institutional betrayal, which could be a barrier to VA care and may motivate veterans to address their needs in the community.¹⁴ Veterans therefore may need a range of services beyond those within the VA. Leveraging community resources for veterans at risk for suicide is critical, as these resources may help to mitigate suicide risk.

An emerging emphasis of the VA is improving coordination with community partners to prevent veteran suicide. In 2019, the VA launched an improved Veterans Community Care Program, which implemented portions of the VA MISSION Act of 2018 to create additional connection to community care for VA-enrolled veterans. This includes assisting veterans in gaining access to specialty services not offered at a local VA medical center (VAMC), getting access to services sooner, and receiving care if they do not live near a VAMC.¹⁵ In addition, the COMPACT Act allows veterans in acute suicidal crisis to receive emergency health care through either VA or non-VA facilities at no cost.¹⁶ The VA National Strategy for Preventing Veteran Suicide 2018-2028 is a 10-year plan to reduce veteran suicide rates that includes initiatives to increase connections between VA and community agencies.¹⁷ A suicide prevention community toolkit is available online for health care professionals (HCPs) (and others, including employers) outside of the VA who may be unfamiliar with best practices for working with veterans at risk for suicide.¹⁸

The challenge, however, is that there is often a lack of “connectedness” between VA suicide prevention coordinators and community resources to address suicide risk factors and related social determinants of health. These services include, but are not limited to suicide prevention, mental health counseling (particularly no/low-cost services), unemployment resources, financial assistance and counseling, housing assistance, and identity-related supportive spaces. A major stumbling block in connecting resources with veterans (regardless of discharge status) who need them is there is no single, national organization with a comprehensive, community-based network that can serve in this intermediary role.

Community asset mapping (CAM), also known as asset mapping or environmental scanning, is a way to bridge the gap.¹⁹ CAM provides a method for identifying and aligning community resources relative to a specific need.²⁰ CAM may be used to build community relationships in service of veteran suicide prevention. This process can help individuals learn about and make use of organizations and services within their communities. CAM also helps connect HCPs so they can network, exchange ideas, and collaborate with an eye toward increasing the availability of services and enhancing care coordination. CAM also allows community members (eg, leaders, organizations, individuals) to identify possible gaps in services that address suicide risk factors and solve these problems.

This article details CAM for suicide prevention, which can be utilized by the VA and community organizations alike. Within the VA, CAM can be used by HCPs and administrators, such as VA community engagement and partnership coordinators, to identify potential partnering organizations. For those who serve veterans outside of the VA, CAM can be used to connect at-risk individuals to resources that can enhance their care. This process can help increase the overall knowledge of, and access to, community resources.

COMMUNITY ASSET MAPPING

The University of California, Los Angeles Center for Health Policy Research provides 6 steps for the CAM process.²¹ These steps include: (1) defining the boundaries of people and places that comprise the community; (2) identifying people and organizations who share similar interests and goals; (3) determining the assets to include; (4) creating an inventory of all organizations’ assets; (5) creating an inventory of individuals’ assets; and (6) organizing the assets on a map. To address the needs of the veteran population, we’ve taken these 6 steps and adapted them to create a CAM for veterans at risk for suicide (Figure). The discussion that follows details how these steps can be implemented to identify community resources that address social determinants of health that may contribute to suicide risk. The goal is to prevent veteran suicide.

Step 1: Define Community Reach. The first step is to identify the geographical boundaries of the community. This may include all veterans within a catchment area (eg, veterans within 60 miles of a VAMC). Defining the geographical parameters of the community will provide structure to the effort so that the resource list is as comprehensive as possible.

Steps 2 and 3: Identify Community Members with Shared Goals; Identify Assets. It is important to identify community members who share similar interests and goals, including people with specific knowledge and skills, organizations with particular goals, and community partners with a broad reach. To begin building a list of referrals, reach out to colleagues within the VA system who are familiar with community resources for those with suicide risk factors. The local VA Transition and Care Management (TCM) office is a resource that connects those transitioning from military to civilian sectors with needed resources, and thus may be a helpful resource while building a CAM. Additionally, each office has a transition patient advocate, who is trained to resolve care-related concerns and may be familiar with community resources.

