Ryan Holliday, PhD

Veterans experiencing homelessness are at an elevated risk for adverse health outcomes, including suicide. This population also experiences chronic health conditions (eg, cardiovascular disease and sexually transmitted infections) and psychiatric conditions (eg, substance use disorders and posttraumatic stress disorder) with a greater propensity than veterans without history of homelessness.^1,2 Similarly, veterans experiencing homelessness often report concurrent stressors, such as justice involvement and unemployment, which further impact social functioning.³

The US Department of Veterans Affairs (VA) offers a range of health and social services to veterans experiencing homelessness. These programs are designed to respond to the multifactorial challenges faced by this population and are aimed at achieving sustained, permanent housing.⁴ To facilitate this effort, these programs provide targeted and tailored health (eg, primary care) and social (eg, case management and vocational rehabilitation) services to address barriers to housing stability (eg, substance use, serious mental illness, interacting with the criminal legal system, and unemployment).

Despite the availability of these programs, engaging veterans in VA services—whether in general or tailored for those experiencing or at risk for homelessness—remains challenging. Many veterans at risk for or experiencing homelessness overuse service settings that provide immediate care, such as urgent care or emergency departments (EDs).^5,6 These individuals often visit an ED to augment or complement medical care they received in an outpatient setting, which can result in an elevated health care burden as well as impacted provision of treatment, especially surrounding care for chronic conditions (eg, cardiovascular health or serious mental illness).^7-9

VA EDs offer urgent care and emergency services and often serve as a point of entry for veterans experiencing homelessness.¹⁰ They offer veterans expedient access to care that can address immediate needs (eg, substance use withdrawal, pain management, and suicide risk). EDs may be easier to access given they have longer hours of operation and patients can present without a scheduled appointment. VA EDs are an important point to identify homelessness and connect individuals to social service resources and outpatient health care referrals (eg, primary care and mental health).^4,11

Some clinicians experience uncertainty in navigating or providing care for veterans experiencing or at risk for homelessness. A qualitative study conducted outside the VA found many clinicians did not know how to approach clinical conversations among unstably housed individuals, particularly when they discussed how to manage care for complex health conditions in the context of ongoing case management challenges, such as discharge planning.12 Another study found that clinicians working with individuals experiencing homelessness may have limited prior training or experience treating these patients.¹³ As a result, these clinicians may be unaware of available social services or unknowingly have biases that negatively impact care. Research remains limited surrounding beliefs about and methods of enhancing care among VA clinicians working with veterans experiencing homelessness in the ED.

This multiphase pilot study sought to understand service delivery processes and gaps in VA ED settings. Phase 1 examined ED clinician perceptions of care, facilitators, and barriers to providing care (including suicide risk assessments) and making postdischarge outpatient referrals among VA ED clinicians who regularly work with veterans experiencing homelessness. Phase 2 used this information to develop a clinical psychoeducational resource to enhance post-ED access to care for veterans experiencing or at risk for homelessness.

QUALITATIVE INTERVIEWS

Semistructured qualitative interviews were conducted with 11 VA ED clinicians from 6 Veteran Integrated Service Networks between August 2022 and February 2023. Clinicians were eligible if they currently worked within a VA ED setting (including urgent care) and indicated that some of their patients were veterans experiencing homelessness. All health care practitioners (HCPs) participated in an interview and a postinterview self-report survey that assessed demographic and job-related characteristics. Eight HCPs identified as female and 3 identified as male. All clinicians identified as White and 3 as Hispanic or Latino. Eight clinicians were licensed clinical social workers, 2 were ED nurses, and 1 was an ED physician.

After each clinician provided informed consent, they were invited to complete a telephone or Microsoft Teams interview. All interviews were recorded and subsequently transcribed. Interviews explored clinicians’ experiences caring for veterans experiencing homelessness, with a focus on services provided within the ED, as well as mandated ED screenings such as a suicide risk assessment. Interview questions also addressed postdischarge knowledge and experiences with referrals to VA health services (eg, primary care, mental health) and social services (eg, housing programs). Interviews lasted 30 to 90 minutes.

Recruitment ended after attaining sufficient thematic data, accomplished via an information power approach to sampling. This occurred when the study aims, sample characteristics, existing theory, and depth and quality of interviews dynamically informed the decision to cease recruitment of additional participants.^14,15 Given the scope of study (examining service delivery and knowledge gaps), the specificity of the targeted sample (VA ED clinicians providing care to veterans experiencing homelessness), the level of pre-existing theoretical background informing the study aims, and depth and quality of interview dialogue, this information power approach provides justification for attaining small sample sizes. Following the interview, HCPs completed a demographic questionnaire. Participants were not compensated.

Data Analysis

Directed content analysis was used to analyze qualitative data, with the framework method employed as an analytic instrument to facilitate analysis.^16-18 Analysts engaged in bracketing and discussed reflexivity before data analysis to reflect on personal subjectivities and reduce potential bias.^19,20

A prototype coding framework was developed that enabled coders to meaningfully summarize and condense data within transcripts into varying domains, categories, or topics found within the interview guide. Domain examples included clinical backgrounds, suicide risk and assessment protocols among veterans experiencing homelessness, beliefs about service delivery for veterans experiencing homelessness, and barriers and facilitators that may impact their ability to provide post-ED discharge care. Coders discussed the findings and if there was a need to modify templates. All transcripts were double coded. Once complete, individual templates were merged into a unified Microsoft Excel sheet, which allowed for more discrete analyses, enabling analysts to examine trends across content areas within the dataset.

Clinical Resource Development

HCPs were queried regarding available outpatient resources for post-ED care (eg, printed discharge paperwork and best practice alerts or automated workflows within the electronic health record). Resources used by participants were examined, as well as which resources clinicians thought would help them care for veterans experiencing homelessness. Noted gaps were used to develop a tailored resource for clinicians who treat veterans experiencing homelessness in the ED. This resource was created with the intention it could inform all ED clinicians, with the option for personalization to align with the needs of local services, based on needed content areas identified (eg, emergency shelters and suicide prevention resources).

Resource development followed an information systems research (ISR) framework that used a 3-pronged process of identifying circumstances for how a tool is developed, the problems it aims to address, and the knowledge that informs its development, implementation, and evaluation.^21,22 Initial wireframes of the resource were provided via email to 10 subject matter experts (SMEs) in veteran suicide prevention, emergency medicine, and homeless programs. SMEs were identified via professional listservs, VA program office leadership, literature searches of similar research, and snowball sampling. Solicited feedback on the resource from the SMEs included its design, language, tone, flow, format, and content (ideation and prototyping). The feedback was collated and used to revise the resource. SMEs then reviewed and provided feedback on the revised resource. This iterative cycle (prototype review, commentary, ideation, prototype review) continued until the SMEs offered no additional edits to the resource. In total, 7 iterations of the resource were developed, critiqued, and revised.

INTERVIEW RESULTS

Compassion Fatigue

Many participants expressed concerns about compassion fatigue among VA ED clinicians. Those interviewed indicated that treating veterans experiencing homelessness sometimes led to the development of what they described as a “callus,” a “sixth sense,” or an inherent sense of “suspicion” or distrust. These feelings resulted from concerns about an individual’s secondary gain or potential hidden agenda (eg, a veteran reporting suicidal ideation to attain shelter on a cold night), with clinicians not wanting to feel as if they were taken advantage of or deceived.

Many clinicians noted that compassion fatigue resulted from witnessing the same veterans experiencing homelessness routinely use emergency services for nonemergent or nonmedical needs. Some also expressed that over time this may result in them becoming less empathetic when caring for veterans experiencing homelessness. They hypothesized that clinicians may experience burnout, which could potentially result in a lack of curiosity and concern about a veteran’s risk for suicide or need for social services. Others may “take things for granted,” leading them to discount stressors that are “very real to the patient, this person.”

Clinicians indicated that such sentiments may impact overall care. Potential negative consequences included stigmatization of veterans experiencing homelessness, incomplete or partial suicide risk screenings with this population, inattentive or impersonal care, and expedited discharge from the ED without appropriate safety planning or social service referrals. Clinicians interviewed intended to find ways to combat compassion fatigue and maintain a commitment to provide comprehensive care to all veterans, including those experiencing homelessness. They felt conflict between a lack of empathy for individuals experiencing homelessness and becoming numb to the problem due to overexposure. However, these clinicians remained committed to providing care to these veterans and fighting to maintain the purpose of recovery-focused care.

Knowledge Gaps on Available Services

While many clinicians knew of general resources available to veterans experiencing homelessness, few had detailed information on where to seek consults for other homeless programs, who to contact regarding these services, when they were available, or how to refer to them. Many reported feeling uneasy when discharging veterans experiencing homelessness from care, often being unable to provide local, comprehensive referrals to support their needs and ensure their well-being. These sentiments were compounded when the veteran reported suicidal thoughts or recent suicidal behavior; clinicians felt concerned about the methods to engage these individuals into evidence-based mental health care within the context of unstable housing arrangements.

Some clinicians appeared to lack awareness of the wide array of VA homeless programming. Most could acknowledge at least some aspects of available programming (eg, the US Department of Housing and Urban Development– VA Supportive Housing program), while others were unaware of services tailored to the needs of those experiencing homelessness (eg, homeless patient aligned care teams), or of services targeting concurrent psychosocial stressors (eg, Veterans Justice Programs). Interviewees hypothesized this as being particularly notable among clinicians who are new to the VA or those who work in VA settings as part of their graduate or medical school training. Those aware of the services were uncertain of the referral process, relying on a single social worker or nurse to connect individuals experiencing homelessness to health and social services.

Interviewed clinicians noted that suicide risk screening of veterans experiencing homelessness was only performed by a limited number of individuals within the ED. Some did not feel sufficiently trained, comfortable, or knowledgeable about how to navigate care for veterans experiencing homelessness and at risk of suicide. Clinicians described “an uncomfortableness about suicidal ideation, where people just freeze up” and “don’t know what to do and don’t know what to say.”

Lack of Tangible Resources, Trainings, and Referrals

HCPs reported occasionally lacking the necessary clinical resources and information in the ED to properly support veterans experiencing homelessness and suicidal ideation. Common concerns included case management and discharge planning, as well as navigating health factors, such as elevated suicide risk. Some HCPs felt the local resources they do have access to—discharge packets or other forms of patient information—were not always tailored for the needs (eg, transportation) or abilities of veterans experiencing homelessness. One noted: “We give them a sheet of paper with some resources, which they don’t have the skills to follow up [with] anyway.”

Many interviewees wished for additional training in working with veterans experiencing homelessness. They reported that prior training from the VA Talent Management System or through unit-based programming could assist in educating clinicians on homeless services and suicide risk assessment. When queried on what training they had received, many noted there was “no formal training on what the VA offers homeless vets,” leading many to describe it as on-the-job training. This appeared especially among newer clinicians, who reported they were reliant upon learning from other, more senior staff within the ED.

The absence of training further illustrates the issue of institutional knowledge on these services and referrals, which was often confined to a single individual or team. Not having readily accessible resources, training, or information appropriate for all skill levels and positions within the ED hindered the ability of HCPs to connect veterans experiencing homelessness with social services to ensure their health and safety postdischarge: “If we had a better knowledge base of what the VA offers and the steps to go through in order to get the veteran set up for those things, it would be helpful.”

CLINICAL RESOURCE

A psychoeducational resource was developed for HCPs treating veterans experiencing homelessness (Figure). The resource was designed to mitigate compassion fatigue and recenter attention on the VA commitment to care while emphasizing the need to be responsive to the concerns of these individuals. Initial wireframes of the resource were developed by a small group of authors in review and appraisal of qualitative findings (EP, RH). These wireframes were developed to broadly illustrate the arrangement/structure of content, range of resources to potentially include (eg, available VA homeless programs or consultation resources), and to draft initial wording and phrasing. Subject matter expert feedback refined these wireframes, providing commentary on specific programs to include or exclude, changes and alterations to the design and flow of the resource, and edits to language, word choice, and tone over numerous iterations.

Given that many ED HCPs presented concerns surrounding secondary gain in the context of suicide risk, this resource focused on suicide risk. At the top of the resource, it states “Veterans at risk for homelessness experience more than double the risk for suicide than stably housed veterans.”²³ Also at the top, the resource states: “For many, the last health care visit prior to suicide is often with VA emergency services."²⁴ The goal of these statements was to educate users on the elevated risk for suicide in veterans experiencing homelessness and their role in preventing such deaths.

Text in this section emphasizes that every veteran deserves the best care possible and recenters HCP attention on providing quality, comprehensive care regardless of housing status. The inclusion of this material was prioritized given the concerns expressed regarding compassion fatigue and suspicions of secondary gain (eg, a veteran reporting suicidal ideation to attain shelter or respite from outside conditions).

The resource also attempts to address high rates of emergency service by veterans experiencing homelessness: “Due to challenges with accessing care, Veterans experiencing homelessness may use emergency or urgent care services more frequently than other Veterans.”²⁵ The resource also indicates that VA resources are available to help homeless and at-risk veterans to acquire stable housing, employment, and engage in healthcare, which are outlined with specific contact information. Given the breadth of local and VA services, a portion of the resource is dedicated to local health and social services available for veterans experiencing homelessness. HCPs complete the first page, which is devoted to local homeless service and program resources.

Following SME consultation, the list of programs provided underwent a series of iterations. The program types listed are deemed to be of greatest benefit to veterans experiencing homelessness and most consulted by HCPs. Including VA and non-VA emergency shelters allows clinicians flexible options if a particular shelter is full, closed, or would not meet the veteran’s needs or preference (eg, lack of childcare or does not allow pets). The second column of this section is left intentionally blank; here, the HCP is to list a local point-of- contact at each program. This encourages clinical teams to seek out and make direct contact with these programs and establish (in)formal relationships with them. The HCP then completes the third column with contact information.

Once completed, the resource acts as a living document. Clinicians and SMEs consulted for this study expressed the desire to have an easily accessible resource that can be updated based on necessary changes (eg, emergency shelter address or hours of operation). The resource can be housed within each local VA emergency or urgent care service setting alongside other available clinical tools.

While local resources are the primary focus, interviewees also suggested that some HCPs are not aware of the available VA services . This material, found on the back of the resource, provides a general overview of services available through VA homeless programs. SME consultation and discussion led to selecting the 5 listed categories: housing services, health care services, case management, employment services, and justice-related programming, each with a brief description.

Information for the National Call Center for Homeless Veterans, community service hotline, and Veterans Crisis Line are included on the front page. These hotlines and phone numbers are always available for veterans experiencing homelessness, enabling them to make these connections themselves, if desired. Additionally, given the challenges noted by some HCPs in performing suicide risk screening, evaluation, and intervention, a prompt for the VA Suicide Risk Management Consultation service was also included on the back page.

Creating a Shared and Local Resource

This clinical resource was developed to establish a centralized, shared, local resource available to VA ED HCPs who lacked knowledge of available services or reported discomfort conducting suicide risk screening for veterans experiencing homelessness. In many cases, ED referrals to homeless programs and suicide prevention care was assigned to a single individual, often a nurse or social worker. As a result, an undue amount of work and strain was placed on these individuals, as this forced them to act as the sole bridge between care in the ED and postdischarge social (eg, homeless programs) and mental health (eg, suicide prevention) services. The creation of a unified, easily accessible document aimed to distribute this responsibility more equitably across ED staff.

DISCUSSION

This project intended to develop a clinician resource to support VA ED clinicians caring for veterans experiencing homelessness and their access to services postdischarge. Qualitative interviews provided insights into the burnout and compassion fatigue present in these settings, as well as the challenges and needs regarding knowledge of local and VA services. Emphasis was placed on leveraging extant resources and subject matter expertise to develop a resource capable of providing brief and informative guidance.

