Moral injury and moral repair in war veterans: A preliminary model and intervention strategy
Introduction
Service members are confronted with numerous moral and ethical challenges in war. They may act in ways that transgress deeply held moral beliefs or they may experience conflict about the unethical behaviors of others. Warriors may also bear witness to intense human suffering and cruelty that shakes their core beliefs about humanity. What happens to service members who are unable to contextualize or justify their actions or the actions of others and are unable to successfully accommodate various morally challenging experiences into their knowledge about themselves and the world? Are they at risk for developing long-lasting psycho-bio-social impairment? Is there a distinct syndrome of psychological, biological, behavioral, and relational problems that arises from serious and/or sustained morally injurious experiences? Or, do existing disorders, such as posttraumatic stress disorder (PTSD), sufficiently explain the sequelae of what we term moral injury? And, can existing psychological treatments for combat and operational PTSD be effective or impactful?
In the first iteration of the PTSD construct (DSM-III) “guilt about surviving while others have not or about behavior required for survival (emphasis added)” was a symptom of PTSD. This was chiefly the result of the predominance of thinking about the phenomenology of Vietnam veterans and clinical care experience with veterans of war. Consequently, prior to the DSM-III-R, clinicians in VA settings arguably tackled moral conflict and guilt (e.g., Friedman, 1981). Since then, there has been very little attention paid to the lasting impact of moral conflict-colored psychological trauma among war veterans in the clinical science community. A possible reason for the scant attention is that clinicians and researchers who work with service members and veterans focus most of their attention on the impact of life-threat trauma, failing to pay sufficient attention to the impact of events with moral and ethical implications; events that provoke shame and guilt may not be assessed or targeted sufficiently. This explanation seems plausible given the emphasis on fear memories in evidence-based models of treatment (e.g., Foa, Steketee, & Rothbaum, 1989).
It is also possible that some clinicians believe that addressing ethical conflicts and moral violations is outside the realm of their expertise, preferring to recommend religious counseling instead. Care-providers may also not hear about moral injury because service members' or veterans' shame and concern about adverse impact or repercussions (e.g., being shunned, rejected, misunderstood) prevent disclosure. Mental health professionals may contribute to this; they may unknowingly provide non-verbal messages that various acts of omission or commission in war are too threatening or abhorrent to hear. Some may believe that treatment would excuse illegal or immoral behavior in some way. Others may veer from the topic to avoid the very thorny question about whether perpetration of violence should lead to diagnosable and potentially compensable PTSD.
Whatever the reasons for the scant attention paid to moral and ethical conflicts (after DSM-III), we argue that serious exploration is indicated because, in our experience, service members and veterans can suffer long-term scars that are not well captured by the current conceptualizations of PTSD or other adjustment difficulties. We are not arguing for a new diagnostic category, per se, nor do we want to medicalize or pathologize the moral and ethical distress that service members and veterans may experience. However, we believe that the clinical and research dialogue is very limited at present because questions about moral injury are not being addressed. In addition, clinicians who observe moral injury and are motivated to target these problems are at a loss because existing evidence-based strategies fail to provide sufficient guidance. Consequently, our goal is two-fold: We want to stimulate discourse and empirical research and, because we are sorely aware of the clinical care vacuum and need (especially in the Department of Defense), we offer specific treatment recommendations based on our conceptual model and a pilot study we are conducting in the Marine Corps.
Below, we first describe the potential morally injurious experiences in war, using the current wars in Iraq and Afghanistan as examples. Second, we review and summarize the research pertaining to events that have the potential to be morally injurious. Third, we discuss why existing conceptualizations of PTSD may not fully capture the different aspects of moral injury. Finally, we propose a working conceptual model, a set of assumptions that guide our treatment approach, and details about the treatment model.
There are three sets of important questions we will not be covering in detail in this article: (1) What military training, deployment length, battlefield context, leadership, rules of engagement, group processes, and personality factors moderate and mediate war-zone transgression?; (2) What aspects of military training (primary and secondary prevention strategies) help service members assimilate and accommodate various moral and ethical challenges, roles, and experiences?; and (3) What are the learning history, personality, religious beliefs, and social and cultural variables that moderate and mediate moral injury afterward? These complex research questions require an interdisciplinary approach (e.g., military, biological, philosophical, sociological and social psychological, legal, religious, mental health perspectives), and our intention is to offer a basic framework that can be used as a point of departure for future theory-building and research.
Section snippets
What might be potentially morally injurious in war?
Service members deployed to Iraq or Afghanistan have been exposed to high levels of violence and its aftermath. In 2003, 52% of soldiers and Marines surveyed reported shooting or directing fire at the enemy, and 32% reported being directly responsible for the death of an enemy combatant (Hoge et al., 2004). Additionally, 65% of those surveyed reported seeing dead bodies or human remains, 31% reported handling or uncovering human remains, and 60% reported having seen ill/wounded women and
Research on military atrocities and killing
Although moral injury, per se, has not been systematically studied, there has been some research on acts of perpetration such as atrocities (i.e., unnecessary, cruel, and abusive harm to others or lethal violence) and killing. Several researchers have demonstrated that self-reports of atrocities are related to chronic PTSD in Vietnam veterans (e.g., Beckham et al., 1998, King et al., 1995, Yehuda et al., 1992). Moreover, the association between reports of atrocities and PTSD is considerably
What aspects of existing theory might explain moral injury?