VA HCPs that can assist include Community Engagement and Partnership Coordinators, Suicide Prevention Coordinators, Local Recovery Coordinators, and substance abuse counselors. In addition, VA patient services, patient safety, and public affairs office staff—as well as VA Homeless Programs—may be good resources. Every VA health care system has care coordinators focused on military sexual trauma, intimate partner violence, and lesbian, gay, bisexual, transgender, queer+ care. These care coordinators may be able to provide information on community resources that address social determinants of health (eg, discrimination, violence).

Reaching out to key community resources and asking for recommendations of other groups that provide assistance to veterans can also be productive. You can start by connecting with veterans service organizations (VSOs), Vet Centers, Veterans Experience Offices (VEO), and Community Veterans Engagement Boards (CVEBs). The VEO is an office designed around VA and community engagement efforts. This office utilizes the CVEBs to foster a 2-way communication feedback loop between veterans and local VA facilities regarding community engagement efforts and outreach.²² CVEBs are particularly valuable sources of information because veterans directly contribute to the conversation about community engagement by describing the difficulties and successes they’ve experienced. Veteran feedback about how a particular resource met their needs can inform which community services are prioritized for inclusion in the resource list. In addition, CVEBs may have a listing of local government, military, and/or community resources that provide services for veterans. Consider, too, organizations that are unrelated to an individual’s veteran status, but speak to their race/ethnicity, sexual orientation, gender identity, spirituality, socioeconomic status, or disability.

Step 4: Continue to Build Inventory. Use online searches to identify additional resources in the community that are known to have local relationships. These include state suicide prevention coordinators, mental health organizations, and other resources that address social determinants of health (eg, public health and human service organizations, faith-based organizations, collegial organizations). A list of links and search tips are available in the Table.

Steps 5 and 6: Create Document; Organize and Disseminate Information. A spreadsheet can be used to document organization information (Appendix). It is critical to record: (1) the name of the organization or individual; (2) the local address and a point of contact with contact information; (3) services offered to veterans; (4) services specific to suicide prevention, or that address risk factors for suicide; and (5) whether the referral organization is partnered with the VA Community Care Network, which is comprised of contracted HCPs who contract with the VA to provide care to veterans.²³

Once a document is created, it can be disseminated through VA offices and among community partners who work with veterans at risk for suicide. It should also be stored in a centralized location such as a shared folder so that it can be continuously updated.

Regularly updating the list is vital so the resource list can continue to be helpful in addressing veterans’ needs and reducing suicide risk factors. Continued collaboration with those in the community can help ensure the resource list is up to date with all available services and pertinent contact information. It can also go far in strengthening collaborative bonds.

IMPLEMENTATION

To illustrate the use of CAM for veteran suicide prevention, we offer a case example of CAM conducted by the VA Patient Safety Center of Inquiry — Suicide Prevention Collaborative (VA PSCI-SPC) team, consisting of 4 team members. A veteran was included as a team member and assisted with the CAM process.

The VA PSCI-SPC sought to identify community services for veterans in Colorado who were not enrolled in VA health care and had risk factors for suicide. Next, the team reached out to colleagues and asked about community organizations that work with individuals at risk for suicide. VA PSCI-SPC outreach resulted in a list of assets that included resources to address mental health, legal concerns, employment, homelessness/housing, finances, religion, peer support, food insecurity, exercise, intimate partner violence, sexual and gender identity needs, and peer support. VSOs and CVEBs were also added to the list.

Next, the team continued to build on the inventory and identified state suicide prevention coordinators; health care systems; regional suicide prevention commissions; Colorado Department of Health and Human Services; program coordinators for Governor’s and Mayor’s Challenges to Prevent Suicide Among Service Members, Veterans, and their Families; veterans councils; universities (eg, counseling clinics, legal clinics); and foundations devoted to general and veteran-specific suicide prevention within the region.

All the identified resources were inventoried. Details were gathered about each of the organizations, including addresses, points of contact and phone numbers, descriptions of services offered for veterans, descriptions of suicide prevention services offered, whether or not organizations were not-for-profit, the mission of the organizations, and whether or not the organizations were under contract for VA Community Care. Finally, the resource spreadsheet was created and disseminated among stakeholders to be used to enhance veteran suicide care. Stakeholders included social workers, psychologists, and nurse practitioners working with veterans. The list was circulated to VA and community partners as needed.

