Exploring Moral Injury: Theory, Measurement, and Applications

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Exploring Moral Injury: Theory, Measurement, and

Applications

Hazel R. Atuel, Ryan Chesnut, Cameron Richardson, Daniel F. Perkins & Carl

A. Castro

To cite this article: Hazel R. Atuel, Ryan Chesnut, Cameron Richardson, Daniel F. Perkins &

Carl A. Castro (2020): Exploring Moral Injury: Theory, Measurement, and Applications, Military

Behavioral Health, DOI: 10.1080/21635781.2020.1753604

To link to this article: https://doi.org/10.1080/21635781.2020.1753604

Published online: 17 Apr 2020.

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RESEARCH ARTICLE

Exploring Moral Injury: Theory, Measurement, and Applications

Hazel R. Atuel

, Ryan Chesnut

, Cameron Richardson

, Daniel F. Perkins

, and Carl A. Castro

Center for Innovation and Research on Veterans & Military Families, University of Southern California (USC), Center for Innovation

and Research on Veterans & Military Families, Los Angeles, California;

Clearinghouse for Military Family Readiness, The Pennsylvania

State University (PSU), Clearinghouse for Military Family Readiness, University Park, Pennsylvania;

School of Social Work and

Psychology, University of Southern California, Los Angeles, California

ABSTRACT

This research brief summarizes and highlights presentations on moral injury related to the-

ory, measurement, and applications. The overall was to identify current gaps and propose

next steps to advance the science of moral injury.

KEYWORDS

Moral injury; theory;

measurement; applica-

tions; research

During the writing of this research brief (late March

2020), our world is facing a new normal. On a global

level, the coronavirus outbreak has disrupted how we

work, interact with each other, engage in mundane

activities, and participate in community life. Our daily

lives had to change. And, in a relatively short period

of time, we were compelled and propelled to accom-

modate alternative ways of living to survive. We had

to change. As we explore new ways or continue old

ways of thriving in newly defined individual and

social spaces, one thing is clear: the experience of

change is both personal and communal. Personal

because each of us had unique ways of readjusting

and communal because this pivoting is a shared

experience with others who are proximal and distal to

us. Ultimately, this experience has changed both our

personal stories and community histories.

What does this reflection on the coronavirus pan-

demic have to do with a research brief on moral

injury? Because as social scientists, we simply could

not help ourselves but think, try to make sense of, or

even go as far as to find purpose in this chaos. We

could conceive of this unprecedented worldwide event

as a real-world experiment on our response to the suf-

fering or death we read in our news feeds, or possibly

know of directly or indirectly. How are we changed

by the knowledge or experience of our own or others’

suffering as well as the death of others? We are raising

this critical question upfront because some of the

issues at the heart of moral injury speak to the human

capacity and ability to respond to an adverse singular

event or series of events that have moral implications.

Whether or not this outbreak, particularly focusing on

the human factors at work (e.g., decisions made at

various levels, rhetoric used to frame the event), will

eventually fall under the rubric of moral injury will be

a topic of later discussions. For now, we would like to

acknowledge and note that these historic events might

force us to reconsider our current knowledge of moral

injury in the foreseeable future. Stated differently,

what we are going through is perhaps an invitation to

move us beyond what we already know and have

applied to a subset of the population to a more

expanded understanding that will have wider implica-

tions to the varieties of human experience.

With that said, let us now turn to what we initially

set out to do.

Toward a science of moral injury

In the Fall of 2019, we at the University of Southern

California’s Center for Innovation and Research on

Veterans & Military Families (USC) and the

Pennsylvania State University’s Clearinghouse for

Military Family Readiness (PSU) were in the planning

stages of a military research summit to be held in

early February 2020. What emerged from our conver-

sations was that we were leaning toward building a

science of moral injury. Admittedly a very ambitious

research agenda, that prompted us to ask each other,

“where do we even start?”. We chose to answer three

basic questions: (1) what do we already know, (2)

ß 2020 Taylor & Francis Group, LLC

CONTACT Hazel R. Atuel [email protected] Center for Innovation and Research on Veterans & Military Families, University of Southern California

(USC), Center for Innovation and Research on Veterans & Military Families, Los Angeles, CA 90089-0001, USA.