This resource is particularly relevant for HCPs new to the VA, including trainees and new hires, who may be less aware of VA and local social services. It has the potential to reduce the burden on VA ED staff to provide guidance and recommendations surrounding postdischarge social services. The resource acknowledges homeless programming focused on social determinants of health that can destabilize housing (eg, legal or occupational challenges). This can incentivize clinicians to discuss these programs with veterans to facilitate their ability to navigate complex health and psychosocial challenges.

HCPs interviewed for this study indicated their apprehension regarding suicide risk screening and evaluation, a process currently mandated within VA ED settings.²⁶ This may be compounded among HCPs with minimal mental health training or those who have worked in community-based settings where such screening and evaluation efforts are not required. The resource reminds clinicians of available VA consultation services, which can provide additional training, clinical guidance, and review of existing local ED processes.

While the resource was directly informed by qualitative interviews conducted with VA emergency service HCPs and developed through an iterative process with SMEs, further research is necessary to determine its effectiveness at increasing access to health and social services among veterans experiencing homelessness. The resource has not been used by HCPs working in these settings to examine uptake or sustained use, nor clinicians’ perceptions of its utility, including acceptability and feasibility; these are important next steps to understand if the resource is functioning as intended.

Compassion fatigue, as well as associated sequelae (eg, burnout, distress, and psychiatric symptoms), is well-documented among individuals working with individuals experiencing homelessness, including VA HCPs.^27-30 Such experiences are likely driven by several factors, including the clinical complexity and service needs of this veteran population. Although compassion fatigue was noted by many clinicians interviewed for this study, it is unclear if the resource alone would address factors driving compassion fatigue, or if additional programming or services may be necessary.

Limitations

The resource requires local HCPs to routinely update its content (eg, establishment of a new emergency shelter in the community or change in hours or contact information of an existing one), which may be challenging. This is especially true as it relates to community resources, which may be more likely to change than national VA programming.

This resource was initially developed following qualitative interviews with a small sample of VA HCPs (explicitly those working within ED settings) and may not be representative of all HCPs engaged in VA care with veterans experiencing homelessness. The perspectives and experiences of those interviewed do not represent the views of all VA ED HCPs and may differ from the perspectives of those in regions with unique cultural and regional considerations.³¹

Given that most of the interviewees were social workers in EDs engaged in care for veterans experiencing homelessness, these findings and informational needs may differ among other types of HCPs who provide services for veterans experiencing homelessness in other settings. Content in the resource was included based on clinician input, and may not reflect the perspectives of veterans, who may perceive some resources as more important (eg, access to primary care or dental services).²⁸

CONCLUSIONS

This project represents the culmination of qualitative interviews and SME input to develop a free-to-use clinician resource to facilitate service delivery and connection to services following discharge from VA EDs for veterans experiencing homelessness. Serving as a template, this resource can be customized to increase knowledge of local VA and community resources to support these individuals. Continued refinement and piloting of this resource to evaluate acceptability, implementation barriers, and use remains warranted.

References

Holliday R, Kinney AR, Smith AA, et al. A latent class analysis to identify subgroups of VHA using homeless veterans at greater risk for suicide mortality. J Affect Disord. 2022;315:162-167. doi:10.1016/j.jad.2022.07.062
Weber J, Lee RC, Martsolf D. Understanding the health of veterans who are homeless: a review of the literature. Public Health Nurs. 2017;34(5):505-511. doi:10.1111/phn.12338
Holliday R, Desai A, Stimmel M, Liu S, Monteith LL, Stewart KE. Meeting the health and social service needs of veterans who interact with the criminal justice system and experience homelessness: a holistic conceptualization and recommendations for tailoring care. Curr Treat Options Psychiatry. 2022;9(3):174-185. doi:10.1007/s40501-022-00275-1
Holliday R, Desai A, Gerard G, Liu S, Stimmel M. Understanding the intersection of homelessness and justice involvement: enhancing veteran suicide prevention through VA programming. Fed Pract. 2022;39(1):8-11. doi:10.12788/fp.0216
Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR. Emergency department use among the homeless and marginally housed: results from a community-based study. Am J Public Health. 2002;92(5):778-784. doi:10.2105/ajph.92.5.778
Tsai J, Doran KM, Rosenheck RA. When health insurance is not a factor: national comparison of homeless and nonhomeless US veterans who use Veterans Affairs emergency departments. Am J Public Health. 2013;103(Suppl 2):S225-S231. doi:10.2105/AJPH.2013.301307
Doran KM, Raven MC, Rosenheck RA. What drives frequent emergency department use in an integrated health system? National data from the Veterans Health Administration. Ann Emerg Med. 2013;62(2):151-159. doi:10.1016/j.annemergmed.2013.02.016
Tsai J, Rosenheck RA. Risk factors for ED use among homeless veterans. Am J Emerg Med. 2013;31(5):855-858. doi:10.1016/j.ajem.2013.02.046
Nelson RE, Suo Y, Pettey W, et al. Costs associated with health care services accessed through VA and in the community through Medicare for veterans experiencing homelessness. Health Serv Res. 2018;53(Suppl 3):5352-5374. doi:10.1111/1475-6773.13054
Gabrielian S, Yuan AH, Andersen RM, Rubenstein LV, Gelberg L. VA health service utilization for homeless and low-income veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles. Med Care. 2014;52(5):454-461. doi:10.1097/MLR.0000000000000112
Larkin GL, Beautrais AL. Emergency departments are underutilized sites for suicide prevention. Crisis. 2010;31(1):1- 6. doi:10.1027/0227-5910/a000001
Decker H, Raguram M, Kanzaria HK, Duke M, Wick E. Provider perceptions of challenges and facilitators to surgical care in unhoused patients: a qualitative analysis. Surgery. 2024;175(4):1095-1102. doi:10.1016/j.surg.2023.11.009
Panushka KA, Kozlowski Z, Dalessandro C, Sanders JN, Millar MM, Gawron LM. “It’s not a top priority”: a qualitative analysis of provider views on barriers to reproductive healthcare provision for homeless women in the United States. Soc Work Public Health. 2023;38(5 -8):428-436. doi:10.1080/19371918.2024.2315180
Saunders B, Sim J, Kingstone T, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52:1893-1907. doi:10.1007/s11135-017-0574-8
Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26(13):1753-1760. doi:10.1177/1049732315617444
Assarroudi A, Heshmati Nabavi F, Armat MR, Ebadi A, Vaismoradi M. Directed qualitative content analysis: the description and elaboration of its underpinning methods and data analysis process. J Res Nurs. 2018;23(1):42-55. doi:10.1177/1744987117741667
Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-1288.
Goldsmith LJ. Using Framework Analysis in Applied Qualitative Research. Qual Rep. 2021;26(6):2061-2076. doi:10.46743/2160-3715/2021.5011
Tufford L, Newman P. Bracketing in qualitative research. Qual Soc Work. 2012;11(1):80-96.
Dodgson JE. Reflexivity in Qualitative Research. J Hum Lact. 2019;35(2):220-222. doi:10.1177/0890334419830990
Hevner AR. A three cycle view of design science research. Scand J Inf Syst. 2007;19(2):4.
Farao J, Malila B, Conrad N, Mutsvangwa T, Rangaka MX, Douglas TS. A user-centred design frame work for mHealth. PLOS ONE. 2020;15(8):e0237910. doi:10.1371/journal.pone.0237910
Hoffberg AS, Spitzer E, Mackelprang JL, Farro SA, Brenner LA. Suicidal Self-Directed Violence Among Homeless US Veterans: A Systematic Review. Suicide Life Threat Behav. 2018;48(4):481-498. doi:10.1111/sltb.12369
Larkin GL, Beautrais AL. Emergency departments are underutilized sites for suicide prevention. Crisis. 2010;31(1):1- 6. doi:10.1027/0227-5910/a000001
Gabrielian S, Yuan AH, Andersen RM, Rubenstein LV, Gelberg L. VA health service utilization for homeless and lowincome Veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles. Med Care. 2014;52(5):454-461. doi:10.1097/MLR.0000000000000112
Holliday R, Hostetter T, Brenner LA, Bahraini N, Tsai J. Suicide risk screening and evaluation among patients accessing VHA services and identified as being newly homeless. Health Serv Res. 2024;59(5):e14301. doi:10.1111/1475-6773.14301
Waegemakers Schiff J, Lane AM. PTSD symptoms, vicarious traumatization, and burnout in front line workers in the homeless sector. Community Ment Health J. 2019;55(3):454-462. doi:10.1007/s10597-018-00364-7
Steenekamp BL, Barker SL. Exploring the experiences of compassion fatigue amongst peer support workers in homelessness services. Community Ment Health J. 2024;60(4):772-783. doi:10.1007/s10597-024-01234-1
Perez S, Kerman N, Dej E, et al. When I can’t help, I suffer: a scoping review of moral distress in service providers working with persons experiencing homelessness. J Ment Health. Published online 2024:1-16. doi:10.1080/09638237.2024.2426986
Monteith LL, Holliday R, Christe’An DI, Sherrill A, Brenner LA, Hoffmire CA. Suicide risk and prevention in Guam: clinical and research considerations and a call to action. Asian J Psychiatry. 2023;83:103546. doi:10.1016/j.ajp.2023.103546
Surís A, Holliday R, Hooshyar D, et al. Development and implementation of a homeless mobile medical/mental veteran intervention. Fed Pract. 2017;34(9):18.

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0425FED MH Homeless.pdf

Author and Disclosure Information

Evan Polzer, MA^a; Lindsey Monteith, PhD^a,b; Lisa Brenner, PhD^a,b; Nazanin Bahraini, PhD^a,b; Kenneth Bruemmer, LCSW^c; Ronald Calderon, MSW^d; Sonya Gabrielian, MD, MPH^e; Shawn Liu, MSW^c; Bridget Matarazzo, PhD^a,b; Tiara Peterkin, LCSW^a,c; Joseph Simonetti, MD, MPH^a; Matthew Stimmel, PhD^c; Jack Tsai, PhD, MSCP^c,f,g; Ryan Holliday, PhD^a,b

Author affiliations
^aVA Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Aurora, Colorado
^bUniversity of Colorado, Boulder
^cVeterans Health Administration Homeless Programs Office, Washington, DC
^dVeterans Affairs Greater Los Angeles Health Care System, California
^eUniversity of California Los Angeles
^fYale University, New Haven, Connecticut
^gUniversity of Texas Health Science Center, Houston

Author disclosures The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.

Correspondence: Evan Polzer (evan.polzer@va.gov)

Fed Pract. 2025;42(Suppl 1):e0601. Published online July 17. doi:10.12788/fp.0601

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Topics

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Read more about Development of a VA Clinician Resource to Facilitate Care Among Veterans Experiencing Homelessness

Sections

Program Profile

Author(s)

Evan Polzer, MA

Lindsey Monteith, PhD

Lisa Brenner, PhD

Nazanin Bahraini, PhD

Kenneth Bruemmer, LCSW

Ronald Calderon, MSW

Sonya Gabrielian, MD, MPH

Shawn Liu, MSW

Bridget Matarazzo, PhD

Tiara Peterkin, LCSW

Joseph Simonetti, MD, MPH

Author(s)

Lindsey Monteith, PhD

Lisa Brenner, PhD

Nazanin Bahraini, PhD

Kenneth Bruemmer, LCSW

Ronald Calderon, MSW

Sonya Gabrielian, MD, MPH

Shawn Liu, MSW

Bridget Matarazzo, PhD

Tiara Peterkin, LCSW

Joseph Simonetti, MD, MPH

Matthew Stimmel, PhD

Jack Tsai, PhD, MSCP

Ryan Holliday, PhD

Author and Disclosure Information

Author disclosures The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.

Correspondence: Evan Polzer (evan.polzer@va.gov)

Fed Pract. 2025;42(Suppl 1):e0601. Published online July 17. doi:10.12788/fp.0601

Author and Disclosure Information

Author disclosures The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.

Correspondence: Evan Polzer (evan.polzer@va.gov)

Fed Pract. 2025;42(Suppl 1):e0601. Published online July 17. doi:10.12788/fp.0601