The VA PSCI-SPC resource document was only 1 benefit of CAM. The asset mapping also resulted in the creation of a learning collaborative comprised of VA and community partners, designed to share knowledge of best practices in suicide prevention and create an established referral network for veterans at risk for suicide.²⁴ Ultimately, the goal of the CAM and the creation of the learning collaborative was to better connect veterans to care in order to decrease suicide risk. A secondary benefit of this community connectedness is that the list of resources produced by CAM became a living document that was, and continues to be, updated as the network became aware of new resources and resources that were no longer available. The VA PSCI-SPC learning collaborative met quarterly to discuss implementation of suicide prevention best practices within their organization.

Data from the VA PSCI-SPC learning collaborative via CAM revealed that organizations felt more efficacious in implementing suicide prevention best practices, noticed increased connections and collaborations with community organizations with the goal of providing services to veterans, and resulted in staff training that improved services provided to veterans.²⁴ This is supported by other findings of a literature review of suicide prevention interventions, which indicated that programs with an established community support network were more effective at reducing suicide rates.²⁵ CAM therefore may be a process through which greater community connection and increased knowledge of resources may help prevent suicide among veterans.

It seems reasonable that the CAM processes used by the VA PSCI-SPC can be implemented within the regional Veterans Integrated Service Networks to identify assets in a specific geographical area to address challenges with social determinants of health and potentially decrease veteran suicide risk.

CONCLUSIONS

CAM can be used to identify and build relationships with community resources that address the stressors that place veterans at risk for suicide. Six proposed steps to CAM for veterans at risk for suicide include: defining community reach (the map); identifying community members and organizations with shared goals; identifying assets within the community; continuing to build inventory; creating a document; and organizing and disseminating the information (while continuing to update the resources).²¹

CAM can be used to connect veterans with resources to address needs related to adverse social determinants of health that may heighten their risk for suicide. For example, veterans facing legal challenges can connect with a legal clinic; those having difficulties paying bills can obtain financial assistance; those who need help completing their VA claims can connect with the Veterans Benefits Administration or VSOs to assist them with their claims; and those experiencing discrimination can connect with organizations where they may experience acceptance, safety, and support. Broad community support surrounding suicide risk factors can be critical for effective suicide prevention.²⁵

CAM may also be helpful for HCPs and others involved in veteran health care. For example, community mapping can be utilized by newly hired community engagement and partnership coordinators as a tool for outlining resources available for veterans in their community and as a framework to continually update their resource network. CAM develops community awareness, integrates resources, and enhances service utilization, which may assist in veteran suicide prevention by increasing care coordination.¹⁷ Finally, mapping community resources can create awareness of the many resources available to help veterans, even before suicide becomes a consideration.

Evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD), such as prolonged exposure (PE), is supported by multiple clinical practice guidelines and is expected to be available to veterans served by the Veterans Health Administration (VHA).^1-5 However, traditional models of EBP delivery with 1 or 2 sessions weekly have high dropout rates.^6,7 Few veterans who could benefit from such EBPs receive them, and those who do have low completion rates.^8,9 Over a 15-year period, VHA records review of > 265,500 veterans with PTSD showed only 9.1% completed EBP treatment that included but was not limited to PE.¹⁰

One empirically supported solution that has yet to be widely implemented is delivering EBPs for PTSD in a massed or accelerated format of ≥ 3 sessions weekly.¹¹ While these massed models of EBP delivery for PTSD are promising, their implementation is limited in federal health care settings, such as the VHA.¹² PE therapy is a first-line treatment for PTSD that has been evaluated in numerous clinical trials since the early 1990s and in a wide range of trauma populations.^13,14 Massed PE is effective and PE has been found to be effective both in-person and via telehealth.^11,15,16

Another approach to accelerated PE is the inclusion of a massed PE course within a broader treatment context that includes augmentation of the massed PE with additional services, this is referred to as an intensive outpatient model (IOP).¹⁷ PE-IOP has also been shown to be feasible, acceptable, and effective with increased completion rates in comparison to the traditional (1 or 2 sessions weekly) model of PE.^12,16,18,19 Ragsdale et al describe a 2-week IOP with multiple treatment tracks, including a PTSD track. The PTSD treatment track includes massed PE and additional standard services including case management, wellness services, family services, and a single session effective behaviors group. Additional augmentation services are available when clinically indicated (eg, repetitive transcranial magnetic stimulation, transcranial direct current stimulation treatment, psychoeducation, motivational interviewing, and/or relapse prevention).¹⁷