Service members face moral and ethical conflicts and may struggle with how to manage their lasting impact. Going forward, should we conceptualize the aftermath of these conflicts as adjustment disorder or PTSD? Or, do issues of morality deserve special attention? To help address these questions, we review the prominent theories of PTSD and gauge their applicability to our conceptualization of moral injury.
Social-cognitive theories of PTSD delineate how traumatic events clash with existing
Basic concepts
Before further describing our concept of moral injury, it will be instructive to review some basic concepts that inform our model and intervention approach.
Working conceptual model
To stimulate a dialogue about moral injury, we offer the following working definition of potentially morally injurious experiences: Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations. This may entail participating in or witnessing inhumane or cruel actions, failing to prevent the immoral acts of others, as well as engaging in subtle acts or experiencing reactions that, upon reflection, transgress a moral code.
Assumptions
Several assumptions guide our intervention approach and selection of specific strategies. First, inherent in our working definition of moral injury is the supposition that anguish, guilt, and shame are signs of an intact conscience and self- and other-expectations about goodness, humanity, and justice. In other words, injury is only possible if acts of transgression produce dissonance (conflict), and dissonance is only possible if the service member has an intact moral belief system.
Conclusion
We have devoted extra attention to two potentially morally injurious acts: atrocities and killing. Because research is very limited, our focus on these two acts arose out of necessity rather than intention. Ideally, we would have also examined the repercussions of learning about the unethical behaviors of others and bearing witness to intense human suffering and cruelty. We believe that an exclusive focus on depraved acts of commission greatly confines the discourse—it is counterproductive to
References (79)
- et al.
Toward a unified treatment for emotional disorders
Behavior Therapy
(2004) - et al.
Social cognitive theory of posttraumatic recovery: The role of perceived self-efficacy
Behaviour Research and Therapy
(2004) - et al.
A cognitive model of posttraumatic stress disorder
Behaviour Research and Therapy
(2000) - et al.
Cognitive vulnerabilities to the development of PTSD: A review of four vulnerabilities and the proposal of an integrative vulnerability model
Clinical Psychology Review
(2009) - et al.
Behavioral/cognitive conceptualizations of post-traumatic stress disorder
Behavior Therapy
(1989) - et al.
Does spirituality add to personality in the study of trait forgiveness?
Personality and Individual Differences
(2004) - et al.
Failure to forgive self and others: A replication and extension of the relationship between forgiveness, personality, social desirability, and general health
Personality and Individual Differences
(2001) - et al.
Belief in a just world and its functions for young prisoners
Journal of Research in Personality
(2005) Emotional processing
Behaviour Research and Therapy
(1980)- et al.
The treatment of maladaptive shame in borderline personality disorder: A pilot study of “opposite action”
Cognitive and Behavioral Practice
(2005)
The prosocial, adaptive qualities of just world beliefs: Implications for the relationship between justice and forgiveness
Personality and Individual Differences
Atrocities exposure in Vietnam combat veterans with chronic posttraumatic stress disorder: Relationship to combat exposure, symptom severity, guilt, and interpersonal violence
Journal of Traumatic Stress
Risk factors and the adversity-stress model
Posttraumatic stress disorder: The etiologic specificity of wartime stressors
The American Journal of Psychiatry
Social bonds and posttraumatic stress disorder
Annual Review of Psychology
Belief in a personal just world, justice judgments, and their functions for prisoners
Criminal Justice and Behavior
Spirituality in the face of terrorist disasters
Spirituality and readjustment following war-zone experiences
The interplay of affect and cognition in attitude formation and change
Journal of Personality and Social Psychology
The relation of empathy to prosocial and related behaviors
Psychological Bulletin
Counseling within the forgiveness triad: On forgiving, receiving forgiveness, and self-forgiveness
Counseling and Values
Self-forgiveness versus excusing: The roles of remorse, effort, and acceptance of responsibility
Self and Identity
Psychosocial therapy for posttraumatic stress disorder
Journal of Clinical Psychology
Emotional processing of fear: Exposure to corrective information
Psychological Bulletin
Psychosocial treatments for posttraumatic stress disorder: A critical review
Annual Review of Psychology
Posttraumatic stress disorder and rape
Treating the trauma of rape: Cognitive–behavioral therapy for PTSD
Mindfulness and trauma: Implications for treatment
Journal of Rational–Emotive & Cognitive-Behavior Therapy
A model of war zone stressors and posttraumatic stress disorder
Journal of Traumatic Stress
Trauma, change in strength of religious faith, and mental health service use among veterans treated for PTSD
The Journal of Nervous and Mental Disease
War zone traumas and posttraumatic stress disorder symptomatology
The Journal of Nervous and Mental Disease
Post-Vietnam syndrome: Recognition and management
Psychosomatics
Shame, status, and social roles: Psychobiology and evolution
Emotion in psychotherapy
The American Psychologist
When the patient reports atrocities: Specific treatment considerations of the Vietnam veteran
Archives of General Psychiatry
Self-forgiveness: The stepchild of forgiveness research
Journal of Social and Clinical Psychology
The temporal course of self-forgiveness
Journal of Social and Clinical Psychology
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