Article PDF

0425FED MH Homeless.pdf

Article PDF

0425FED MH Homeless.pdf

QUALITATIVE INTERVIEWS

Data Analysis

Clinical Resource Development

INTERVIEW RESULTS

Compassion Fatigue

Knowledge Gaps on Available Services

Lack of Tangible Resources, Trainings, and Referrals

CLINICAL RESOURCE

Creating a Shared and Local Resource

DISCUSSION

Limitations

CONCLUSIONS

QUALITATIVE INTERVIEWS

Data Analysis

Clinical Resource Development

INTERVIEW RESULTS

Compassion Fatigue

Knowledge Gaps on Available Services

Lack of Tangible Resources, Trainings, and Referrals

CLINICAL RESOURCE

Creating a Shared and Local Resource

DISCUSSION

Limitations

CONCLUSIONS

References

Holliday R, Kinney AR, Smith AA, et al. A latent class analysis to identify subgroups of VHA using homeless veterans at greater risk for suicide mortality. J Affect Disord. 2022;315:162-167. doi:10.1016/j.jad.2022.07.062
Weber J, Lee RC, Martsolf D. Understanding the health of veterans who are homeless: a review of the literature. Public Health Nurs. 2017;34(5):505-511. doi:10.1111/phn.12338
Holliday R, Desai A, Stimmel M, Liu S, Monteith LL, Stewart KE. Meeting the health and social service needs of veterans who interact with the criminal justice system and experience homelessness: a holistic conceptualization and recommendations for tailoring care. Curr Treat Options Psychiatry. 2022;9(3):174-185. doi:10.1007/s40501-022-00275-1
Holliday R, Desai A, Gerard G, Liu S, Stimmel M. Understanding the intersection of homelessness and justice involvement: enhancing veteran suicide prevention through VA programming. Fed Pract. 2022;39(1):8-11. doi:10.12788/fp.0216
Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR. Emergency department use among the homeless and marginally housed: results from a community-based study. Am J Public Health. 2002;92(5):778-784. doi:10.2105/ajph.92.5.778
Tsai J, Doran KM, Rosenheck RA. When health insurance is not a factor: national comparison of homeless and nonhomeless US veterans who use Veterans Affairs emergency departments. Am J Public Health. 2013;103(Suppl 2):S225-S231. doi:10.2105/AJPH.2013.301307
Doran KM, Raven MC, Rosenheck RA. What drives frequent emergency department use in an integrated health system? National data from the Veterans Health Administration. Ann Emerg Med. 2013;62(2):151-159. doi:10.1016/j.annemergmed.2013.02.016
Tsai J, Rosenheck RA. Risk factors for ED use among homeless veterans. Am J Emerg Med. 2013;31(5):855-858. doi:10.1016/j.ajem.2013.02.046
Nelson RE, Suo Y, Pettey W, et al. Costs associated with health care services accessed through VA and in the community through Medicare for veterans experiencing homelessness. Health Serv Res. 2018;53(Suppl 3):5352-5374. doi:10.1111/1475-6773.13054
Gabrielian S, Yuan AH, Andersen RM, Rubenstein LV, Gelberg L. VA health service utilization for homeless and low-income veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles. Med Care. 2014;52(5):454-461. doi:10.1097/MLR.0000000000000112
Larkin GL, Beautrais AL. Emergency departments are underutilized sites for suicide prevention. Crisis. 2010;31(1):1- 6. doi:10.1027/0227-5910/a000001
Decker H, Raguram M, Kanzaria HK, Duke M, Wick E. Provider perceptions of challenges and facilitators to surgical care in unhoused patients: a qualitative analysis. Surgery. 2024;175(4):1095-1102. doi:10.1016/j.surg.2023.11.009
Panushka KA, Kozlowski Z, Dalessandro C, Sanders JN, Millar MM, Gawron LM. “It’s not a top priority”: a qualitative analysis of provider views on barriers to reproductive healthcare provision for homeless women in the United States. Soc Work Public Health. 2023;38(5 -8):428-436. doi:10.1080/19371918.2024.2315180
Saunders B, Sim J, Kingstone T, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52:1893-1907. doi:10.1007/s11135-017-0574-8
Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26(13):1753-1760. doi:10.1177/1049732315617444
Assarroudi A, Heshmati Nabavi F, Armat MR, Ebadi A, Vaismoradi M. Directed qualitative content analysis: the description and elaboration of its underpinning methods and data analysis process. J Res Nurs. 2018;23(1):42-55. doi:10.1177/1744987117741667
Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-1288.
Goldsmith LJ. Using Framework Analysis in Applied Qualitative Research. Qual Rep. 2021;26(6):2061-2076. doi:10.46743/2160-3715/2021.5011
Tufford L, Newman P. Bracketing in qualitative research. Qual Soc Work. 2012;11(1):80-96.
Dodgson JE. Reflexivity in Qualitative Research. J Hum Lact. 2019;35(2):220-222. doi:10.1177/0890334419830990
Hevner AR. A three cycle view of design science research. Scand J Inf Syst. 2007;19(2):4.
Farao J, Malila B, Conrad N, Mutsvangwa T, Rangaka MX, Douglas TS. A user-centred design frame work for mHealth. PLOS ONE. 2020;15(8):e0237910. doi:10.1371/journal.pone.0237910
Hoffberg AS, Spitzer E, Mackelprang JL, Farro SA, Brenner LA. Suicidal Self-Directed Violence Among Homeless US Veterans: A Systematic Review. Suicide Life Threat Behav. 2018;48(4):481-498. doi:10.1111/sltb.12369
Larkin GL, Beautrais AL. Emergency departments are underutilized sites for suicide prevention. Crisis. 2010;31(1):1- 6. doi:10.1027/0227-5910/a000001
Gabrielian S, Yuan AH, Andersen RM, Rubenstein LV, Gelberg L. VA health service utilization for homeless and lowincome Veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles. Med Care. 2014;52(5):454-461. doi:10.1097/MLR.0000000000000112
Holliday R, Hostetter T, Brenner LA, Bahraini N, Tsai J. Suicide risk screening and evaluation among patients accessing VHA services and identified as being newly homeless. Health Serv Res. 2024;59(5):e14301. doi:10.1111/1475-6773.14301
Waegemakers Schiff J, Lane AM. PTSD symptoms, vicarious traumatization, and burnout in front line workers in the homeless sector. Community Ment Health J. 2019;55(3):454-462. doi:10.1007/s10597-018-00364-7
Steenekamp BL, Barker SL. Exploring the experiences of compassion fatigue amongst peer support workers in homelessness services. Community Ment Health J. 2024;60(4):772-783. doi:10.1007/s10597-024-01234-1
Perez S, Kerman N, Dej E, et al. When I can’t help, I suffer: a scoping review of moral distress in service providers working with persons experiencing homelessness. J Ment Health. Published online 2024:1-16. doi:10.1080/09638237.2024.2426986
Monteith LL, Holliday R, Christe’An DI, Sherrill A, Brenner LA, Hoffmire CA. Suicide risk and prevention in Guam: clinical and research considerations and a call to action. Asian J Psychiatry. 2023;83:103546. doi:10.1016/j.ajp.2023.103546
Surís A, Holliday R, Hooshyar D, et al. Development and implementation of a homeless mobile medical/mental veteran intervention. Fed Pract. 2017;34(9):18.

References

Holliday R, Kinney AR, Smith AA, et al. A latent class analysis to identify subgroups of VHA using homeless veterans at greater risk for suicide mortality. J Affect Disord. 2022;315:162-167. doi:10.1016/j.jad.2022.07.062
Weber J, Lee RC, Martsolf D. Understanding the health of veterans who are homeless: a review of the literature. Public Health Nurs. 2017;34(5):505-511. doi:10.1111/phn.12338
Holliday R, Desai A, Stimmel M, Liu S, Monteith LL, Stewart KE. Meeting the health and social service needs of veterans who interact with the criminal justice system and experience homelessness: a holistic conceptualization and recommendations for tailoring care. Curr Treat Options Psychiatry. 2022;9(3):174-185. doi:10.1007/s40501-022-00275-1
Holliday R, Desai A, Gerard G, Liu S, Stimmel M. Understanding the intersection of homelessness and justice involvement: enhancing veteran suicide prevention through VA programming. Fed Pract. 2022;39(1):8-11. doi:10.12788/fp.0216
Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR. Emergency department use among the homeless and marginally housed: results from a community-based study. Am J Public Health. 2002;92(5):778-784. doi:10.2105/ajph.92.5.778
Tsai J, Doran KM, Rosenheck RA. When health insurance is not a factor: national comparison of homeless and nonhomeless US veterans who use Veterans Affairs emergency departments. Am J Public Health. 2013;103(Suppl 2):S225-S231. doi:10.2105/AJPH.2013.301307
Doran KM, Raven MC, Rosenheck RA. What drives frequent emergency department use in an integrated health system? National data from the Veterans Health Administration. Ann Emerg Med. 2013;62(2):151-159. doi:10.1016/j.annemergmed.2013.02.016
Tsai J, Rosenheck RA. Risk factors for ED use among homeless veterans. Am J Emerg Med. 2013;31(5):855-858. doi:10.1016/j.ajem.2013.02.046
Nelson RE, Suo Y, Pettey W, et al. Costs associated with health care services accessed through VA and in the community through Medicare for veterans experiencing homelessness. Health Serv Res. 2018;53(Suppl 3):5352-5374. doi:10.1111/1475-6773.13054
Gabrielian S, Yuan AH, Andersen RM, Rubenstein LV, Gelberg L. VA health service utilization for homeless and low-income veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles. Med Care. 2014;52(5):454-461. doi:10.1097/MLR.0000000000000112
Larkin GL, Beautrais AL. Emergency departments are underutilized sites for suicide prevention. Crisis. 2010;31(1):1- 6. doi:10.1027/0227-5910/a000001
Decker H, Raguram M, Kanzaria HK, Duke M, Wick E. Provider perceptions of challenges and facilitators to surgical care in unhoused patients: a qualitative analysis. Surgery. 2024;175(4):1095-1102. doi:10.1016/j.surg.2023.11.009
Panushka KA, Kozlowski Z, Dalessandro C, Sanders JN, Millar MM, Gawron LM. “It’s not a top priority”: a qualitative analysis of provider views on barriers to reproductive healthcare provision for homeless women in the United States. Soc Work Public Health. 2023;38(5 -8):428-436. doi:10.1080/19371918.2024.2315180
Saunders B, Sim J, Kingstone T, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52:1893-1907. doi:10.1007/s11135-017-0574-8
Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26(13):1753-1760. doi:10.1177/1049732315617444
Assarroudi A, Heshmati Nabavi F, Armat MR, Ebadi A, Vaismoradi M. Directed qualitative content analysis: the description and elaboration of its underpinning methods and data analysis process. J Res Nurs. 2018;23(1):42-55. doi:10.1177/1744987117741667
Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-1288.
Goldsmith LJ. Using Framework Analysis in Applied Qualitative Research. Qual Rep. 2021;26(6):2061-2076. doi:10.46743/2160-3715/2021.5011
Tufford L, Newman P. Bracketing in qualitative research. Qual Soc Work. 2012;11(1):80-96.
Dodgson JE. Reflexivity in Qualitative Research. J Hum Lact. 2019;35(2):220-222. doi:10.1177/0890334419830990
Hevner AR. A three cycle view of design science research. Scand J Inf Syst. 2007;19(2):4.
Farao J, Malila B, Conrad N, Mutsvangwa T, Rangaka MX, Douglas TS. A user-centred design frame work for mHealth. PLOS ONE. 2020;15(8):e0237910. doi:10.1371/journal.pone.0237910
Hoffberg AS, Spitzer E, Mackelprang JL, Farro SA, Brenner LA. Suicidal Self-Directed Violence Among Homeless US Veterans: A Systematic Review. Suicide Life Threat Behav. 2018;48(4):481-498. doi:10.1111/sltb.12369
Larkin GL, Beautrais AL. Emergency departments are underutilized sites for suicide prevention. Crisis. 2010;31(1):1- 6. doi:10.1027/0227-5910/a000001
Gabrielian S, Yuan AH, Andersen RM, Rubenstein LV, Gelberg L. VA health service utilization for homeless and lowincome Veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles. Med Care. 2014;52(5):454-461. doi:10.1097/MLR.0000000000000112
Holliday R, Hostetter T, Brenner LA, Bahraini N, Tsai J. Suicide risk screening and evaluation among patients accessing VHA services and identified as being newly homeless. Health Serv Res. 2024;59(5):e14301. doi:10.1111/1475-6773.14301
Waegemakers Schiff J, Lane AM. PTSD symptoms, vicarious traumatization, and burnout in front line workers in the homeless sector. Community Ment Health J. 2019;55(3):454-462. doi:10.1007/s10597-018-00364-7
Steenekamp BL, Barker SL. Exploring the experiences of compassion fatigue amongst peer support workers in homelessness services. Community Ment Health J. 2024;60(4):772-783. doi:10.1007/s10597-024-01234-1
Perez S, Kerman N, Dej E, et al. When I can’t help, I suffer: a scoping review of moral distress in service providers working with persons experiencing homelessness. J Ment Health. Published online 2024:1-16. doi:10.1080/09638237.2024.2426986
Monteith LL, Holliday R, Christe’An DI, Sherrill A, Brenner LA, Hoffmire CA. Suicide risk and prevention in Guam: clinical and research considerations and a call to action. Asian J Psychiatry. 2023;83:103546. doi:10.1016/j.ajp.2023.103546
Surís A, Holliday R, Hooshyar D, et al. Development and implementation of a homeless mobile medical/mental veteran intervention. Fed Pract. 2017;34(9):18.

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Examining Moral Injury in Legal-Involved Veterans: Psychometric Properties of the Moral Injury Events Scale

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Examining Moral Injury in Legal-Involved Veterans: Psychometric Properties of the Moral Injury Events Scale

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W. Blake Martin, PhD

Nicholas Holder, PhD

Ryan Holliday, PhD

Haekyung Jeon-Slaughter, PhD

James P. LePage, PhD

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.

References

Griffin BJ, Purcell N, Burkman K, et al. Moral injury: an integrative review. J Trauma Stress. 2019;32(3):350-362. doi:10.1002/jts.22362
Currier JM, Holland JM, Malott J. Moral injury, meaning making, and mental health in returning veterans. J Clin Psychol. 2015;71(3):229-240. doi:10.1002/jclp.22134
Jinkerson JD. Defining and assessing moral injury: a syndrome perspective. Traumatology. 2016;22(2):122-130. doi:10.1037/trm0000069
Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695-706. doi:10.1016/j.cpr.2009.07.003
Maguen S, Litz B. Moral injury in veterans of war. PTSD Res Q. 2012;23(1):1-6. www.vva1071.org/uploads/3/4/4/6/34460116/moral_injury_in_veterans_of_war.pdf
Drescher KD, Foy DW, Kelly C, Leshner A, Schutz K, Litz B. An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology. 2011;17(1):8-13. doi:10.1177/1534765610395615
Wisco BE, Marx BP, May CL, et al. Moral injury in U.S. combat veterans: results from the national health and resilience in veterans study. Depress Anxiety. 2017; 34(4):340-347. doi:10.1002/da.22614
Bryan CJ, Bryan AO, Anestis MD, et al. Measuring moral injury: psychometric properties of the moral injury events scale in two military samples. Assessment. 2016;23(5):557- 570. doi:10.1177/1073191115590855
Currier JM, Smith PN, Kuhlman S. Assessing the unique role of religious coping in suicidal behavior among U.S. Iraq and Afghanistan veterans. Psychol Relig Spiritual. 2017;9(1):118-123. doi:10.1037/rel0000055
Kopacz MS, Connery AL, Bishop TM, et al. Moral injury: a new challenge for complementary and alternative medicine. Complement Ther Med. 2016;24:29-33. doi:10.1016/j.ctim.2015.11.003
Vargas AF, Hanson T, Kraus D, Drescher K, Foy D. Moral injury themes in combat veterans’ narrative responses from the national vietnam veterans’ readjustment study. Traumatology. 2013;19(3):243-250. doi:10.1177/1534765613476099
Borges LM, Barnes SM, Farnsworth JK, Bahraini NH, Brenner LA. A commentary on moral injury among health care providers during the COVID-19 pandemic. Psychol Trauma. 2020;12(S1):S138-S140. doi:10.1037/tra0000698
Borges LM, Holliday R, Barnes SM, et al. A longitudinal analysis of the role of potentially morally injurious events on COVID-19-related psychosocial functioning among healthcare providers. PLoS One. 2021;16(11):e0260033. doi:10.1371/journal.pone.0260033
Currier JM, Holland JM, Rojas-Flores L, Herrera S, Foy D. Morally injurious experiences and meaning in Salvadorian teachers exposed to violence. Psychol Trauma. 2015;7(1):24-33. doi:10.1037/a0034092
Nickerson A, Schnyder U, Bryant RA, Schick M, Mueller J, Morina N. Moral injury in traumatized refugees. Psychother Psychosom. 2015;84(2):122-123. doi:10.1159/000369353
Papazoglou K, Chopko B. The role of moral suffering (moral distress and moral injury) in police compassion fatigue and PTSD: An unexplored topic. Front Psychol. 2017;8:1999. doi:10.3389/fpsyg.2017.01999
Papazoglou K, Blumberg DM, Chiongbian VB, et al. The role of moral injury in PTSD among law enforcement officers: a brief report. Front Psychol. 2020;11:310. doi:10.3389/fpsyg.2020.00310
Martin WB, Holliday R, LePage JP. Trauma and diversity: moral injury among justice involved veterans: an understudied clinical concern. Stresspoints. 2020;33(5).
Currier JM, Drescher KD, Nieuwsma J. Future directions for addressing moral injury in clinical practice: concluding comments. In: Currier JM, Drescher KD, Nieuwsma J, eds. Addressing Moral Injury in Clinical Practice. American Psychological Association; 2021:261-271. doi:10.1037/0000204-015
Alexander AR, Mendez L, Kerig PK. Moral injury as a transdiagnostic risk factor for mental health problems in detained youth. Crim Justice Behav. 2023;51(2):194-212. doi:10.1177/00938548231208203
DeCaro JB, Straka K, Malek N, Zalta AK. Sentenced to shame: moral injury exposure in former lifers. Psychol Trauma. 2024; 15(5):722-730. doi:10.1037/tra0001400
Orak U, Kelton K, Vaughn MG, Tsai J, Pietrzak RH. Homelessness and contact with the criminal legal system among U.S. combat veterans: an exploration of potential mediating factors. Crim Justice Behav. 2022;50(3):392-409. doi:10.1177/00938548221140352
Bronson J, Carson EA, Noonan M. Veterans in Prison and Jail, 2011-12. US Department of Justice, Bureau of Justice Statistics; Published December 2015. Accessed March 4, 2025. https://bjs.ojp.gov/content/pub/pdf/vpj1112.pdf
Maruschak LM, Bronson J, Alper M. Veterans in Prison: Survey of Prison Inmates, 2016. US Department of Justice, Bureau of Justice Statistics; March 2021. Accessed March 4, 2025. https://bjs.ojp.gov/redirect-legacy/content/pub/pdf/vpspi16st.pdf
Blodgett JC, Avoundjian T, Finlay AK, et al. Prevalence of mental health disorders among justiceinvolved veterans. Epidemiol Rev. 2015;37:163-176. doi:10.1093/epirev/mxu003
Finlay AK, Owens MD, Taylor E, et al. A scoping review of military veterans involved in the criminal justice system and their health and healthcare. Health Justice. 2019;7(1):6. doi:10.1186/s40352-019-0086-9
Holliday R, Martin WB, Monteith LL, Clark SC, LePage JP. Suicide among justice-involved veterans: a brief overview of extant research, theoretical conceptualization, and recommendations for future research. J Soc Distress Homeless. 2020;30(1):41-49. doi:10.1080/10530789.2019.1711306
Wortzel HS, Binswanger IA, Anderson CA, Adler LE. Suicide among incarcerated veterans. J Am Acad Psychiatry Law. 2009;37(1):82-91.
Desai A, Holliday R, Borges LM, et al. Facilitating successful reentry among justice-involved veterans: the role of veteran and offender identity. J Psychiatr Pract. 2021;27(1):52-60. doi:10.1097/PRA.0000000000000520
Asencio EK, Burke PJ. Does incarceration change the criminal identity? A synthesis of labeling and identity theory perspectives on identity change. Sociol Perspect. 2011;54(2):163-182. doi:10.1525/sop.2011.54.2.163
Borges LM, Desai A, Barnes SM, Johnson JPS. The role of social determinants of health in moral injury: implications and future directions. Curr Treat Options Psychiatry. 2022;9(3):202-214. doi:10.1007/s40501-022-00272-4
Houle SA, Ein N, Gervasio J, et al. Measuring moral distress and moral injury: a systematic review and content analysis of existing scales. Clin Psychol Rev. 2024;108:102377. doi:10.1016/j.cpr.2023.102377
Nash WP, Marino Carper TL, Mills MA, Au T, Goldsmith A, Litz BT. Psychometric evaluation of the moral injury events scale. Mil Med. 2013;178(6):646-652. doi:10.7205/MILMED-D-13-00017
Zerach G, Ben-Yehuda A, Levi-Belz Y. Prospective associations between psychological factors, potentially morally injurious events, and psychiatric symptoms among Israeli combatants: the roles of ethical leadership and ethical preparation. Psychol Trauma. 2023;15(8):1367-1377. doi:10.1037/tra0001466
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association; 2013.
Weathers FW, Litz BT, Keane TM, Palmeri PA, Marx BP. The PTSD Checklist for DSM-5 (PCL-5). National Center for PTSD. Accessed March 4, 2025. www.ptsd.va.gov
Bovin MJ, Marx BP, Weathers FW, et al. Psychometric properties of the PTSD checklist for diagnostic and statistical manual of mental disorders-fifth edition (PCL-5) in veterans. Psychol Assess. 2016;28(11):1379-1391. doi:10.1037/pas0000254
Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The osttraumatic stress disorder checklist for DSM-5 (PCL- 5): development and initial psychometric evaluation. J Trauma Stress. 2015;28(6):489-498. doi:10.1002/jts.22059
Kroenke K, Spi tzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. doi:10.1046/j.1525-1497.2001.016009606.x
Brown TA. Confirmatory Factor Analysis for Applied Research. 2nd ed. Guilford Press; 2015.
Kaiser HF. The application of electronic computers to factor analysis. Educ Psychol Meas. 1960;20(1):141-151. doi:10.1177/001316446002000116
Schorr Y, Stein NR, Maguen S, Barnes JB, Bosch J, Litz BT. Sources of moral injury among war veterans: a qualitative evaluation. J Clin Psychol. 2018;74(12):2203-2218. doi:10.1002/jclp.22660