MILITARY BEHAVIORAL HEALTH

https://doi.org/10.1080/21635781.2020.1753604

what else do we need to know, and (3) what are the

scientific building-blocks needed to move the field

forward? Guided by these queries and reined in by

what can be done in a one-day summit, we decided to

focus on identifying gaps in and advancements for the

current knowledge base in terms of theory, measure-

ment, and applications. We do not need to belabor

you, the reader, on the importance of theory and

measurement in laying the conceptual foundation of a

particular field, coupled with the critical role of appli-

cations in empirically demonstrating the robustness

and utility of a particular construct. What was import-

ant for us was to set the conceptual and empirical

footings as parallel tracks within this budding scien-

tific field.

Considering that the majority of research has

focused on the clinical correlates of moral injury (see

Griffin et al., 2019 for the most recent review), we

decided to convene researchers and practitioners who

offered alternative explanations or presented on rela-

tively new findings that had direct consequences to

theory, measurement, or practice (in terms of preven-

tion and intervention). Our deliberate choice to hear

divergent perspectives was driven by a desire to pro-

mote conversations that would forge new ways of

conceptualizing and measuring moral injury, as well

as its cross-cultural applications. Hence, on February

11, 2020, USC and PSU hosted the joint research

summit titled, “Exploring Moral Injury: Theory,

Measurement, and Applications” in Los Angeles,

California. What follows are summaries and highlights

of the different presentations shared at the summit.

Theoretical frameworks on moral injury

Dr. Donna Ames (University of California, Los

Angeles and the Los Angeles Veterans Affairs Medical

Center) presented on the spiritual dimension of moral

injury – ranging from measurement (Koenig et al.,

2018) to spiritually integrated treatments (Pearce

et al., 2018 ). This work is in collaboration with Dr.

Harold Koenig whose work on moral injury is based

on the intersection of spirituality, theology, and

health. First, based on the validation studies of the

Moral Injury Symptom Scale-Military Version (MISS-

M; Koenig et al., 2018), results reveal that Post-

Traumatic Stress Disorder (PTSD) is distinct from

moral injury, suggesting that what can be described as

an inner conflict (e.g., spiritual struggles, shame, loss

of trust, meaning, and hope) can be differentiated

from clinical symptoms (e.g., PTSD symptoms,

depression, anxiety). Moreover, Dr. Ames stressed the

importance of the relational component of moral

injury. As she explained, a person suffering from

moral injury has a broken relationship with self, with

another person, and/or with a higher being or power.

When spirituality or religiosity is salient, there is the

possibility of receiving treatments other than or above

and beyond the traditional offerings made available at

Veterans Affairs Medical Centers, specifically

Cognitive Processing Therapy (CPT; Resick et al.,

2017) and Prolonged Exposure Therapy (PE; Foa

et al., 2007). Second, developed in conjunction with

chaplains, spiritually integrated treatments focus on

moral injury dimensions (e.g., shame, moral concerns,

religious struggles, loss of faith) that are not part of

secular treatment modules. When tailored this way,

healing is postulated to occur at the level of the soul

and involves engaging in traditional spiritual or reli-

gious acts such as lament, repentance, confession,

and atonement.

Dr. Hazel Atuel (USC) presented on a virtue-based

definition of moral injury (Atuel & Castro, 2019;

Atuel, Jones, Greenberg, Williamson, Barr, Vermetten

et al., in preparation) that borrows from moral phil-

osophy (e.g., Nichomacean Ethics; trans. 2006), moral

psychology (e.g., Strohminger et al., 2017), character

psychology (e.g., Lapsley & Stey, 2014), and social

psychology (e.g., Brewer, 1991). This multidisciplinary

framework advances a broader theoretical foundation

that is not defined by and does not necessarily reflect

clinical impairments. This framework provides a char-

acter pathway that is differentiated from the trad-

itional clinical pathway by defining moral injury as a

psychological state that arises in the aftermath of

moral failure. To have an effect on an individual’

character and identity, the moral failure experience

has to be of significance, often involving suffering or

death. The definition of suffering, however, is not lim-

ited to traumatic events (e.g., war trauma, sexual

assault). Rather, suffering is argued to stem from a

wider range of behaviors or interactions reflecting the

lack of human goodness (or human excellence in

terms of the Aristotelian moral virtues), with simple

acts (e.g., apathy or meanness toward another person)

on one end and traumatic events at the other end of

this spectrum. Moral injury situates an individual in a

less than virtuous state of being (in the Aristotelian

context of character and identity), where the moral

injury struggle is postulated to be an identity negoti-

ation process between the ‘good-me’ (real-self) and

the ‘bad-me’ (who the person has become in the after-

math of moral failure).