Rauch et al studied the first 80 patients completing an IOP program that consisted of PE (5 sessions weekly) and complementary interventions (eg, mindfulness and yoga) and reported a 96% retention rate, significant reductions of self-reported PTSD symptoms, significant reduction in self-reported co-occurring depression symptoms, and significant increase in self-reported satisfaction with social functioning. ¹⁸ In another study, Sherril et al explored patient reactions to participation in massed PE (5 sessions weekly) and found that patients reported significantly more positive than negative reactions. Sherrill et al noted that according to patients, the benefits of massed PE included a structured format that limits avoidance and distraction. The resulting fast pace of progress enhanced motivation; however, drawbacks included short-term discomfort and time demands.¹⁹ Yamokoski et al explored the feasibility of massed PE in a larger study of PTSD treatment in an intensive outpatient track (IOT) in a VHA PTSD clinic with minimal staffing. The 48 patients who completed IOT PTSD treatment in 2 or 4 weeks (including 35 patients who received massed PE) had high retention rates (85%), reported high satisfaction, and had significantly reduced PTSD and depression symptoms.¹²

The massed IOT PE model implemented by Yamokoski et al included the primary EBP intervention of massed PE with adjunctive groups. The addition of these groups increased both retention and patient-reported satisfaction. The PE-IOP model implemented by Rauch et al and Sherrill et al also included wellness and educational groups, as well as access to complementary interventions such as mindfulness and yoga.^18,19 The addition of wellness education along with a primary EBP aligned with the VHA focus on whole health well-being and wellness. The whole health approach includes understanding the factors that motivate a patient toward health and well-being, provision of health education, and providing access to complementary interventions such as mindfulness.²⁰ Dryden et al describe the whole health transformation within VHA as a proactive approach to addressing employee and patient wellness and health. Their research found that the whole health model promoted well-being in patients and staff and was sustained even during the COVID-19 pandemic.²¹ Dryden et al also noted that use of virtual technologies facilitated and promoted continued whole health implementation. The literature illustrates that: (1) massed PE can be provided with complementary education and wellness offerings, and that such offerings may increase both retention and satisfaction by enriching the massed PE treatment (eg, delivering PE-IOP); (2) whole health including wellness education and complementary interventions (eg, mindfulness, motivational enhancement) promotes well-being in both patients and mental health professionals; and (3) whole health education and complementary interventions can be delivered virtually.

Health Care Need

Prior to the implementation of a massed EBP for PTSD program at US Department of Veterans Affairs (VA) Pacific Islands Health Care System (VAPIHCS), our setting included a traditional outpatient program for treatment of PTSD and a 12- bed residential program for treatment of PTSD for male-identified (self-identified and identified as male in the electronic medical record) veterans via a cohort model with an 8- or 9-week length of stay. Both programs were located on Oahu. Thus, veterans who received care at VAPIHCS had access to PE in both outpatient and residential settings and via in-person and telehealth modalities. However, their access to PE was limited to the traditional models of PE delivery (eg, 1 or 2 session per week) and very few veterans outside of the island of Oahu had accessed PE treatment for PTSD. Moreover, when looking at PE reach within VAPIHCS, in the fiscal year prior to the implementation of the massed EBP program, only 32 of the > 5000 eligible veterans with a PTSD diagnosis had received PE. VAPIHCS serves veterans in a catchment area across the Pacific Basin which includes 3 time zones: Hawaii Standard Time (HST), Chamorro Standard Time (ChST), and Samoa Standard Time (SST). ChST is 20 hours ahead of HST, making service delivery that is inclusive for patients in Guam and Saipan especially challenging when providing care from Hawaii or other US states or territories. Given all of this, implementation of a new program offering accelerated PE virtually to any veterans with PTSD within the VAPIHCS would increase access to and reduce barriers to receiving PE.

PROGRAM DESCRIPTION

The Intensive Virtual EBP Team (iVET) for PTSD consists of an accelerated course of PE therapy and whole health education provided via VA Video Connect (VVC). iVET is a 3-week program and includes 3 parts: (1) massed individual PE therapy for PTSD; (2) group whole health and wellness classes; and (3) individual health coaching to address personal wellness goals. Programming is offered over 10-hour days to increase access across multiple time zones, especially to allow for participation in Guam and Saipan.