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0425FED MH Moral HR.pdf

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W. Blake Martin, PhD^a,b; Nicholas Holder, PhD^c,d,e; Ryan Holliday, PhD^f,g,h; Haekyung Jeon-Slaughter, PhD^a,b; James P. LePage, PhD^a,b

Author affiliations
^aVA North Texas Health Care System, Dallas
^bUniversity of Texas Southwestern Medical Center, Dallas
^cSan Francisco Veterans Affairs Health Care System, California
^dUniversity of California San Francisco School of Medicine
^eCenter for Data to Discovery and Delivery Innovation, San Francisco, California
^fVeterans Affairs Pacific Islands Health Care System, Honolulu, Hawaii
^gVeterans Affairs Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Aurora, Colorado
^hUniversity of Colorado Anschutz Medical Campus, Aurora

Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.

Correspondence: James LePage (james.lepage@va.gov)

Fed Pract. 2025;42(suppl 1):e05073. Published online April 15. doi:10.12788/fp.0573

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Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.

Correspondence: James LePage (james.lepage@va.gov)

Fed Pract. 2025;42(suppl 1):e05073. Published online April 15. doi:10.12788/fp.0573

Author and Disclosure Information

W. Blake Martin, PhD^a,b; Nicholas Holder, PhD^c,d,e; Ryan Holliday, PhD^f,g,h; Haekyung Jeon-Slaughter, PhD^a,b; James P. LePage, PhD^a,b

Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.

Correspondence: James LePage (james.lepage@va.gov)

Fed Pract. 2025;42(suppl 1):e05073. Published online April 15. doi:10.12788/fp.0573

Article PDF

0425FED MH Moral HR.pdf

Article PDF

0425FED MH Moral HR.pdf

METHODS

Measures

STATISTICAL METHODS

RESULTS

Factor Analysis

EFA of MIES-LIP

Convergent Validity

DISCUSSION

Limitations

CONCLUSIONS

METHODS

Measures

STATISTICAL METHODS

RESULTS

Factor Analysis

EFA of MIES-LIP

Convergent Validity

DISCUSSION

Limitations

CONCLUSIONS

References

Griffin BJ, Purcell N, Burkman K, et al. Moral injury: an integrative review. J Trauma Stress. 2019;32(3):350-362. doi:10.1002/jts.22362
Currier JM, Holland JM, Malott J. Moral injury, meaning making, and mental health in returning veterans. J Clin Psychol. 2015;71(3):229-240. doi:10.1002/jclp.22134
Jinkerson JD. Defining and assessing moral injury: a syndrome perspective. Traumatology. 2016;22(2):122-130. doi:10.1037/trm0000069
Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695-706. doi:10.1016/j.cpr.2009.07.003
Maguen S, Litz B. Moral injury in veterans of war. PTSD Res Q. 2012;23(1):1-6. www.vva1071.org/uploads/3/4/4/6/34460116/moral_injury_in_veterans_of_war.pdf
Drescher KD, Foy DW, Kelly C, Leshner A, Schutz K, Litz B. An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology. 2011;17(1):8-13. doi:10.1177/1534765610395615
Wisco BE, Marx BP, May CL, et al. Moral injury in U.S. combat veterans: results from the national health and resilience in veterans study. Depress Anxiety. 2017; 34(4):340-347. doi:10.1002/da.22614
Bryan CJ, Bryan AO, Anestis MD, et al. Measuring moral injury: psychometric properties of the moral injury events scale in two military samples. Assessment. 2016;23(5):557- 570. doi:10.1177/1073191115590855
Currier JM, Smith PN, Kuhlman S. Assessing the unique role of religious coping in suicidal behavior among U.S. Iraq and Afghanistan veterans. Psychol Relig Spiritual. 2017;9(1):118-123. doi:10.1037/rel0000055
Kopacz MS, Connery AL, Bishop TM, et al. Moral injury: a new challenge for complementary and alternative medicine. Complement Ther Med. 2016;24:29-33. doi:10.1016/j.ctim.2015.11.003
Vargas AF, Hanson T, Kraus D, Drescher K, Foy D. Moral injury themes in combat veterans’ narrative responses from the national vietnam veterans’ readjustment study. Traumatology. 2013;19(3):243-250. doi:10.1177/1534765613476099
Borges LM, Barnes SM, Farnsworth JK, Bahraini NH, Brenner LA. A commentary on moral injury among health care providers during the COVID-19 pandemic. Psychol Trauma. 2020;12(S1):S138-S140. doi:10.1037/tra0000698
Borges LM, Holliday R, Barnes SM, et al. A longitudinal analysis of the role of potentially morally injurious events on COVID-19-related psychosocial functioning among healthcare providers. PLoS One. 2021;16(11):e0260033. doi:10.1371/journal.pone.0260033
Currier JM, Holland JM, Rojas-Flores L, Herrera S, Foy D. Morally injurious experiences and meaning in Salvadorian teachers exposed to violence. Psychol Trauma. 2015;7(1):24-33. doi:10.1037/a0034092
Nickerson A, Schnyder U, Bryant RA, Schick M, Mueller J, Morina N. Moral injury in traumatized refugees. Psychother Psychosom. 2015;84(2):122-123. doi:10.1159/000369353
Papazoglou K, Chopko B. The role of moral suffering (moral distress and moral injury) in police compassion fatigue and PTSD: An unexplored topic. Front Psychol. 2017;8:1999. doi:10.3389/fpsyg.2017.01999
Papazoglou K, Blumberg DM, Chiongbian VB, et al. The role of moral injury in PTSD among law enforcement officers: a brief report. Front Psychol. 2020;11:310. doi:10.3389/fpsyg.2020.00310
Martin WB, Holliday R, LePage JP. Trauma and diversity: moral injury among justice involved veterans: an understudied clinical concern. Stresspoints. 2020;33(5).
Currier JM, Drescher KD, Nieuwsma J. Future directions for addressing moral injury in clinical practice: concluding comments. In: Currier JM, Drescher KD, Nieuwsma J, eds. Addressing Moral Injury in Clinical Practice. American Psychological Association; 2021:261-271. doi:10.1037/0000204-015
Alexander AR, Mendez L, Kerig PK. Moral injury as a transdiagnostic risk factor for mental health problems in detained youth. Crim Justice Behav. 2023;51(2):194-212. doi:10.1177/00938548231208203
DeCaro JB, Straka K, Malek N, Zalta AK. Sentenced to shame: moral injury exposure in former lifers. Psychol Trauma. 2024; 15(5):722-730. doi:10.1037/tra0001400
Orak U, Kelton K, Vaughn MG, Tsai J, Pietrzak RH. Homelessness and contact with the criminal legal system among U.S. combat veterans: an exploration of potential mediating factors. Crim Justice Behav. 2022;50(3):392-409. doi:10.1177/00938548221140352
Bronson J, Carson EA, Noonan M. Veterans in Prison and Jail, 2011-12. US Department of Justice, Bureau of Justice Statistics; Published December 2015. Accessed March 4, 2025. https://bjs.ojp.gov/content/pub/pdf/vpj1112.pdf
Maruschak LM, Bronson J, Alper M. Veterans in Prison: Survey of Prison Inmates, 2016. US Department of Justice, Bureau of Justice Statistics; March 2021. Accessed March 4, 2025. https://bjs.ojp.gov/redirect-legacy/content/pub/pdf/vpspi16st.pdf
Blodgett JC, Avoundjian T, Finlay AK, et al. Prevalence of mental health disorders among justiceinvolved veterans. Epidemiol Rev. 2015;37:163-176. doi:10.1093/epirev/mxu003
Finlay AK, Owens MD, Taylor E, et al. A scoping review of military veterans involved in the criminal justice system and their health and healthcare. Health Justice. 2019;7(1):6. doi:10.1186/s40352-019-0086-9
Holliday R, Martin WB, Monteith LL, Clark SC, LePage JP. Suicide among justice-involved veterans: a brief overview of extant research, theoretical conceptualization, and recommendations for future research. J Soc Distress Homeless. 2020;30(1):41-49. doi:10.1080/10530789.2019.1711306
Wortzel HS, Binswanger IA, Anderson CA, Adler LE. Suicide among incarcerated veterans. J Am Acad Psychiatry Law. 2009;37(1):82-91.
Desai A, Holliday R, Borges LM, et al. Facilitating successful reentry among justice-involved veterans: the role of veteran and offender identity. J Psychiatr Pract. 2021;27(1):52-60. doi:10.1097/PRA.0000000000000520
Asencio EK, Burke PJ. Does incarceration change the criminal identity? A synthesis of labeling and identity theory perspectives on identity change. Sociol Perspect. 2011;54(2):163-182. doi:10.1525/sop.2011.54.2.163
Borges LM, Desai A, Barnes SM, Johnson JPS. The role of social determinants of health in moral injury: implications and future directions. Curr Treat Options Psychiatry. 2022;9(3):202-214. doi:10.1007/s40501-022-00272-4
Houle SA, Ein N, Gervasio J, et al. Measuring moral distress and moral injury: a systematic review and content analysis of existing scales. Clin Psychol Rev. 2024;108:102377. doi:10.1016/j.cpr.2023.102377
Nash WP, Marino Carper TL, Mills MA, Au T, Goldsmith A, Litz BT. Psychometric evaluation of the moral injury events scale. Mil Med. 2013;178(6):646-652. doi:10.7205/MILMED-D-13-00017
Zerach G, Ben-Yehuda A, Levi-Belz Y. Prospective associations between psychological factors, potentially morally injurious events, and psychiatric symptoms among Israeli combatants: the roles of ethical leadership and ethical preparation. Psychol Trauma. 2023;15(8):1367-1377. doi:10.1037/tra0001466
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association; 2013.
Weathers FW, Litz BT, Keane TM, Palmeri PA, Marx BP. The PTSD Checklist for DSM-5 (PCL-5). National Center for PTSD. Accessed March 4, 2025. www.ptsd.va.gov
Bovin MJ, Marx BP, Weathers FW, et al. Psychometric properties of the PTSD checklist for diagnostic and statistical manual of mental disorders-fifth edition (PCL-5) in veterans. Psychol Assess. 2016;28(11):1379-1391. doi:10.1037/pas0000254
Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The osttraumatic stress disorder checklist for DSM-5 (PCL- 5): development and initial psychometric evaluation. J Trauma Stress. 2015;28(6):489-498. doi:10.1002/jts.22059
Kroenke K, Spi tzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. doi:10.1046/j.1525-1497.2001.016009606.x
Brown TA. Confirmatory Factor Analysis for Applied Research. 2nd ed. Guilford Press; 2015.
Kaiser HF. The application of electronic computers to factor analysis. Educ Psychol Meas. 1960;20(1):141-151. doi:10.1177/001316446002000116
Schorr Y, Stein NR, Maguen S, Barnes JB, Bosch J, Litz BT. Sources of moral injury among war veterans: a qualitative evaluation. J Clin Psychol. 2018;74(12):2203-2218. doi:10.1002/jclp.22660