2 H. R. ATUEL ET AL.

Measurement

A number of measurement gaps were identified prior

to the summit, the most pressing of which is the need

for more high-quality data and replication trials to

help test theoretical propositions and preliminary

empirical findings. In service to this goal, Dr.

Cameron Richardson (PSU) presented on a recent

conceptual replication and extension of prior factor

analytic work on the Moral Injury Event Scale

(Richardson et al., 2020) and associated definitional

and measurement considerations drawn in part from

social domain theory (Turiel, 1983; Smetana, 2006).

Essential to the task of developing a science of moral

injury is to be clear on what is and is not within the

scope of investigation. With the goal of achieving clar-

ity on scope, Dr. Richardson attempted to differentiate

between moral transgressions, which encompass

actions that impinge on others’ welfare, and social

conventional transgressions, which comprise poten-

tially important yet morally irrelevant actions that fall

outside agreed upon norms. A prototypic example of

a social conventional transgression in a military con-

text is the failure to salute a superior. In this scenario,

the action has been sanctioned by the Military as a

means of showing respect and maintaining order and

efficiency; however, an individual choosing to trans-

gress, or a unit collaboratively choosing to forgo the

formality of the salute, is not anticipated to affect an

individual’s welfare, and as such it is anticipated to lie

outside the bounds of moral injury.

Regarding the attempt to replicate the MIES factor

structures found in prior studies (Nash et al., 2013;

Bryan et al., 2016), Dr. Richardson noted he and his

colleagues found that a two-factor solution, which dif-

fered from previous solutions, fit the data best for a

normative sample of veterans drawn from the

Veterans Metric Initiative (TVMI; Vogt et al., 2018),

which is a panel study of post-9/11 US veterans’

reintegration into civilian life. The two-factor solution

consisted of self- and other-transgressions, which is

aligned with current theoretical notions of moral

injury sub-types (Litz et al., 2018; Stein et al., 2012).

In addition, he and colleagues found that the event

(e.g., “I saw things that were morally wrong”) and

reaction (e.g., “I am troubled by having witnessed

others’ immoral acts”) items were statistically indistin-

guishable (Richardson et al., 2020); thus, the removal

of the event items did not appreciably affect model fit.

Given the generality of the item wording, discussion

revolved around the potential utility of deploying the

MIES as a non-threatening screener.

Applications

The third focus of our research summit involved dis-

cussions pertaining to the application of moral injury

theory and measurement to the everyday lives of mili-

tary service members, their families, and their com-

munities. Since Litz et al. (2009) seminal article on

moral injury that reinvigorated social scientists’ inter-

est in the topic, an abundance of scholarly work has

been produced. A search of the Scopus database from

1960 to 2008 produced only eight scholarly works

with the term “moral injury” in the abstract. In con-

trast, a search from 2009 to the present returned 265

scholarly products containing the term “moral injury”

in the abstract.

The notable increase in scholarly attention over the

last decade has primarily focused on definitional, the-

oretical, and operational clarity. Arguably, significant

gaps in scholarship focused on rigorous examinations

of moral injury’s impact on functioning (e.g., individ-

ual, familial, communal), associated risk and protect-

ive factors, and methods and mechanisms for healing

moral wounds still exists. Yet, the need for applied

moral injury research was fully recognized by the

summit organizers and attendees, because it is perhaps

the most pressing issue facing practitioners, policy-

makers, communities, and families engaging with

those who have been morally injured.

Our time spent discussing moral injury applications

involved three presentations that covered moral

injury’s impact on US veterans’ social well-being,

Adaptive Disclosure as a therapeutic treatment option

for morally injured service members, and the experi-

ence of moral injury among UK veterans.

Moral injury is postulated to be associated with

impaired social well-being (Carey & Hodgson, 2018;

Jinkerson, 2016; Koenig et al., 2017; Litz et al., 2009).