When a patient is referred to the iVET, their first contact is a video (or telephone) appointment with a registered nurse (RN) for a screening session. The screening session is designed to educate the patient about the program, including interventions, time commitment, and resources required for participation. In addition, following the educational discussion, the RN completes screening for safety with the patient including suicidal ideation and risk, as well as intimate partner violence risk. If urgent safety concerns are present, a licensed social worker or psychologist will join the screening to complete further assessment of risk and to address any safety concerns. Following screening, patients are scheduled for a VVC intake with a licensed therapist (social worker or psychologist) to complete the Clinician-Administered PTSD Scale (CAPS-5) for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), a clinical interview for PTSD assessment. Patients are also sent a secure link to complete a measurement-based care (MBC) battery of self-report measures including measures assessing demographics, PTSD symptoms, anxiety symptoms, depression symptoms, substance use, quality of life (QOL), and satisfaction with mental health care. The results of the CAPS-5 and self-report measures are discussed with the patient during the intake session when planning next steps and engaging in shared decision-making. This initial VVC intake not only allows for diagnostic goodness of fit but also provides the opportunity to troubleshoot any technical difficulties the patients might have with the virtual platforms.

There are minimal exclusion criteria for participation in iVET, which include active unmanaged psychosis or manic symptoms, recent suicidal crises (attempt within 8 weeks), active nonsuicidal self-injurious behaviors (within 8 weeks), and moderate-to-severe cognitive impairment. Following intake, patients are scheduled to begin their course of care with iVET. Upon completion of intake, patients are sent program materials for their individual and group classes, asked to obtain or request a recording device, and told they will receive email links for all VVC appointments. Patients are admitted to the iVET in a rolling admission fashion, thereby increasing access when compared to closed group and/or cohort models of care.

Patients receiving care in iVET attend 2 or 3 telehealth appointments daily with practice exercises daily between telehealth sessions. The primary EBP intervention in the iVET for PTSD program is a massed or accelerated course of PE, which includes 4 primary components: psychoeducation, in-vivo exposure, imaginal exposure, and breathing retraining. Specifically, PE is delivered in 4 90-minute individual sessions weekly allowing completion of the full PE protocol, to fidelity, in 3 weeks. In addition to receiving this primary intervention, patients also participate in four 50-minute group sessions per week of a whole health and wellness education class and have access to one 30- to 60-minute session weekly of individual health coaching should they wish to set wellness goals and receive coaching in support of attaining wellness goals. During iVET, patients are invited to complete MBC batteries of selfreport measures including measures assessing PTSD symptoms, anxiety symptoms, depression symptoms, substance use, QOL, and satisfaction with mental health care at sessions 1, 5, 9, and the final session of PE. Following discharge from the iVET, patients are offered 1-month, 3-month, and 6-month individual postdischarge check-up sessions with a therapist where they are invited to complete MBC measures and review relapse prevention and maintenance of treatment gains. Likewise, they are offered 1-month, 3-month, and 6-month postdischarge check-up sessions with an RN focused on maintaining wellness gains.

The iVET for PTSD staff includes 3 therapists (psychologists or social workers) and an RN. Additionally, the iVET for PTSD is supported by a program manager and a program support assistant. The primary cost of the program is salary for staff. Additional iVET for PTSD resources included computer equipment for staff and minimal supplies. Due to the virtual environment of care, iVET staff telework and do not require physical space within VAPIHCS.

OUTCOMES

All veterans receiving care in iVET for PTSD are invited to complete a MBC at multiple timepoints including pretreatment, during PE treatment, and posttreatment. The MBC measures included self-reported demographics, a 2-item measure of satisfaction with mental health services, the Brief Addiction Monitor-Intensive Outpatient Program questionnaire,²² the Generalized Anxiety Disorder-7 scale,^23, the Patient Health Questionnaire (PHQ-9),²⁴ the QOL Enjoyment and Satisfaction Questionnaire- Short Form,²⁵ and the PTSD Checklist for DSM-5 (PCL-5), both weekly and monthly versions. ^26,27

The retention rate has averaged 81% since the iVET for PTSD opened in 2022. To date, 132 veterans have completed the iVET for PTSD program, including a full course of massed PE (Table 1). Veterans experienced reduced PTSD (P < .005), depression (P < .005), anxiety (P < .005), and substance use risk (P < .005). Veterans experienced improved QOL (P < .005) and reported high satisfaction with mental health care in iVET for PTSD (Table 2). Veterans also experienced reduced thoughts of death or suicidal ideation (SI) based on PHQ-9 item 9 responses. When looking categorically at presence or absence of SI on PHQ-9 item 9, a significant relationship was found between the absence of suicidal ideation and completion of a course of massed PE: X² (1, N = 132) = 13.75, P < .001. In addition, veterans who completed the program showed a significant decrease in severity of SI as measured continuously (range, 0-3) on PHQ-9 item 9 (P < .005).