References

Griffin BJ, Purcell N, Burkman K, et al. Moral injury: an integrative review. J Trauma Stress. 2019;32(3):350-362. doi:10.1002/jts.22362
Currier JM, Holland JM, Malott J. Moral injury, meaning making, and mental health in returning veterans. J Clin Psychol. 2015;71(3):229-240. doi:10.1002/jclp.22134
Jinkerson JD. Defining and assessing moral injury: a syndrome perspective. Traumatology. 2016;22(2):122-130. doi:10.1037/trm0000069
Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695-706. doi:10.1016/j.cpr.2009.07.003
Maguen S, Litz B. Moral injury in veterans of war. PTSD Res Q. 2012;23(1):1-6. www.vva1071.org/uploads/3/4/4/6/34460116/moral_injury_in_veterans_of_war.pdf
Drescher KD, Foy DW, Kelly C, Leshner A, Schutz K, Litz B. An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology. 2011;17(1):8-13. doi:10.1177/1534765610395615
Wisco BE, Marx BP, May CL, et al. Moral injury in U.S. combat veterans: results from the national health and resilience in veterans study. Depress Anxiety. 2017; 34(4):340-347. doi:10.1002/da.22614
Bryan CJ, Bryan AO, Anestis MD, et al. Measuring moral injury: psychometric properties of the moral injury events scale in two military samples. Assessment. 2016;23(5):557- 570. doi:10.1177/1073191115590855
Currier JM, Smith PN, Kuhlman S. Assessing the unique role of religious coping in suicidal behavior among U.S. Iraq and Afghanistan veterans. Psychol Relig Spiritual. 2017;9(1):118-123. doi:10.1037/rel0000055
Kopacz MS, Connery AL, Bishop TM, et al. Moral injury: a new challenge for complementary and alternative medicine. Complement Ther Med. 2016;24:29-33. doi:10.1016/j.ctim.2015.11.003
Vargas AF, Hanson T, Kraus D, Drescher K, Foy D. Moral injury themes in combat veterans’ narrative responses from the national vietnam veterans’ readjustment study. Traumatology. 2013;19(3):243-250. doi:10.1177/1534765613476099
Borges LM, Barnes SM, Farnsworth JK, Bahraini NH, Brenner LA. A commentary on moral injury among health care providers during the COVID-19 pandemic. Psychol Trauma. 2020;12(S1):S138-S140. doi:10.1037/tra0000698
Borges LM, Holliday R, Barnes SM, et al. A longitudinal analysis of the role of potentially morally injurious events on COVID-19-related psychosocial functioning among healthcare providers. PLoS One. 2021;16(11):e0260033. doi:10.1371/journal.pone.0260033
Currier JM, Holland JM, Rojas-Flores L, Herrera S, Foy D. Morally injurious experiences and meaning in Salvadorian teachers exposed to violence. Psychol Trauma. 2015;7(1):24-33. doi:10.1037/a0034092
Nickerson A, Schnyder U, Bryant RA, Schick M, Mueller J, Morina N. Moral injury in traumatized refugees. Psychother Psychosom. 2015;84(2):122-123. doi:10.1159/000369353
Papazoglou K, Chopko B. The role of moral suffering (moral distress and moral injury) in police compassion fatigue and PTSD: An unexplored topic. Front Psychol. 2017;8:1999. doi:10.3389/fpsyg.2017.01999
Papazoglou K, Blumberg DM, Chiongbian VB, et al. The role of moral injury in PTSD among law enforcement officers: a brief report. Front Psychol. 2020;11:310. doi:10.3389/fpsyg.2020.00310
Martin WB, Holliday R, LePage JP. Trauma and diversity: moral injury among justice involved veterans: an understudied clinical concern. Stresspoints. 2020;33(5).
Currier JM, Drescher KD, Nieuwsma J. Future directions for addressing moral injury in clinical practice: concluding comments. In: Currier JM, Drescher KD, Nieuwsma J, eds. Addressing Moral Injury in Clinical Practice. American Psychological Association; 2021:261-271. doi:10.1037/0000204-015
Alexander AR, Mendez L, Kerig PK. Moral injury as a transdiagnostic risk factor for mental health problems in detained youth. Crim Justice Behav. 2023;51(2):194-212. doi:10.1177/00938548231208203
DeCaro JB, Straka K, Malek N, Zalta AK. Sentenced to shame: moral injury exposure in former lifers. Psychol Trauma. 2024; 15(5):722-730. doi:10.1037/tra0001400
Orak U, Kelton K, Vaughn MG, Tsai J, Pietrzak RH. Homelessness and contact with the criminal legal system among U.S. combat veterans: an exploration of potential mediating factors. Crim Justice Behav. 2022;50(3):392-409. doi:10.1177/00938548221140352
Bronson J, Carson EA, Noonan M. Veterans in Prison and Jail, 2011-12. US Department of Justice, Bureau of Justice Statistics; Published December 2015. Accessed March 4, 2025. https://bjs.ojp.gov/content/pub/pdf/vpj1112.pdf
Maruschak LM, Bronson J, Alper M. Veterans in Prison: Survey of Prison Inmates, 2016. US Department of Justice, Bureau of Justice Statistics; March 2021. Accessed March 4, 2025. https://bjs.ojp.gov/redirect-legacy/content/pub/pdf/vpspi16st.pdf
Blodgett JC, Avoundjian T, Finlay AK, et al. Prevalence of mental health disorders among justiceinvolved veterans. Epidemiol Rev. 2015;37:163-176. doi:10.1093/epirev/mxu003
Finlay AK, Owens MD, Taylor E, et al. A scoping review of military veterans involved in the criminal justice system and their health and healthcare. Health Justice. 2019;7(1):6. doi:10.1186/s40352-019-0086-9
Holliday R, Martin WB, Monteith LL, Clark SC, LePage JP. Suicide among justice-involved veterans: a brief overview of extant research, theoretical conceptualization, and recommendations for future research. J Soc Distress Homeless. 2020;30(1):41-49. doi:10.1080/10530789.2019.1711306
Wortzel HS, Binswanger IA, Anderson CA, Adler LE. Suicide among incarcerated veterans. J Am Acad Psychiatry Law. 2009;37(1):82-91.
Desai A, Holliday R, Borges LM, et al. Facilitating successful reentry among justice-involved veterans: the role of veteran and offender identity. J Psychiatr Pract. 2021;27(1):52-60. doi:10.1097/PRA.0000000000000520
Asencio EK, Burke PJ. Does incarceration change the criminal identity? A synthesis of labeling and identity theory perspectives on identity change. Sociol Perspect. 2011;54(2):163-182. doi:10.1525/sop.2011.54.2.163
Borges LM, Desai A, Barnes SM, Johnson JPS. The role of social determinants of health in moral injury: implications and future directions. Curr Treat Options Psychiatry. 2022;9(3):202-214. doi:10.1007/s40501-022-00272-4
Houle SA, Ein N, Gervasio J, et al. Measuring moral distress and moral injury: a systematic review and content analysis of existing scales. Clin Psychol Rev. 2024;108:102377. doi:10.1016/j.cpr.2023.102377
Nash WP, Marino Carper TL, Mills MA, Au T, Goldsmith A, Litz BT. Psychometric evaluation of the moral injury events scale. Mil Med. 2013;178(6):646-652. doi:10.7205/MILMED-D-13-00017
Zerach G, Ben-Yehuda A, Levi-Belz Y. Prospective associations between psychological factors, potentially morally injurious events, and psychiatric symptoms among Israeli combatants: the roles of ethical leadership and ethical preparation. Psychol Trauma. 2023;15(8):1367-1377. doi:10.1037/tra0001466
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association; 2013.
Weathers FW, Litz BT, Keane TM, Palmeri PA, Marx BP. The PTSD Checklist for DSM-5 (PCL-5). National Center for PTSD. Accessed March 4, 2025. www.ptsd.va.gov
Bovin MJ, Marx BP, Weathers FW, et al. Psychometric properties of the PTSD checklist for diagnostic and statistical manual of mental disorders-fifth edition (PCL-5) in veterans. Psychol Assess. 2016;28(11):1379-1391. doi:10.1037/pas0000254
Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The osttraumatic stress disorder checklist for DSM-5 (PCL- 5): development and initial psychometric evaluation. J Trauma Stress. 2015;28(6):489-498. doi:10.1002/jts.22059
Kroenke K, Spi tzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. doi:10.1046/j.1525-1497.2001.016009606.x
Brown TA. Confirmatory Factor Analysis for Applied Research. 2nd ed. Guilford Press; 2015.
Kaiser HF. The application of electronic computers to factor analysis. Educ Psychol Meas. 1960;20(1):141-151. doi:10.1177/001316446002000116
Schorr Y, Stein NR, Maguen S, Barnes JB, Bosch J, Litz BT. Sources of moral injury among war veterans: a qualitative evaluation. J Clin Psychol. 2018;74(12):2203-2218. doi:10.1002/jclp.22660

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VA is a Leader in Mental Health and Social Service Research and Operations

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VA is a Leader in Mental Health and Social Service Research and Operations

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Ryan Holliday, PhD

Nicholas Holder, PhD

The US Department of Veterans Affairs (VA) mission is defined by President Abraham Lincoln’s promise “to care for him who shall have borne the battle, and for his widow, and his orphan.” Critically, the biopsychosocial needs of veterans differ from the needs of civilians due to the nature of military service.¹ Veterans commonly experience traumatic brain injury (TBI) due to combat- or training-related injuries.² Psychologically, veterans are disproportionately likely to be diagnosed with mental health conditions, such as posttraumatic stress disorder (PTSD), often linked to military exposures.³ Spiritually, veterans frequently express moral injury after living through circumstances when they perpetrate, fail to prevent, or witness events that contradict moral beliefs/ expectations.⁴ Veterans also have significant social challenges, including high rates of homelessness. ⁵ A critical strength of the VA mission is its awareness of these complex sequelae and its ability to provide well-informed treatment and social services to meet veterans’ unique needs.

Foundational to a well-informed health care system is a robust research and operational quality improvement infrastructure. The VA Office of Research and Development (ORD) has worked tirelessly to understand and address the unique, idiographic needs of veterans. In 2024 the ORD had a budget of $2.4 billion, excluding quality improvement initiatives enhancing VA operations.⁶

The integrated VA health care system is a major strength for providing state-of-the-science to inform veterans’ treatment and social service needs. The VA features medical centers and clinics capable of synergistically leveraging extant infrastructure to facilitate collaborations and centralized procedures across sites. The VA also has dedicated research centers, such as the National Center for PTSD, Centers of Excellence, Centers of Innovation, and Mental Illness, Research, Education and Clinical Centers that focus on PTSD, suicide prevention, TBI, and other high-priority areas. These centers recruit, train, and invest in experts dedicated to improving veterans’ lives. The VA Corporate Data Warehouse provides a national, system-wide repository for patient-level data, allowing for advanced analysis of large datasets.⁷

This special issue is a showcase of the strengths of VA mental health and social service research, aligning with the current strategic priorities of VA research. Topics focus on the unique needs of veterans, including sequelae (eg, PTSD, homelessness, moral injury), with particular attention to veterans. Manuscripts highlight the strengths of collaborations, including those between specialized research centers and national VA operational partners. Analyses highlight the VA research approach, leveraging data and perspectives from inside and outside the VA, and studying new and established approaches to care. This issue highlights the distinct advantages that VA research provides: experts with the tools, experience, and dedication to addressing the unique needs of veterans. Given the passion for veteran care among VA researchers, including those featured in this issue, we strongly believe the VA will continue to be a leader in this research.

References

Oster C, Morello A, Venning A, Redpath P, Lawn S. The health and wellbeing needs of veterans: a rapid review. BMC Psychiatry. 2017;17(1):414. doi:10.1186/s12888-017-1547-0
Cypel YS, Vogt D, Maguen S, et al. Physical health of Post- 9/11 U.S. military veterans in the context of Healthy People 2020 targeted topic areas: results from the Comparative Health Assessment Interview Research Study. Prev Med Rep. 2023;32:102122. doi:10.1016/j.pmedr.2023.102122
Lehavot K, Katon JG, Chen JA, Fortney JC, Simpson TL. Post-traumatic stress disorder by gender and veteran Status. Am J Prev Med. 2018;54(1):e1-e9. doi:10.1016/j.amepre.2017.09.008
Griffin BJ, Purcell N, Burkman K, et al. Moral injury: an integrative review. J Trauma Stress. 2019;32(3):350-362. doi:10.1002/jts.22362
Tsai J, Pietrzak RH, Szymkowiak D. The problem of veteran homelessness: an update for the new decade. Am J Prev Med. 2021;60(6):774-780. doi:10.1016/j.amepre.2020.12.012
US Department of Veterans Affairs, Office of Research and Development. About the office of research & development. Updated January 22, 2025. Accessed March 18, 2025. https://www.research.va.gov/about/default.cfm
Fihn SD, Francis J, Clancy C, et al. Insights from advanced analytics at the Veterans Health Administration. Health Aff (Millwood). 2014;33(7):1203-1211. doi:10.1377/hlthaff.2014.0054

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Ryan Holliday, PhD^a,b,c; Nicholas Holder, PhD^d,e,f

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^aVeterans Affairs (VA) Pacific Islands Health Care System, Honolulu, Hawaii; ^bRocky Mountain Regional VA Medical Center, Aurora, Colorado; ^cUniversity of Colorado Anschutz Medical Campus, Aurora; ^dSan Francisco VA Health Care System, California; ^eUniversity of California San Francisco School of Medicine; fCenter for Data to Discovery and Delivery Innovation

Correspondence: Ryan Holliday (ryan.holliday@va.gov)

Fed Pract. 2023;42(suppl 1). Published online April 2. doi:10.12788/fp.0578

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Fed Pract. 2023;42(suppl 1). Published online April 2. doi:10.12788/fp.0578

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References

Oster C, Morello A, Venning A, Redpath P, Lawn S. The health and wellbeing needs of veterans: a rapid review. BMC Psychiatry. 2017;17(1):414. doi:10.1186/s12888-017-1547-0
Cypel YS, Vogt D, Maguen S, et al. Physical health of Post- 9/11 U.S. military veterans in the context of Healthy People 2020 targeted topic areas: results from the Comparative Health Assessment Interview Research Study. Prev Med Rep. 2023;32:102122. doi:10.1016/j.pmedr.2023.102122
Lehavot K, Katon JG, Chen JA, Fortney JC, Simpson TL. Post-traumatic stress disorder by gender and veteran Status. Am J Prev Med. 2018;54(1):e1-e9. doi:10.1016/j.amepre.2017.09.008
Griffin BJ, Purcell N, Burkman K, et al. Moral injury: an integrative review. J Trauma Stress. 2019;32(3):350-362. doi:10.1002/jts.22362
Tsai J, Pietrzak RH, Szymkowiak D. The problem of veteran homelessness: an update for the new decade. Am J Prev Med. 2021;60(6):774-780. doi:10.1016/j.amepre.2020.12.012
US Department of Veterans Affairs, Office of Research and Development. About the office of research & development. Updated January 22, 2025. Accessed March 18, 2025. https://www.research.va.gov/about/default.cfm
Fihn SD, Francis J, Clancy C, et al. Insights from advanced analytics at the Veterans Health Administration. Health Aff (Millwood). 2014;33(7):1203-1211. doi:10.1377/hlthaff.2014.0054

References

Oster C, Morello A, Venning A, Redpath P, Lawn S. The health and wellbeing needs of veterans: a rapid review. BMC Psychiatry. 2017;17(1):414. doi:10.1186/s12888-017-1547-0
Cypel YS, Vogt D, Maguen S, et al. Physical health of Post- 9/11 U.S. military veterans in the context of Healthy People 2020 targeted topic areas: results from the Comparative Health Assessment Interview Research Study. Prev Med Rep. 2023;32:102122. doi:10.1016/j.pmedr.2023.102122
Lehavot K, Katon JG, Chen JA, Fortney JC, Simpson TL. Post-traumatic stress disorder by gender and veteran Status. Am J Prev Med. 2018;54(1):e1-e9. doi:10.1016/j.amepre.2017.09.008
Griffin BJ, Purcell N, Burkman K, et al. Moral injury: an integrative review. J Trauma Stress. 2019;32(3):350-362. doi:10.1002/jts.22362
Tsai J, Pietrzak RH, Szymkowiak D. The problem of veteran homelessness: an update for the new decade. Am J Prev Med. 2021;60(6):774-780. doi:10.1016/j.amepre.2020.12.012
US Department of Veterans Affairs, Office of Research and Development. About the office of research & development. Updated January 22, 2025. Accessed March 18, 2025. https://www.research.va.gov/about/default.cfm
Fihn SD, Francis J, Clancy C, et al. Insights from advanced analytics at the Veterans Health Administration. Health Aff (Millwood). 2014;33(7):1203-1211. doi:10.1377/hlthaff.2014.0054

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Trauma-Informed Training for Veterans Treatment Court Professionals: Program Development and Initial Feedback

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Alisha Desai, PhD

Ryan Holliday, PhD

Matthew Stimmel, PhD

Lauren M. Borges, PhD

Veterans who interact with the criminal justice system (ie, justice-involved veterans) have heightened rates of mental health and psychosocial needs, including posttraumatic stress disorder (PTSD), substance use disorder, depression, suicidal ideation and attempt, and homelessness.^1,2 Alongside these criminogenic risk factors, recidivism is common among justice-involved veterans: About 70% of incarcerated veterans disclosed at least one prior incarceration.³

To address the complex interplay of psychosocial factors, mental health concerns, and justice involvement among veterans, veterans treatment courts (VTCs) emerged as an alternative to incarceration.⁴ VTC participation often consists of integrated treatment and rehabilitative services (eg, vocational training, health care), ongoing monitoring for substance use, graduated responses to address treatment adherence, and ongoing communication with the judge and legal counsel.⁴

A primary aim of these courts is to address psychosocial needs believed to underlie criminal behavior, thus reducing risk of recidivism and promoting successful recovery and community integration for eligible veterans. To do so, VTCs collaborate with community-based and/or US Department of Veterans Affairs services, such as the Veterans Justice Outreach program (VJO). VJO specialists identify and refer justice-involved veterans to Veterans Health Administration (VHA) and community care and serve as a liaison between VTC staff and VHA health care professionals (HCPs).⁵

VTC outcome studies highlight the importance of not only diverting veterans to problem-solving courts, but also ensuring their optimal participation. Successful graduates of VTC programs demonstrate significant improvements in mental health symptoms, life satisfaction, and social support, as well as lower rates of law enforcement interactions.^6,7 However, less is known about supporting those veterans who have difficulty engaging in VTCs and either discontinue participation or require lengthier periods of participation to meet court graduation requirements.⁸ One possibility to improve engagement among these veterans is to enhance court practices to best meet their needs.