To date, there is a paucity of research examining the

relationships between moral injury arising from self-

and other- directed transgressions and social well-

being, especially among veterans. Dr. Ryan Chesnut

(PSU) presented on a longitudinal study using the

first four waves of data from TVMI (Vogt et al., 2018)

that he and his colleagues conducted to examine the

relationships among self- and other-directed moral

injury and four aspects of social well-being: social

support, social functioning, social activity involve-

ment, and social satisfaction (Chesnut et al., under

We originally invited at least two speakers for each topic. Due to

scheduling conflicts, Dr. Cameron Richardson became the lone speaker on

measurement.

MILITARY BEHAVIORAL HEALTH 3

review). He noted three important findings from their

analyses. First, other-directed moral injury was

inversely related to all four social well-being outcomes

at baseline; however, self-directed moral injury was

negatively associated with baseline social functioning

but positively associated with baseline social activity

involvement. Second, all four social well-being out-

comes declined over time. Third, self- and other-

directed moral injury differentially predicted these

declines in social well-being with other-directed moral

injury having consistently stronger effects than self-

directed moral injury. Collectively, these findings

imply that the relationships among moral injury sub-

types and veterans’ social well-being are complex and

require greater scholarly attention. Moreover, these

findings indicate the period of service separation may

be an optimal window for targeting prevention and

treatment efforts to curtail veterans’ declines in social

well-being.

While consensus continues to mount that moral

injury is a unique type of psychological stressor, there

is an ongoing debate about best practices for treatment.

Some scholars (Held et al., 2018;Pauletal.,2014)

argue established evidence-based treatments for PTSD

should suffice, while other scholars (Gray et al., 2012;

Litz et al., 2016) suggest standard PTSD treatments

may be insufficient for treating moral injury. Dr. Matt

Gray (University of Wyoming) presented on a thera-

peutic approach, Adaptive Disclosure, that he and his

colleagues developed to address combat-related stress

stemming from three sources: fear, loss, and moral

injury. He noted two principal challenges with applying

established PTSD treatments to moral injury: (1) indi-

viduals’ appraisals of the morally injurious experien-

ce(s) may be accurate, which may make cognitive

restructuring practices inutile or possibly even harmful;

and (2) shame and guilt (the primary emotional reac-

tions of moral injury) are fundamentally different than

fear and anxiety (the primary emotional reactions of

PTSD), which may make exposure techniques ineffect-

ive. Given these challenges, Adaptive Disclosure seeks

to help service members experiencing distress due to

moral injury by helping them make sense of the mor-

ally injurious experience(s) and focusing their attention

on what the future holds for them. Adaptive Disclosure

stresses forgiveness (of both self and others) and mak-

ing amends (real or symbolic). Dr. Gray presented the

results of a small, uncontrolled feasibility study of a

six-session version of Adaptive Disclosure implemented

with 44 Marines at Camp Pendleton (Gray et al.,

2012). Results indicated Adaptive Disclosure merits fur-

ther exploration as a treatment for moral injury.

Currently, a non-inferiority trial is underway investigat-

ing the effects of a 12-session version of Adaptive

Disclosure on combat-related stress conditions com-

pared to the standard version of CPT (Resick

et al., 2017).

Our research summit’s presentations predominately

focused on moral injury within the context of US

military service. However, moral injury is not unique

to the US. Dr. Victoria Williamson (King’s Center for

Military Health Research) presented on work that she

and her colleagues have undertaken to examine moral

injury within UK veterans (Williamson et al., 2020).

Similar to studies of US veterans, Dr. Williamson and

her colleagues found that moral injury was a common

experience among the veterans they interviewed. Dr.

Williamson also noted that while morally injurious

events were uniquely experienced by some of the vet-

erans in their study, a number of veterans also

reported experiencing mixed events, that is experien-

ces that simultaneously threatened their life and trans-

gressed their deeply held moral beliefs. This highlights

the complexity of combat and suggests treatments

designed for combat-related stress conditions need to

be able to address multiple experiences. Veterans who

reported morally injurious and mixed events also

described impairments in their mental, social (includ-

ing familial), and occupational functioning. A number

of risk factors for experiencing moral injury were

identified, such as unclear rules of engagement, lack

of unit preparedness, and lack of support from

commanders and social networks. Similar to the pres-

entation on moral injury and US veterans’ social well-

being, Dr. Williamson noted the transition from mili-

tary to civilian life may be an important period for

providing prevention and intervention services, as this

transition could be a risk factor for the development

of moral injury and its associated sequalae.