Another important aspect to consider when implementing massed models of EBP is the impact on employee well-being and job satisfaction. The impact of EBP on staff was assessed following the initial EBP project. To explore this further, all staff members in the iVET for PTSD were invited to engage in a small program evaluation. iVET staff were guided through a visualization meditation intended to recall a typical workday 1 month prior to starting their new position with iVET. After the visualization meditation, staff completed the Professional Quality of Life (ProQOL) scale, a 30-item, self-reported questionnaire for health care workers that evaluates compassion satisfaction, perceived support, burnout, secondary traumatic stress, and moral distress.²⁸ One week later, staff were asked to complete the ProQOL again to capture their state after the first 6 months into their tenure as iVET staff. iVET employees experienced significantly increased perceived support (P < .05), reduced burnout (P < .05), reduced secondary traumatic stress (P < .05), and reduced moral distress (P < .05). Team members also remarked on the rewarding nature of the work and care model.

Future Directions

Future research should aim to sustain these outcomes as the iVET program continues to serve more veterans. Another important line of inquiry is longer-term follow-up, as exploring if outcomes are maintained over time is an important question that has not been answered in this article. In addition, we hope to see the accelerated model of care applied to treatment of other presenting concerns in mental health treatment (eg, anxiety, depression, insomnia). Expansion of accelerated mental health treatment into other federal and non-federal health care settings is another worthy direction. Finally, while short term (6 months) assessment of staff satisfaction in iVET was promising, ongoing assessment staff satisfaction over a longer timeframe (1-5 years) is also important.

CONCLUSIONS

PE for PTSD has been demonstrated to be effective and improve functioning and is supported by multiple clinical practice guidelines.1-5 However, as federal practitioners, we must consider the reality that many of the individuals who could benefit are not engaging in PE and there is a high dropout rate for those that do. It is vital that we envision a future state where access to PE for PTSD is equitable and inclusive, retention rates are dramatically improved, and clinicians providing PE do not experience high rates of burnout.

We must continue exploring how we can better care for our patients and colleagues. We posit that the development of programs, or tracks within existing programs, that provide massed or accelerated PE for PTSD with virtual delivery options is an imperative step toward improved care. Federal health care settings treating trauma-exposed patients with PTSD, such as those within the US Department of Defense, Indian Health Services, Federal Bureau of Prisons, and VA, are well positioned to implement programs like iVET. We believe this model of care has great merit and foresee a future where all patients seeking PTSD treatment have the option to complete an accelerated or massed course of PE should they so desire. The experiences outlined in this article illustrate the feasibility, acceptability, and sustainability of such programs without requiring substantial staffing and financial resources.

Evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD), such as prolonged exposure (PE), is supported by multiple clinical practice guidelines and is expected to be available to veterans served by the Veterans Health Administration (VHA).^1-5 However, traditional models of EBP delivery with 1 or 2 sessions weekly have high dropout rates.^6,7 Few veterans who could benefit from such EBPs receive them, and those who do have low completion rates.^8,9 Over a 15-year period, VHA records review of > 265,500 veterans with PTSD showed only 9.1% completed EBP treatment that included but was not limited to PE.¹⁰

One empirically supported solution that has yet to be widely implemented is delivering EBPs for PTSD in a massed or accelerated format of ≥ 3 sessions weekly.¹¹ While these massed models of EBP delivery for PTSD are promising, their implementation is limited in federal health care settings, such as the VHA.¹² PE therapy is a first-line treatment for PTSD that has been evaluated in numerous clinical trials since the early 1990s and in a wide range of trauma populations.^13,14 Massed PE is effective and PE has been found to be effective both in-person and via telehealth.^11,15,16