In addition to delivering treatment, VHA mental health professionals may serve a critical interdisciplinary role by lending expertise to support VTC practices. For example, equipping court professionals with clinical knowledge and skills related to motivation may strengthen the staff’s interactions with participants, enabling them to address barriers as they arise and to facilitate veterans’ treatment adherence. Additionally, responsiveness to the impact of trauma exposure, which is common among this population, may prove important as related symptoms can affect veterans’ engagement, receptivity, and behavior in court settings. Indeed, prior examinations of justice-involved veterans have found trauma exposure rates ranging from 60% to 90% and PTSD rates ranging from 27% to 40%.^1,2 Notably, involvement with the justice system (eg, incarceration) may itself further increase risk of trauma exposure (eg, experiencing a physical or sexual assault in prison) or exacerbate existing PTSD.⁹ Nonetheless, whereas many drug courts and domestic violence courts have been established, problem-solving courts with a specialized focus on trauma exposure remain rare, suggesting a potential gap in court training.

VHA HCPs have the potential to facilitate justice-involved veterans’ successful court and treatment participation by coordinating with VJO specialists to provide training and consultation to the courts. Supporting efforts to effectively and responsively address criminogenic risk (eg, mental health) in VTC settings may in turn reduce the likelihood of recidivism.¹⁰ Given the elevated rates of trauma exposure among justice-involved veterans and the relative lack of trauma-focused VTCs, we developed a trauma-informed training for VTC professionals that centered on related clinical presentations of justice-involved veterans and frequently occurring challenges in the context of court participation.

Program Development

This educational program aimed to (1) provide psychoeducation on trauma exposure, PTSD, and existing evidence-based treatments; (2) present clinical considerations for justice-involved veterans related to trauma exposure and/or PTSD; and (3) introduce skills to facilitate effective communication and trauma-informed care practices among professionals working with veterans in a treatment court.

Prior to piloting the program, we conducted a needs assessment with VTC professionals and identified relevant theoretical constructs and brief interventions for inclusion in the training. Additionally, given the dearth of prior research on mental health education for VTCs, the team consulted with the developers of PTSD 101, a VHA workshop for veterans’ families that promotes psychoeducation, support, and effective communication.¹¹ Doing so informed approaches to delivering education to nonclinical audiences that interact with veterans with histories of trauma exposure. As this was a program development project, it was determined to be exempt from institutional review board review.

Needs Assessment

In the initial stages of development, local VJO specialists identified regional VTCs and facilitated introductions to these courts. Two of the 3 Rocky Mountain region VTCs that were contacted expressed interest in receiving trauma-informed training. Based on preliminary interest, the facilitators conducted a needs assessment with VJO and VTC staff from these 2 courts to capture requests for specific content and past experiences with other mental health trainings.

Guided by the focus group model, the needs assessments took place during three 1-hour meetings with VJO specialists and a 1-hour meeting with VJO specialists, VTC professionals, and community-based clinical partners.¹² Additionally, attending a VTC graduation and court session allowed for observations of court practices and interactions with veterans. A total of 13 professionals (judges, court coordinators, case managers, peer mentors, VJO specialists, and clinicians who specialize in substance use disorder and intimate partner violence) participated in the needs assessments.

The most critical need identified by court professionals was a focus on how to apply knowledge about trauma and PTSD to interactions with justice-involved veterans. This was reportedly absent from prior training sessions the courts had received. Both Rocky Mountain region VTCs expressed a strong interest in and openness to adapting practices based on research and practice recommendations. Additional requests that emerged included a refresher on psychoeducation related to trauma and how to address the personal impact of working with this population (eg, compassion fatigue).

Training Components

Based on the needs identified by VTC professionals and informed by consultation with the developers of PTSD 101,

the training consisted of 3 components: psychoeducation, skills training, and consultation (Table 1).

Psychoeducation. The initial portion of the training consisted of psychoeducation to increase VTC staff familiarity with the distinctions between trauma exposure and a formal diagnosis of PTSD, mechanisms underlying PTSD, and evidence-based treatment. To deepen conceptual understanding of trauma and PTSD beyond an overview of criteria set forth in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), psychoeducation centered on the drivers of avoidance (eg, short-term benefit vs long-term consequences), behaviors that often facilitate avoidance (eg, substance use), functions underlying these behaviors (eg, distress reduction), and structure and mechanisms of change in evidence-based treatments for PTSD, including cognitive processing therapy and prolonged exposure.^13,14

Fostering court familiarity with cognitive processing therapy and prolonged exposure may bolster veteran engagement in treatment through regular reinforcement of skills and concepts introduced in therapy. This may prove particularly salient given the limited engagement with mental health treatment and elevated dropout rates from PTSD treatment among the general veteran population.^15,16

Exercises and metaphors were used to illustrate concepts in multiple ways. For example, training attendees engaged in a “stop, drop, and roll” thought exercise in which they were asked to brainstorm behavioral reactions to catching on fire. This exercise illustrated the tendency for individuals to revert to common yet unhelpful attempts at problem solving (eg, running due to panic, which would exacerbate the fire), particularly in crisis and without prior education regarding adaptive ways to respond. Attendee-generated examples, such as running, were used to demonstrate the importance of practicing and reinforcing skill development prior to a crisis, to ensure proficiency and optimal response. Additionally, in prompting consideration of one’s response tendencies, this exercise may engender empathy and understanding for veterans.

Skills training. Efforts to promote veteran engagement in court, facilitate motivation and readiness for change, and address barriers that arise (eg, distress associated with court appearances) may support successful and timely graduation. As such, skills training constituted the largest component of the training and drew from observations of court practices and the VTCs’ identified challenges. Consistent with the project’s aims and reported needs of the court, skills that target common presentations following trauma exposure (eg, avoidance, hypervigilance) were prioritized for this pilot training. Strategies included brief interventions from dialectical behavior therapy, acceptance and commitment therapy, and motivational interviewing to strengthen the support provided by staff to veterans and address their needs (Table 2).

^17-19 Additionally, we presented strategies for implementing sanctions and rewards that were influenced by trauma-informed care practices, such as highlighting veteran strengths and promoting agency in decision making.

Training attendees also participated in exercises to reiterate skills. For example, attendees completed an ambivalence matrix using an audience-identified common behavior that is difficult to change (eg, heavy alcohol use as a coping mechanism for distress).

Attendees engaged in an exercise that involved identifying unhelpful thoughts and behaviors, targets for validation, and veteran strengths from a hypothetical case vignette. This vignette involved a VTC participant who initially engaged effectively but began to demonstrate difficulty appropriately engaging in court and mental health treatment as well as challenging interactions with VTC staff (eg, raised voice during court sessions, not respecting communication boundaries).

Pilot Test

Based on scheduling parameters communicated by court coordinators, the pilot training was designed as a presentation during times reserved for court staffing meetings. To accommodate court preferences due to the COVID-19 pandemic, one 90-minute training was conducted virtually in March 2022, and the other training was conducted in person in April 2022 for 2 hours. The trainings were facilitated by 2 VHA clinical psychologists and included the judge, court coordinator, VJO specialist, peer mentors, case managers, probation/parole officers, and community-based HCPs who partner with the court (eg, social workers, psychologists). About 12 to 15 professionals attended each training session.

Feedback

Feedback was solicited from attendees via an anonymous online survey. Seven participants completed the survey; the response rate of about 20% was consistent with those observed for other surveys of court professionals.²⁰ Many attendees also provided feedback directly to the facilitators. Feedback highlighted that the skills-based components not only were perceived as most helpful but also notably distinguished this training. “What set this training apart from other training events was the practical applications,” one attendee noted. “It was not just information or education, both instructors did an incredible job of explaining exactly how we could apply the knowledge they were sharing. They did this in such a way that it was easy to understand and apply.”

Specific skills were consistently identified as helpful, including managing intense emotions, addressing ambivalence, and approaching sanctions and rewards. Additionally, employing a less formal approach to the training, with relatable overviews of concepts and immediate responsiveness to requests for expansion on a topic, was perceived as a unique benefit: Another attendee appreciated that “It was beneficial to sit around a table with a less formal presentation and be able to ask questions.” This approach seemed particularly well suited for the program’s cross-disciplinary audience. Attendees reported that they valued the relatively limited focus on DSM-5 criteria. Attendees emphasized that education specific to veterans on evidence-based PTSD treatments, psychoeducation, and avoidance was very helpful. Respondents also recommended that the training be lengthened to a daylong workshop to accommodate greater opportunity to practice skills and consultation.

The consultation portion of the training provided insight into additional areas of importance to incorporate into future iterations. Identified needs included appropriate and realistic boundary setting (eg, addressing disruptions in the courtroom), suggestions for improving and expanding homework assigned by the court, and ways to address concerns about PTSD treatment shared by veterans in court (eg, attributing substance use relapses to the intensiveness of trauma-focused treatment vs lack of familiarity with alternate coping skills). Additionally, the VTC professionals’ desire to support mental health professionals’ work with veterans was clearly evident, highlighting the bidirectional value of interdisciplinary collaboration between VHA mental health professionals and VTC professionals.

Discussion

A trauma-informed training was developed and delivered to 2 VTCs in the Rocky Mountain region with the goal of providing relevant psychoeducation and introducing skills to bolster court practices that address veteran needs. Psychoeducational components of the training that were particularly well received and prompted significant participant engagement included discussions and examples of avoidance, levels of validation, language to facilitate motivation and address barriers, mechanisms underlying treatment, and potential functions underlying limited veteran treatment engagement. Distress tolerance, approaches to sanctions and rewards, and use of ambivalence matrices to guide motivation were identified as particularly helpful skills.

The pilot phase of this trauma-informed training provided valuable insights into developing mental health trainings for VTCs. Specifically, VTCs may benefit from the expertise of VHA HCPs and are particularly interested in learning brief skills to improve their practices. The usefulness of such trainings may be bolstered by efforts to form relationships with the court to identify their perceived needs and employing an iterative process that is responsive to feedback both during and after the training. Last, each stage of this project was strengthened by collaboration with VJO specialists, highlighting the importance of future collaboration between VJO and VHA mental health clinics to further support justice-involved veterans. For example, VJO specialists were instrumental in identifying training needs related to veterans’ clinical presentations in court, facilitating introductions to local VTCs, and helping to address barriers to piloting, like scheduling.

Modifications and Future Directions

The insights gained through the process of training design, delivery, and feedback inform future development of this training. Based on the feedback received, subsequent versions of the training may be expanded into a half- or full-day workshop to allow for adequate time for skills training and feedback, as well as consultation. Doing so will enable facilitators to further foster attendees’ familiarity with and confidence in their ability to use these skills. Furthermore, the consultation portion of this training revealed areas that may benefit from greater attention, including how to address challenging interactions in court (eg, addressing gender dynamics between court professionals and participants) and better support veterans who are having difficulty engaging in mental health treatment (eg, courts’ observation of high rates of dropout around the third or fourth session of evidence-based treatment for PTSD). Last, all attendees who responded to the survey expressed interest in a brief resource guide based on the training, emphasizing the need for ready access to key skills and concepts to support the use of strategies learned.

An additional future aim of this project is to conduct a more thorough evaluation of the needs and outcomes related to this trauma-informed training for VTC professionals. With the rapid growth of VTCs nationwide, relatively little examination of court processes and practices has occurred, and there is a lack of research on the development or effectiveness of mental health trainings provided to VTCs.²¹ Therefore, we intend to conduct larger scale qualitative interviews with court personnel and VJO specialists to obtain a clearer understanding of the needs related to skills-based training and gaps in psychoeducation. These comprehensive needs assessments may also capture common comorbidities that were not incorporated into the pilot training (eg, substance use disorders) but may be important training targets for court professionals. This information will be used to inform subsequent expansion and adaptation of the training into a longer workshop. Program evaluation will be conducted via survey-based feedback on perceived usefulness of the workshop and self-report of confidence in and use of strategies to improve court practices. Furthermore, efforts to obtain veteran outcome data, such as treatment engagement and successful participation in VTC, may be pursued.

Limitations

This training development and pilot project provided valuable foundational information regarding a largely unexamined component of treatment courts—the benefit of skills-based trainings to facilitate court practices related to justice-involved veterans. However, it is worth noting that survey responses were limited; thus, the feedback received may not reflect all attendees’ perceptions. Additionally, because both training sessions were conducted solely with 2 courts in the Rocky Mountain area, feedback may be limited to the needs of this geographic region.

Conclusions

A trauma-informed training was developed for VTCs to facilitate relevant understanding of justice-involved veterans’ needs and presentations in court, introduce skills to address challenges that arise (eg, motivation, emotional dysregulation), and provide interdisciplinary support to court professionals. This training was an important step toward fostering strong collaborations between VHA HCPs and community-based veterans courts, and feedback received during development and following implementation highlighted the perceived need for a skills-based approach to such trainings. Further program development and evaluation can strengthen this training and provide a foundation for dissemination to a broader scope of VTCs, with the goal of reducing recidivism risk among justice-involved veterans by promoting effective engagement in problem-solving court.

References

1. Blodgett JC, Avoundjian T, Finlay AK, et al. Prevalence of mental health disorders among justice-involved veterans. Epidemiol Rev. 2015;37(1):163-176. doi:10.1093/epirev/mxu003

2. Saxon AJ, Davis TM, Sloan KL, McKnight KM, McFall ME, Kivlahan DR. Trauma, symptoms of posttraumatic stress disorder, and associated problems among incarcerated veterans. Psychiatr Serv. 2001;52(7):959-964. doi:10.1176/appi.ps.52.7.959

3. Bronson J, Carson AC, Noonan M. Veterans in prison and jail, 2011-12. December 2015. Accessed January 11, 2023. https://bjs.ojp.gov/content/pub/pdf/vpj1112.pdf

4. Cartwright T. “To care for him who shall have borne the battle”: the recent development of veterans treatment courts in America. Stanford Law Rev. 2011;22(1):295-316.

5. Finlay AK, Smelson D, Sawh L, et al. U.S. Department of Veterans Affairs Veterans Justice Outreach Program: connecting justice-involved veterans with mental health and substance use disorder Treatment. Crim Justice Policy Rev. 2016;27(2):10.1177/0887403414562601. doi:10.1177/0887403414562601

6. Knudsen KJ, Wingenfeld S. A specialized treatment court for veterans with trauma exposure: implications for the field. Community Ment Health J. 2016;52(2):127-135. doi:10.1007/s10597-015-9845-9

7. Montgomery LM, Olson JN. Veterans treatment court impact on veteran mental health and life satisfaction. J Psychol Behav Sci. 2018;6(1):1-4. doi:10.15640/jpbs.v6n1a1

8. Tsai J, Finlay A, Flatley B, Kasprow WJ, Clark S. A national study of veterans treatment court participants: who benefits and who recidivates. Adm Policy Ment Health. 2018;45(2):236-244. doi:10.1007/s10488-017-0816-z

9. Wolff NL, Shi J. Trauma and incarcerated persons. In: Scott CL, ed. Handbook of Correctional Mental Health. American Psychiatric Publishing, Inc.; 2010:277-320.