Next steps

Our research summit culminated in a discussion of

how to advance the field of moral injury. This discus-

sion mirrored the summit’s programmatic structure of

theory, measurement, and applications.

Theory

There was consensus that further attention needs to be

given to defining and delineating the moral injury con-

struct. Currently, there is no agreed upon definition of

moral injury and a number of related terms are begin-

ning to emerge within the literature, such as moral pain

(Farnsw ort h et al., 2017), moral frustration (Litz &

4 H. R. ATUEL ET AL.

Kerig, 2019), and moral distress (Litz & Kerig, 2019).

Indeed, some speakers at the summit introduced new

terminology during their presentations, such as moral

decay and moral dissonance. Certainly, moral injury is

a complex psychological experience requiring a detailed

and nuanced array of terminology to adequately explain

its etiology and developmental course. However, with-

out a clear and agreed upon conceptual definition, the

research waters will continue to be muddied, and the

field will not advance at an adequate pace to effectively

inform practice.

Perhaps this slow progress in laying a theoretical

foundation can be primarily attributed to social scien-

tists being siloed within our own academic disciplines.

If moral injury, as some have argued (e.g., Shay, 2003),

is a relatively new term for an age-old problem, we

need to look to older disciplines to realize the concep-

tual gains we seek. For us, this means borrowing from

various branches within philosophy, theology, and reli-

gious studies, to name just a few. What the past decade

has taught us is the study of moral injury does not and

cannot be solely within the purview of our own discip-

line (e.g., psychology), but needs to be informed by a

multidisciplinary framework. Only then can we broaden

the lexicon of moral injury beyond its current clinical

confines, and expan d its applicability into the realm of

everyday human experiences. This long-term theoretical

investment must be made to advance the field.

In the short-term and at the very least, in order for

the field to achieve conceptual clarity, agreement must

be reached on what makes moral injury unique and dif-

ferentiated from other psychological states and mental

health issues. In our opinion, the most closely related

construct that moral injury needs to be delineated from

is PTSD. Research focused on this differentiation is

accumulating (e.g., Barnes et al., 2019;Bryanetal.,

2018;Koenigetal.,2020), yet the question continues to

be asked: “Is moral injury distinct from PTSD?” What

is needed at this point is a resource that synthesi zes the

extant research focused on differentiating moral injury

and PTSD in a non-technical manner that is of practical

use regardless of one’s professional background.

Currently, we are working to develop such a resource

by creating an evidence-infor med visual matrix of the

unique and overlapping aspects of moral injury

and PTSD.

Measurement

Our discussions highlighted several gaps in the cur-

rent knowledge base that need to be addressed for the

field to make significant progress over the next dec-

ade. Since the introduction of the MIES in 2013, a

number of moral injury measures have been devel-

oped, such as the Moral Injury Questionnaire (Currier

et al., 2015), the Expressions of Moral Injury Scale –

Military Version (Currier et al., 2018)), the Moral

Injury Symptom Scale (Koenig et al., 2018), and the

Perpetration-Induced Distress Scale for civilians

(Steinmetz et al., 2019). Currently, there is an inter-

national consortium of researchers and clinicians

working on the development of a new scale, the

Moral Injury Outcome Scale (Yeterian et al., 2019).

These moral injury specific instruments are in add-

ition to a number of currently available psychological

measures that assess one or more theoretically rele-

vant aspects of moral injury (for a review, see Koenig

et al., 2019).

Yet, despite the wide array of options for measur-

ing the moral injury construct, there is no gold stand-

ard assessment. Moreover, a screening tool is not

currently available, which certainly hampers the field’s

ability to efficiently identify those in need of greater

support and evaluate treatment impact. Our consensus

opinion is that the field needs to shift from measure-

ment development to refinement. Important questions

for the field to answer are: (1) “ What are the various

moral injury assessments actually measuring?”; (2)

“How well are they measuring what they purport to

assess?”; (3) “What are their similarities ”; (4) “

What

are their differences?”; and (5) “Which measures work

best for whom and under what circumstances?” This

last question is an especially important one for the

field to ask, as moral injury will likely be experienced

and expressed differently in various populations (e.g.,

normative vs clinical samples, active duty vs reserve

or national guard samples, military vs civilian sam-

ples) and in response to one’s perceived level of

involvement and/or control over the morally injurious

event (e.g., perpetrator, victim, witness).