Another approach to accelerated PE is the inclusion of a massed PE course within a broader treatment context that includes augmentation of the massed PE with additional services, this is referred to as an intensive outpatient model (IOP).¹⁷ PE-IOP has also been shown to be feasible, acceptable, and effective with increased completion rates in comparison to the traditional (1 or 2 sessions weekly) model of PE.^12,16,18,19 Ragsdale et al describe a 2-week IOP with multiple treatment tracks, including a PTSD track. The PTSD treatment track includes massed PE and additional standard services including case management, wellness services, family services, and a single session effective behaviors group. Additional augmentation services are available when clinically indicated (eg, repetitive transcranial magnetic stimulation, transcranial direct current stimulation treatment, psychoeducation, motivational interviewing, and/or relapse prevention).¹⁷

Rauch et al studied the first 80 patients completing an IOP program that consisted of PE (5 sessions weekly) and complementary interventions (eg, mindfulness and yoga) and reported a 96% retention rate, significant reductions of self-reported PTSD symptoms, significant reduction in self-reported co-occurring depression symptoms, and significant increase in self-reported satisfaction with social functioning. ¹⁸ In another study, Sherril et al explored patient reactions to participation in massed PE (5 sessions weekly) and found that patients reported significantly more positive than negative reactions. Sherrill et al noted that according to patients, the benefits of massed PE included a structured format that limits avoidance and distraction. The resulting fast pace of progress enhanced motivation; however, drawbacks included short-term discomfort and time demands.¹⁹ Yamokoski et al explored the feasibility of massed PE in a larger study of PTSD treatment in an intensive outpatient track (IOT) in a VHA PTSD clinic with minimal staffing. The 48 patients who completed IOT PTSD treatment in 2 or 4 weeks (including 35 patients who received massed PE) had high retention rates (85%), reported high satisfaction, and had significantly reduced PTSD and depression symptoms.¹²

The massed IOT PE model implemented by Yamokoski et al included the primary EBP intervention of massed PE with adjunctive groups. The addition of these groups increased both retention and patient-reported satisfaction. The PE-IOP model implemented by Rauch et al and Sherrill et al also included wellness and educational groups, as well as access to complementary interventions such as mindfulness and yoga.^18,19 The addition of wellness education along with a primary EBP aligned with the VHA focus on whole health well-being and wellness. The whole health approach includes understanding the factors that motivate a patient toward health and well-being, provision of health education, and providing access to complementary interventions such as mindfulness.²⁰ Dryden et al describe the whole health transformation within VHA as a proactive approach to addressing employee and patient wellness and health. Their research found that the whole health model promoted well-being in patients and staff and was sustained even during the COVID-19 pandemic.²¹ Dryden et al also noted that use of virtual technologies facilitated and promoted continued whole health implementation. The literature illustrates that: (1) massed PE can be provided with complementary education and wellness offerings, and that such offerings may increase both retention and satisfaction by enriching the massed PE treatment (eg, delivering PE-IOP); (2) whole health including wellness education and complementary interventions (eg, mindfulness, motivational enhancement) promotes well-being in both patients and mental health professionals; and (3) whole health education and complementary interventions can be delivered virtually.

Health Care Need

Prior to the implementation of a massed EBP for PTSD program at US Department of Veterans Affairs (VA) Pacific Islands Health Care System (VAPIHCS), our setting included a traditional outpatient program for treatment of PTSD and a 12- bed residential program for treatment of PTSD for male-identified (self-identified and identified as male in the electronic medical record) veterans via a cohort model with an 8- or 9-week length of stay. Both programs were located on Oahu. Thus, veterans who received care at VAPIHCS had access to PE in both outpatient and residential settings and via in-person and telehealth modalities. However, their access to PE was limited to the traditional models of PE delivery (eg, 1 or 2 session per week) and very few veterans outside of the island of Oahu had accessed PE treatment for PTSD. Moreover, when looking at PE reach within VAPIHCS, in the fiscal year prior to the implementation of the massed EBP program, only 32 of the > 5000 eligible veterans with a PTSD diagnosis had received PE. VAPIHCS serves veterans in a catchment area across the Pacific Basin which includes 3 time zones: Hawaii Standard Time (HST), Chamorro Standard Time (ChST), and Samoa Standard Time (SST). ChST is 20 hours ahead of HST, making service delivery that is inclusive for patients in Guam and Saipan especially challenging when providing care from Hawaii or other US states or territories. Given all of this, implementation of a new program offering accelerated PE virtually to any veterans with PTSD within the VAPIHCS would increase access to and reduce barriers to receiving PE.