10. Bonta J, Andrews DA. Risk-need-responsivity model for offender assessment and rehabilitation. Rehabilitation. 2007;6:1-22. https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/rsk-nd-rspnsvty/index-en.aspx

11. US Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, Family Services Section; Caska-Wallace CM, Campbell SB, Glynn SM. PTSD 101 for family and friends: a support and education workshop. 2020.

12. Tipping J. Focus groups: a method of needs assessment. J Contin Educ Health Prof. 1998;18(3):150-154. doi:10.1002/chp.1340180304

13. Resick PA, Monson CM, Chard KM. Cognitive Processing Therapy for PTSD: A Comprehensive Manual. The Guilford Press; 2017.

14. Foa EB, Hembree EA, Rothbaum BO. Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences: Therapist Guide. Oxford University Press; 2007. doi:10.1093/med:psych/9780195308501.001.0001

15. Seal KH, Maguen S, Cohen B, et al. VA mental health services utilization in Iraq and Afghanistan veterans in the first year of receiving new mental health diagnoses. J Trauma Stress. 2010;23(1):5-16. doi:10.1002/jts.20493

16. Edwards-Stewart A, Smolenski DJ, Bush NE, et al. Posttraumatic stress disorder treatment dropout among military and veteran populations: a systematic review and meta-analysis. J Trauma Stress. 2021;34(4):808-818. doi:10.1002/jts.22653

17. Linehan MM. Dialectical Behavior Therapy Skills Training Manual. 2nd ed. Guildford Press; 2015.

18. Hayes SC, Strosahl KD, Wilson KG. Acceptance and Commitment Therapy: The Process and Practice of Mindful Change. 2nd ed. Guildford Press; 2016.

19. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd ed. The Guildford Press; 2002.

20. National Center for State Courts. A survey of members of major national court organizations. October 2010. Accessed January 11, 2023. https://www.ncsc.org/__data/assets/pdf_file/0015/16350/survey-summary-10-26.pdf

21. Baldwin JM, Brooke EJ. Pausing in the wake of rapid adoption: a call to critically examine the veterans treatment court concept. J Offender Rehabil. 2019;58(1):1-29. doi:10.1080/10509674.2018.1549181

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^aRocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado

^bUniversity of Colorado Anschutz Medical Campus, Aurora^cUS Department of Veterans Affairs Veterans Justice Programs, Washington DC

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Based on the needs identified by VTC professionals and informed by consultation with the developers of PTSD 101,

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Understanding the Intersection of Homelessness and Justice Involvement: Enhancing Veteran Suicide Prevention Through VA Programming

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Despite the success of several US Department of Veterans Affairs (VA) initiatives in facilitating psychosocial functioning, rehabilitation, and re-entry among veterans experiencing homelessness and/or interactions with the criminal justice system (ie, justice-involved veterans), suicide risk among these veterans remains a significant public health concern. Rates of suicide among veterans experiencing homelessness are more than double that of veterans with no history of homelessness.¹ Similarly, justice-involved veterans experience myriad mental health concerns, including elevated rates of psychiatric symptoms, suicidal thoughts, and self-directed violence relative to those with no history of criminal justice involvement.²

In addition, a bidirectional relationship between criminal justice involvement and homelessness, often called the “institutional circuit,” is well established. Criminal justice involvement can directly result in difficulty finding housing.³ For example, veterans may have their lease agreement denied based solely on their history of criminogenic behavior. Moreover, criminal justice involvement can indirectly impact a veteran’s ability to maintain housing. Indeed, justice-involved veterans can experience difficulty attaining and sustaining employment, which in turn can result in financial difficulties, including inability to afford rental or mortgage payments.

Similarly, those at risk for or experiencing housing instability may resort to criminogenic behavior to survive in the context of limited psychosocial resources.^4-6 For instance, a veteran experiencing homelessness may seek refuge from inclement weather in a heated apartment stairwell and subsequently be charged with trespassing. Similarly, these veterans also may resort to theft to eat or pay bills. To this end, homelessness and justice involvement are likely a deleterious cycle that is difficult for the veteran to escape.

Unfortunately, the concurrent impact of housing insecurity and criminal justice involvement often serves to further exacerbate mental health sequelae, including suicide risk (Figure).⁷ In addition to precipitating frustration and helplessness among veterans who are navigating these stressors, these social determinants of health can engender a perception that the veteran is a burden to those in their support system. For example, these veterans may depend on friends or family to procure housing or transportation assistance for a job, medical appointments, and court hearings.

Understanding the Institutional Circuit and Suicide Risk

Furthermore, homelessness and justice involvement can impact veterans’ interpersonal relationships. For instance, veterans with a history of criminal justice involvement may feel stigmatized and ostracized from their social support system. Justice-involved veterans sometimes endorse being labeled an offender, which can result in perceptions that one is poorly perceived by others and generally seen as a bad person.⁸ In addition, the conditions of a justice-involved veteran’s probation or parole may further exacerbate social relationships. For example, veterans with histories of engaging in intimate partner violence may lose visitation rights with their children, further reinforcing negative views of self and impacting the veterans’ family network.

As such, these homeless and justice-involved veterans may lack a meaningful social support system when navigating psychosocial stressors. Because hopelessness, burdensomeness, and perceptions that one lacks a social support network are potential drivers of suicidal self-directed violence among these populations, facilitating access to and engagement in health (eg, psychotherapy, medication management) and social (eg, case management, transitional housing) services is necessary to enhance veteran suicide prevention efforts.⁹

Several VA homeless and justice-related programs have been developed to meet the needs of these veterans (Table). Such programs offer direct access to health and social services capable of addressing mental health symptoms and suicide risk. Moreover, these programs support veterans at various intercepts, or points at which there is an opportunity to identify those at elevated risk and provide access to evidence-based care. For instance, VA homeless programs exist tailored toward those currently, or at risk for, experiencing homelessness. Additionally, VA justice-related programs can target intercepts prior to jail or prison, such as working with crisis intervention teams or diversion courts as well as intercepts following release, such as providing services to facilitate postincarceration reentry. Even VA programs that do not directly administer mental health intervention (eg, Grant and Per Diem, Veterans Justice Outreach) serve as critical points of contact that can connect these veterans to evidence-based suicide prevention treatments (eg, Cognitive Behavioral Therapy for Suicide Prevention; pharmacotherapy) in the VA or the community.

VA Programs Targeting the Needs of Homeless and Justice-Involved Veterans

Within these programs, several suicide prevention efforts also are currently underway. In particular, the VA has mandated routine screening for suicide risk. This includes screening for the presence of elevations in acute risk (eg, suicidal intent, recent suicide attempt) and, within the context of acute risk, conducting a comprehensive risk evaluation that captures veterans’ risk and protective factors as well as access to lethal means. These clinical data are used to determine the veteran’s severity of acute and chronic risk and match them to an appropriate intervention.

Despite these ongoing efforts, several gaps in understanding exist, such as for example, elucidating the potential role of traditional VA homeless and justice-related programming in reducing risk for suicide.¹⁰ Additional research specific to suicide prevention programming among these populations also remains important.¹¹ In particular, no examination to date has evaluated national rates of suicide risk assessment within these settings or elucidated if specific subsets of homeless and justice-involved veterans may be less likely to receive suicide risk screening. For instance, understanding whether homeless veterans accessing mental health services are more likely to be screened for suicide risk relative to homeless veterans accessing care in other VA settings (eg, emergency services). Moreover, the effectiveness of existing suicide-focused evidence-based treatments among homeless and justice-involved veterans remains unknown. Such research may reveal a need to adapt existing interventions, such as safety planning, to the idiographic needs of homeless or justice-involved veterans in order to improve effectiveness.¹⁰ Finally, social determinants of health, such as race, ethnicity, gender, and rurality may confer additional risk coupled with difficulties accessing and engaging in care within these populations.¹¹ As such, research specific to these veteran populations and their inherent suicide prevention needs may further inform suicide prevention efforts.

Despite these gaps, it is important to acknowledge ongoing research and programmatic efforts focused on enhancing mental health and suicide prevention practices within VA settings. For example, efforts led by Temblique and colleagues acknowledge not only challenges to the execution of suicide prevention efforts in VA homeless programs, but also potential methods of enhancing care, including additional training in suicide risk screening and evaluation due to provider discomfort.¹² Such quality improvement projects are paramount in their potential to identify gaps in health service delivery and thus potentially save veteran lives.

The VA currently has several programs focused on enhancing care for homeless and justice-involved veterans, and many incorporate suicide prevention initiatives. Further understanding of factors that may impact health service delivery of suicide risk assessment and intervention among these populations may be beneficial in order to enhance veteran suicide prevention efforts.

References

1. McCarthy JF, Bossarte RM, Katz IR, et al. Predictive modeling and concentration of the risk of suicide: implications for preventive interventions in the US Department of Veterans Affairs. Am J Public Health. 2015;105(9):1935-1942. doi:10.2105/AJPH.2015.302737

2. Holliday R, Hoffmire CA, Martin WB, Hoff RA, Monteith LL. Associations between justice involvement and PTSD and depressive symptoms, suicidal ideation, and suicide attempt among post-9/11 veterans. Psychol Trauma. 2021;13(7):730-739. doi:10.1037/tra0001038

3. Tsai J, Rosenheck RA. Risk factors for homelessness among US veterans. Epidemiol Rev. 2015;37:177-195. doi:10.1093/epirev/mxu004

4. Fischer PJ. Criminal activity among the homeless: a study of arrests in Baltimore. Hosp Community Psychiatry. 1988;39(1):46-51. doi:10.1176/ps.39.1.46

5. McCarthy B, Hagan J. Homelessness: a criminogenic situation? Br J Criminol. 1991;31(4):393–410.doi:10.1093/oxfordjournals.bjc.a048137

6. Solomon P, Draine J. Issues in serving the forensic client. Soc Work. 1995;40(1):25-33.

7. Holliday R, Forster JE, Desai A, et al. Association of lifetime homelessness and justice involvement with psychiatric symptoms, suicidal ideation, and suicide attempt among post-9/11 veterans. J Psychiatr Res. 2021;144:455-461. doi:10.1016/j.jpsychires.2021.11.007

8. Desai A, Holliday R, Borges LM, et al. Facilitating successful reentry among justice-involved veterans: the role of veteran and offender identity. J Psychiatr Pract. 2021;27(1):52-60. Published 2021 Jan 21. doi:10.1097/PRA.0000000000000520

9. Holliday R, Martin WB, Monteith LL, Clark SC, LePage JP. Suicide among justice-involved veterans: a brief overview of extant research, theoretical conceptualization, and recommendations for future research. J Soc Distress Homeless. 2021;30(1):41-49. doi: 10.1080/10530789.2019.1711306

10. Hoffberg AS, Spitzer E, Mackelprang JL, Farro SA, Brenner LA. Suicidal self-directed violence among homeless US veterans: a systematic review. Suicide Life Threat Behav. 2018;48(4):481-498. doi:10.1111/sltb.12369

11. Holliday R, Liu S, Brenner LA, et al. Preventing suicide among homeless veterans: a consensus statement by the Veterans Affairs Suicide Prevention Among Veterans Experiencing Homelessness Workgroup. Med Care. 2021;59(suppl 2):S103-S105. doi:10.1097/MLR.0000000000001399.

12. Temblique EKR, Foster K, Fujimoto J, Kopelson K, Borthick KM, et al. Addressing the mental health crisis: a one year review of a nationally-led intervention to improve suicide prevention screening at a large homeless veterans clinic. Fed Pract. 2022;39(1):12-18. doi:10.12788/fp.0215

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^aRocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Aurora, Colorado
^bVeterans Affairs (VA) Eastern Colorado Health Care System, Aurora, Colorado
^cVeterans Health Administration Homeless Programs Office, Washington, DC
^dUS Department of Veterans Affairs Veterans Justice Programs
^eDepartment of Psychiatry, University of Colorado Anschutz Medical Campus

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Validation of the Timberlawn Couple and Family Evaluation Scales–Self-Report in Veterans with PTSD

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A modified version of the the Timberlawn Couple and Family Evaluation Scales was validated to assess intimate partner relationship functioning among veterans who suffer from PTSD.

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Although about 8.3% of the general adult civilian population will be diagnosed with posttraumatic stress disorder (PTSD) in their lifetime, rates of PTSD are even higher in the veteran population.^1,2 PTSD is associated with a number of psychosocial consequences in veterans, including decreased intimate partner relationship functioning.^3,4 For example, Cloitre and colleagues reported that PTSD is associated with difficulty with socializing, intimacy, responsibility, and control, all of which increase difficulties in intimate partner relationships.⁵ Similarly, researchers also have noted that traumatic experiences can affect an individual’s attachment style, resulting in progressive avoidance of interpersonal relationships, which can lead to marked difficulties in maintaining and beginning intimate partner relationships.^6,7 Despite these known consequences of PTSD, as Dekel and Monson noted in a review,further research is still needed regarding the mechanisms by which trauma and PTSD result in decreased intimate partner relationship functioning among veterans.⁸ Nonetheless, as positive interpersonal relationships are associated with decreased PTSD symptom severity^9,10 and increased engagement in PTSD treatment,¹¹ determining methods of measuring intimate partner relationship functioning in veterans with PTSD is important to inform future research and aid the provision of care.

To date, limited research has examined the valid measurement of intimate partner relationship functioning among veterans with PTSD. Many existing measures that comprehensively assess intimate partner relationship functioning are time and resource intensive. One such measure, the Timberlawn Couple and Family Evaluation Scales (TCFES), comprehensively assesses multiple pertinent domains of intimate partner relationship functioning (ie, structure, autonomy, problem solving, affect regulation, and disagreement/conflict).¹² By assessing multiple domains, the TCFES offers a method of understanding the specific components of an individual’s intimate partner relationship in need of increased clinical attention.¹² However, the TCFES is a time- and labor-intensive observational measure that requires a couple to interact while a blinded, independent rater observes and rates their interactions using an intricate coding process. This survey structure precludes the ability to quickly and comprehensively assess a veteran’s intimate partner functioning in settings such as mental health outpatient clinics where mental health providers engage in brief, time-limited psychotherapy. As such, brief measures of intimate partner relationship functioning are needed to best inform clinical care among veterans with PTSD.

The primary aim of the current study was to create a psychometrically valid, yet brief, self-report version of the TCFES to assess multiple domains of intimate partner relationship functioning. The psychometric properties of this measure were assessed among a sample of US veterans with PTSD who were in an intimate partner relationship. We specifically examined factor structure, reliability, and associations to established measures of specific domains of relational functioning.

Methods

Ninety-four veterans were recruited via posted advertisements, promotion in PTSD therapy groups/staff meetings, and word of mouth at the Dallas Veterans Affairs Medical Center (VAMC). Participants were eligible if they had a documented diagnosis of PTSD as confirmed in the veteran’s electronic medical record and an affirmative response to currently being involved in an intimate partner relationship (ie, legally married, common-law spouse, involved in a relationship/partnership). There were no exclusion criteria.

Interested veterans were invited to complete several study-related self-report measures concerning their intimate partner relationships that would take about an hour. They were informed that the surveys were voluntary and confidential, and that they would be compensated for their participation. All veterans who participated provided written consent and the study was approved by the Dallas VAMC institutional review board.