Methods

Although we did not have presentations addressing

methodology (another scientific building-block), we

recognized the importance of not being solely reliant

on quantitative methods for measuring moral injury.

There is a richness to the moral injury construct that

cannot be adequately captured through a series of

closed-ended questions. The qualitative work Dr.

Williamson presented at our summit made this expli-

citly clear. Qualitative methods can enhance our

understanding of moral injury by providing us with

first-hand accounts of individuals’ experiences with

transgressive acts, suffering, and healing. In other

words, the use of qualitative methods allows for a

MILITARY BEHAVIORAL HEALTH 5

retrospective thick description approach (see Geertz,

2008) to the moral injury experience and contextual-

izes moral injury within a trajectory that interacts

with an individual’s biography, history, situation, rela-

tionships, and interactions (see Denzin, 2011). After

all, moral injury is an event or series of events that

occur at a given point in time within a person’s life-

time. The rich descriptions gained from this type of

research can help to refine the content of quantitative

measures. Finally, in addition, think-aloud protocols

can be employed with the currently available moral

injury instruments as a means of gaining deeper

insight in to participants’ cognitive processes related

to scale items. This would allow researchers to know

if respondents are understanding scale items as

intended, as well as provide insight in to how best to

adjust item wording if needed.

Applications

Finally, our discussion turned to ways to advance

applied moral injury research. Similar to the multitude

of moral injury measures, we noted there are a plethora

of treatments currently available for moral injury. Dr.

Gray presented on Adaptive Disclosure, but other pro-

posed treatment options include Prolonged Exposure

(Foa et al., 2007), Cognitive Processing Therapy (Resick

et al., 2017), Spiritually Integrated Cognitive Processing

Therapy (Pearce et al., 2018), Impact of Killing

(Maguen et al., 2017), Acceptance and Commitment

Therapy (Nieuwsma et al., 2015), and Eye Movement

Desensitization and Reprocessing therapy (Hurley,

2018). Yet, despite the impressive number of interven-

tion options, there is a general lack of efficacy or effect-

iveness data supporting their utility for treating moral

injury (Griffin et al., 2019). Attention needs to shift

from developing or modifying interventions for moral

injury to rigorously examining their impact. The non-

inferiority trial Dr. Gray mentioned in his presentation

is a good first step in this direction. Further, evaluation

studies documenting implementation barriers encoun-

tered and solutions found are required to advance prac-

tice. To that end, researchers may want to consider

using effectiveness-implementation hybrid designs

(Curran et al., 2012).

In addition to shifting the field’s attention to efficacy

and effectiven ess trials, we also discussed the merits of

adopting a public health approach to treating moral

injury. Such an approach would involve a continuum of

care ranging from prevention to intervention to main-

tenance. The public health framework developed by the

Institute of Medicine (O’Connell et al., 2009)could

serve as a useful template for developing a moral injury

continuum of care. Given the current state of affairs

with respect to treatment, which necessarily inhibits our

ability to study maintenance at this time, focusing on

prevention efforts appears to be the most logical way to

advance a public health perspective on moral injury.

Such work would need to focus on identifying risk and

protective factors and examining the utility of imple-

menting specific programs, such as Battlemind (Castro

et al., 2006) and Battlefield-Ethics Training (Warner

et al., 2011), at the universal, selective, and indicated

levels of prevention.

The social scientific study of moral injury is mov-

ing into its adolescent years. While the last decade

saw a significant increase in the amount of scholarly

attention devoted to the moral injury construct, there

is still much work to be done to ensure the next dec-

ade of research produces a mature field of study. Our

research summit identified a number of useful direc-

tions and initiatives for the field to pursue. Our hope

is that our summit, and this report, will stimulate

scholarly activities and collaborations that lead us to a

comprehensive science of moral injury. Such a science

would allow us as researchers, clinicians, practitioners,

and policy-makers to achieve the most important

function of studying moral injury: meeting the needs

of our service members, their families, and their

communities.

Acknowledgements

We would like to thank the international delegation of pre-

senters and attendees for coming to the 2020 Joint USC-

PSU Military Research Summit as well as the Panel

Presentation at the Los Angeles Veterans Collaborative. We

would also like to thank the generous support of Prudential

Financial and our respective institutions.

Funding

Dr. Victoria Williamson presented findings from a research

study funded by the Forces in Mind Trust (FiMT17/0920E).

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