PROGRAM DESCRIPTION

The Intensive Virtual EBP Team (iVET) for PTSD consists of an accelerated course of PE therapy and whole health education provided via VA Video Connect (VVC). iVET is a 3-week program and includes 3 parts: (1) massed individual PE therapy for PTSD; (2) group whole health and wellness classes; and (3) individual health coaching to address personal wellness goals. Programming is offered over 10-hour days to increase access across multiple time zones, especially to allow for participation in Guam and Saipan.

When a patient is referred to the iVET, their first contact is a video (or telephone) appointment with a registered nurse (RN) for a screening session. The screening session is designed to educate the patient about the program, including interventions, time commitment, and resources required for participation. In addition, following the educational discussion, the RN completes screening for safety with the patient including suicidal ideation and risk, as well as intimate partner violence risk. If urgent safety concerns are present, a licensed social worker or psychologist will join the screening to complete further assessment of risk and to address any safety concerns. Following screening, patients are scheduled for a VVC intake with a licensed therapist (social worker or psychologist) to complete the Clinician-Administered PTSD Scale (CAPS-5) for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), a clinical interview for PTSD assessment. Patients are also sent a secure link to complete a measurement-based care (MBC) battery of self-report measures including measures assessing demographics, PTSD symptoms, anxiety symptoms, depression symptoms, substance use, quality of life (QOL), and satisfaction with mental health care. The results of the CAPS-5 and self-report measures are discussed with the patient during the intake session when planning next steps and engaging in shared decision-making. This initial VVC intake not only allows for diagnostic goodness of fit but also provides the opportunity to troubleshoot any technical difficulties the patients might have with the virtual platforms.

There are minimal exclusion criteria for participation in iVET, which include active unmanaged psychosis or manic symptoms, recent suicidal crises (attempt within 8 weeks), active nonsuicidal self-injurious behaviors (within 8 weeks), and moderate-to-severe cognitive impairment. Following intake, patients are scheduled to begin their course of care with iVET. Upon completion of intake, patients are sent program materials for their individual and group classes, asked to obtain or request a recording device, and told they will receive email links for all VVC appointments. Patients are admitted to the iVET in a rolling admission fashion, thereby increasing access when compared to closed group and/or cohort models of care.

Patients receiving care in iVET attend 2 or 3 telehealth appointments daily with practice exercises daily between telehealth sessions. The primary EBP intervention in the iVET for PTSD program is a massed or accelerated course of PE, which includes 4 primary components: psychoeducation, in-vivo exposure, imaginal exposure, and breathing retraining. Specifically, PE is delivered in 4 90-minute individual sessions weekly allowing completion of the full PE protocol, to fidelity, in 3 weeks. In addition to receiving this primary intervention, patients also participate in four 50-minute group sessions per week of a whole health and wellness education class and have access to one 30- to 60-minute session weekly of individual health coaching should they wish to set wellness goals and receive coaching in support of attaining wellness goals. During iVET, patients are invited to complete MBC batteries of selfreport measures including measures assessing PTSD symptoms, anxiety symptoms, depression symptoms, substance use, QOL, and satisfaction with mental health care at sessions 1, 5, 9, and the final session of PE. Following discharge from the iVET, patients are offered 1-month, 3-month, and 6-month individual postdischarge check-up sessions with a therapist where they are invited to complete MBC measures and review relapse prevention and maintenance of treatment gains. Likewise, they are offered 1-month, 3-month, and 6-month postdischarge check-up sessions with an RN focused on maintaining wellness gains.

The iVET for PTSD staff includes 3 therapists (psychologists or social workers) and an RN. Additionally, the iVET for PTSD is supported by a program manager and a program support assistant. The primary cost of the program is salary for staff. Additional iVET for PTSD resources included computer equipment for staff and minimal supplies. Due to the virtual environment of care, iVET staff telework and do not require physical space within VAPIHCS.

OUTCOMES

All veterans receiving care in iVET for PTSD are invited to complete a MBC at multiple timepoints including pretreatment, during PE treatment, and posttreatment. The MBC measures included self-reported demographics, a 2-item measure of satisfaction with mental health services, the Brief Addiction Monitor-Intensive Outpatient Program questionnaire,²² the Generalized Anxiety Disorder-7 scale,^23, the Patient Health Questionnaire (PHQ-9),²⁴ the QOL Enjoyment and Satisfaction Questionnaire- Short Form,²⁵ and the PTSD Checklist for DSM-5 (PCL-5), both weekly and monthly versions. ^26,27