Of the 94 veterans recruited, 3 veterans’ data were removed from current analyses after informed consent but before completing the surveys when they indicated they were not currently in a relationship or were divorced. After consent, the 91 participants were administered several study-related self-report measures. The measures took between 30 and 55 minutes to complete. Participants were then compensated $25 for their participation.

Intimate Partner Relationship Functioning

The 16-item TCFES self-report version (TCFES-SR) was developed to assess multiple domains of interpersonal functioning (Appendix). The observational TCFES assesses 5 intimate partner relationship characteristic domains (ie, structure, autonomy, problem solving, affect regulation, and disagreement/conflict) during a couple’s interaction by an independent trained rater.¹² Each of the 16 TCFES-SR items were modeled after original constructs measured by the TCFES, including power, closeness, clarify, other’s views, responsibility, closure, negotiation, expressiveness, responsiveness, positive regard, negative regard, mood/tone, empathy, frequency, affective quality, and generalization and escalation. To maintain consistency with the TCFES, each item of the TCFES-SR was scored from 1 (severely dysfunctional) to 5 (highly functional). Additionally, all item wording for the TCFES-SR was based on wording in the TCFES manual after consultation with an expert who facilitated the development of the TCFES.¹² On average, the TCFES-SR took 5 to 10 minutes to complete.

To measure concurrent validity of the modified TCFES-SR, several additional interpersonal measures were selected and administered based on prior research and established domains of the TCFES. The Positive and Negative Quality in Marriage Scale (PANQIMS) was administered to assess perceived attitudes toward a relationship.^13,14 The PANQIMS generates 2 subscales: positive quality and negative quality in the relationship. Because the PANQIMS specifically assesses married relationships and our sample included married and nonmarried participants, wording was modified (eg, “spouse/partner”).

The relative power subscale of the Network Relationships Inventory–Relationship Qualities Version (NRI-RQV) measure was administered to assess the unequal/shared role romantic partners have in power equality (ie, relative power).¹⁵

The Revised Dyadic Adjustment Scale (RDAS) is a self-report measure that assesses multiple dimensions of marital adjustment and functioning.¹⁶ Six subscales of the RDAS were chosen based on items of the TCFES-SR: decision making, values, affection, conflict, activities, and discussion.

The Interpersonal Reactivity Index (IRI) empathetic concern subscale was administered to assess empathy across multiple contexts and situations¹⁷ and the Experiences in Close Relationships-Revised Questionnaire (ECR-R) was administered to assess relational functioning by determining attachment-related anxiety and avoidance.¹⁸

Sociodemographic Information

A sociodemographic questionnaire also was administered. The questionnaire assessed gender, age, education, service branch, length of interpersonal relationship, race, and ethnicity of the veteran as well as gender of the veteran’s partner.

Statistical Analysis

Factor structure of the TCFES-SR was determined by conducting an exploratory factor analysis. To allow for correlation between items, the Promax oblique rotation method was chosen.¹⁹ Number of factors was determined by agreement between number of eigenvalues ≥ 1, visual inspection of the scree plot, and a parallel analysis. Factor loadings of ≥ 0.3 were used to determine which items loaded on to which factors.

Convergent validity was assessed by conducting Pearson’s bivariate correlations between identified TCFES-SR factor(s) and other administered measures of interpersonal functioning (ie, PANQIMS positive and negative quality; NRI-RQV relative power subscale; RDAS decision making, values, affection, conflict, activities, and discussion subscales; IRI-empathetic concern subscale; and ECR-R attachment-related anxiety and avoidance subscales). Strength of relationship was determined based on the following guidelines: ± 0.3 to 0.49 = small, ± 0.5 to 0.69 = moderate, and ± 0.7 to 1.00 = large. Internal consistency was also determined for TCFES-SR factor(s) using Cronbach’s α. A standard level of significance (α=.05) was used for all statistical analyses.

Results

Eighty-six veterans provided complete data (Table 1). The Kaiser-Meyer-Olkin measure of sampling adequacy was indicative that sample size was adequate (.91), while Bartlett’s test of sphericity found the variables were suitable for structure detection, χ²(120) = 800.00, P < .001. While 2 eigenvalues were ≥ 1, visual inspection of the scree plot and subsequent parallel analysis identified a unidimensional structure (ie, 1 factor) for the TCFES-SR. All items were found to load to this single factor, with all loadings being ≥ 0.5 (Table 2). Additionally, internal consistency was excellent for the scale (α = .93).

Pearson’s bivariate correlations were significant (P < .05) between TCFES-SR total score, and almost all administered interpersonal functioning measures (Table 3). Interestingly, no significant associations were found between any of the administered measures, including the TCFES-SR total score, and the IRI-empathetic concern subscale (P > .05).

Discussion

These findings provide initial support for the psychometric properties of the TCFES-SR, including excellent internal consistency and the adequate association of its total score to established measures of interpersonal functioning. Contrary to the TCFES, the TCFES-SR was shown to best fit a unidimensional factor rather than a multidimensional measure of relationship functioning. However, the TCFES-SR was also shown to have strong convergent validity with multiple domains of relationship functioning, indicating that the measure of overall intimate partner relationship functioning encompasses a number of relational domains (ie, structure, autonomy, problem solving, affect regulation, and disagreement/conflict). Critically, the TCFES-SR is brief and was administered easily in our sample, providing utility as clinical tool to be used in time-sensitive outpatient settings.

A unidimensional factor has particular strength in providing a global portrait of perceived intimate partner relationship functioning, and mental health providers can administer the TCFES-SR to assess for overall perceptions of intimate partner relationship functioning rather than administering a number of measures focusing on specific interpersonal domains (eg, decision making processes or positive/negative attitudes towards one’s relationship). This allows for the quick assessment (ie, 5-10 minutes) of overall intimate partner relationship functioning rather than administration of multiple self-report measures which can be time-intensive and expensive. However, the TCFES-SR also is limited by a lack of nuanced understanding of perceptions of functioning specific to particular domains. For example, the TCFES-SR score cannot describe intimate partner functioning in the domain of problem solving. Therefore, brief screening tools need to be developed that assess multiple intimate partner relationship domains.

Importantly, overall intimate partner relationship functioning as measured by the TCFES-SR may not incorporate perceptions of relationship empathy, as the total score did not correlate with a measure of empathetic concern (ie, the IRI-empathetic concern subscale). As empathy was based on one item in the TCFES-SR vs 7 in the IRI-empathetic concern subscale, it is unclear if the TCFES-SR only captures a portion of the construct of empathy (ie, sensitivity to partner) vs the comprehensive assessment of trait empathy that the IRI subscale measures. Additionally, the IRI-empathetic concern subscale did not significantly correlate with any of the other administered measures of relationship functioning. Given the role of empathy in positive, healthy intimate partner relationships, future research should explore the role of empathetic concern among veterans with PTSD as it relates to overall (eg, TCFES-SR) and specific aspects of intimate partner relationship functioning.²⁰

While the clinical applicability of the TCFES-SR requires further examination, this measure has a number of potential uses. Information captured quickly by the TCFES-SR may help to inform appropriate referral for treatment. For instance, veterans reporting low total scores on the TCFES-SR may indicate a need for a referral for intervention focused on improving overall relationship functioning (eg, Integrative Behavioral Couple Therapy).^21,22 Measurement-based care (ie, tracking and discussing changes in symptoms during treatment using validated self-report measures) is now required by the Joint Commission as a standard of care,and has been shown to improve outcomes in couples therapy.^23,24 As a brief self-report measure, the TCFES-SR may be able to facilitate measurement-based care and assist providers in tracking changes in overall relationship functioning over the course of treatment. However, the purpose of the current study was to validate the TCFES-SR and not to examine the utility of the TCFES-SR in clinical care; additional research is needed to determine standardized cutoff scores to indicate a need for clinical intervention.

Limitations

Several limitations should be noted. The current study only assessed perceived intimate partner relationship functioning from the perspective of the veteran, thus limiting implications as it pertains to the spouse/partner of the veteran. PTSD diagnosis was based on chart review rather than a psychodiagnostic measure (eg, Clinician Administered PTSD Scale); therefore, whether this diagnosis was current or in remission was unclear. Although our sample was adequate to conduct an exploratory factor analysis,the overall sample size was modest, and results should be considered preliminary with need for further replication.²⁵ The sample was also primarily male, white or black, and non-Hispanic; therefore, results may not generalize to a more sociodemographically diverse population. Finally, given the focus of the study to develop a self-report measure, we did not compare the TCFES-SR to the original TCFES. Thus, further research examining the relationship between the TCFES-SR and TCFES may be needed to better understand overlap and potential incongruence in these measures, and to ascertain any differences in their factor structures.

Conclusion

This study is novel in that it adapted a comprehensive observational measure of relationship functioning to a self-report measure piloted among a sample of veterans with PTSD in an intimate partner relationship, a clinical population that remains largely understudied. Although findings are preliminary, the TCFES-SR was found to be a reliable and valid measure of overall intimate partner relationship functioning. Given the rapid administration of this self-report measure, the TCFES-SR may hold clinical utility as a screen of intimate partner relationship deficits in need of clinical intervention. Replication in a larger, more diverse sample is needed to further examine the generalizability and confirm psychometric properties of the TCFES-SR. Additionally, further understanding of the clinical utility of the TCFES-SR in treatment settings remains critical to promote the development and maintenance of healthy intimate partner relationships among veterans with PTSD. Finally, development of effective self-report measures of intimate partner relationship functioning, such as the TCFES-SR, may help to facilitate needed research to understand the effect of PTSD on establishing and maintaining healthy intimate partner relationships among veterans.

Acknowledgments

The current study was funded by the Timberlawn Psychiatric Research Foundation. This material is the result of work supported in part by the US Department of Veterans Affairs; the Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention; Sierra Pacific MIRECC; and the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, Department of Veterans Affairs.

References

1. Kilpatrick DG, Resnick HS, Milanak ME, Miller MW, Keyes KM, Friedman MJ. National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. J Trauma Stress. 2013;26(5):537-547.

2. Lehavot K, Goldberg SB, Chen JA, et al. Do trauma type, stressful life events, and social support explain women veterans’ high prevalence of PTSD? Soc Psychiatry Psychiatr Epidemiol. 2018;53(9):943-953.

3. Galovski T, Lyons JA. Psychological sequelae of combat violence: a review of the impact of PTSD on the veteran’s family and possible interventions. Aggress Violent Behav. 2004;9(5):477-501.

4. Ray SL, Vanstone M. The impact of PTSD on veterans’ family relationships: an interpretative phenomenological inquiry. Int J Nurs Stud. 2009;46(6):838-847.

5. Cloitre M, Miranda R, Stovall-McClough KC, Han H. Beyond PTSD: emotion regulation and interpersonal problems as predictors of functional impairment in survivors of childhood abuse. Behav Ther. 2005;36(2):119-124.

6. McFarlane AC, Bookless C. The effect of PTSD on interpersonal relationships: issues for emergency service works. Sex Relation Ther. 2001;16(3):261-267.

7. Itzhaky L, Stein JY, Levin Y, Solomon Z. Posttraumatic stress symptoms and marital adjustment among Israeli combat veterans: the role of loneliness and attachment. Psychol Trauma. 2017;9(6):655-662.

8. Dekel R, Monson CM. Military-related post-traumatic stress disorder and family relations: current knowledge and future directions. Aggress Violent Behav. 2010;15(4):303-309.

9. Allen ES, Rhoades GK, Stanley SM, Markman HJ. Hitting home: relationships between recent deployment, posttraumatic stress symptoms, and marital functioning for Army couples. J Fam Psychol. 2010;24(3):280-288.

10. Laffaye C, Cavella S, Drescher K, Rosen C. Relationships among PTSD symptoms, social support, and support source in veterans with chronic PTSD. J Trauma Stress. 2008;21(4):394-401.

11. Meis LA, Noorbaloochi S, Hagel Campbell EM, et al. Sticking it out in trauma-focused treatment for PTSD: it takes a village. J Consult Clin Psychol. 2019;87(3):246-256.

12. Lewis JM, Gossett JT, Housson MM, Owen MT. Timberlawn Couple and Family Evaluation Scales. Dallas, TX: Timberlawn Psychiatric Research Foundation; 1999.

13. Fincham FD, Linfield KJ. A new look at marital quality: can spouses feel positive and negative about their marriage? J Fam Psychol. 1997;11(4):489-502.

14. Kaplan KJ. On the ambivalence-indifference problem in attitude theory and measurement: a suggested modification of the semantic differential technique. Psychol Bull. 1972;77(5):361-372.

15. Buhrmester D, Furman W. The Network of Relationship Inventory: Relationship Qualities Version [unpublished measure]. University of Texas at Dallas; 2008.

16. Busby DM, Christensen C, Crane DR, Larson JH. A revision of the Dyadic Adjustment Scale for use with distressed and nondistressed couples: construct hierarchy and multidimensional scales. J Marital Fam Ther. 1995;21(3):289-308.

17. Davis MH. A multidimensional approach to individual differences in empathy. JSAS Catalog Sel Doc Psychol. 1980;10:85.

18. Fraley RC, Waller NG, Brennan KA. An item-response theory analysis of self-report measures of adult attachment. J Pers Soc Psychol. 2000;78(2):350-365.

19. Tabachnick BG, Fidell L. Using Multivariate Statistics. 6th ed. Boston, MA: Pearson; 2013.

20. Sautter FJ, Armelie AP, Glynn SM, Wielt DB. The development of a couple-based treatment for PTSD in returning veterans. Prof Psychol Res Pr. 2011;42(1):63-69.

21. Jacobson NS, Christensen A, Prince SE, Cordova J, Eldridge K. Integrative behavioral couple therapy: an acceptance-based, promising new treatment of couple discord. J Consult Clin Psychol. 2000;9(2):351-355.

22. Makin-Byrd K, Gifford E, McCutcheon S, Glynn S. Family and couples treatment for newly returning veterans. Prof Psychol Res Pr. 2011;42(1):47-55.

23. Peterson K, Anderson J, Bourne D. Evidence Brief: Use of Patient Reported Outcome Measures for Measurement Based Care in Mental Health Shared Decision Making. Washington, DC: Department of Veterans Affairs; 2018. https://www.ncbi.nlm.nih.gov/books/NBK536143. Accessed September 13, 2019.

24. Fortney JC, Unützer J, Wrenn G, et al. A tipping point for measurement-based care. Psychiatr Serv. 2017;68(2):179-188.

25. Costello AB, Osborne JW. Best practices in exploratory factor analysis: four recommendations for getting the most from your analysis. Pract Assess Res Eval. 2005;10(7):1-9.

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Author and Disclosure Information

Ryan Holliday is a Clinical Research Psychologist at the Rocky Mountain Regional VA Medical Center, Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention in Aurora, Colorado and Assistant Professor in the Department of Psychiatry at the University of Colorado Anschutz Medical Campus. Nicholas Holder is an Advanced Research Postdoctoral Fellow at the San Francisco Veterans Affairs Health Care System, Sierra Pacific MIRECC, and in the Department of Psychiatry at the University of California, San Francisco School of Medicine. Jessica Wiblin is a VA Advanced Fellow in Women’s Health at the VA Los Angeles HSR&D CSHIIP (Center for the Study of Healthcare Innovation, Implementation, & Policy) in California. Alina Surís is a Clinical Professor in the Department of Psychiatry at the University of Texas Southwestern Medical Center in Dallas, Texas.
Correspondence: Ryan Holliday (ryan.holliday@va.gov)

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A modified version of the the Timberlawn Couple and Family Evaluation Scales was validated to assess intimate partner relationship functioning among veterans who suffer from PTSD.

Methods

Intimate Partner Relationship Functioning

Sociodemographic Information

Statistical Analysis

Results

Discussion

Limitations

Conclusion

Acknowledgments

Methods

Intimate Partner Relationship Functioning

Sociodemographic Information

Statistical Analysis

Results

Discussion

Limitations

Conclusion

Acknowledgments