Guest Perspective: Guilt, Shame, and Moral Injury from Events during the COVID-19 Pandemic
Editor’s Note: As part of the Center for Deployment Psychology’s ongoing mission to provide high-quality education on military- and deployment-related psychology, we are proud to present our latest “Guest Perspective.” Intermittently, we will be presenting blogs by esteemed guests and subject matter experts from outside the CDP. This allows us to offer more insight and opinions on a variety of topics of interest to behavioral health providers.
As these blog entries are written by outside authors, one important disclaimer: all of the opinions and ideas expressed in them are strictly those of the author alone and should not be taken as those of the CDP, Uniformed University of the Health Sciences (USUHS), or the Department of Defense (DoD).
That being said, we’re very happy to offer a platform where we can feature these individuals and the information they have to share. We’d like to make this an ongoing dialogue. If you have questions, remarks, or would like more information on a topic, please feel free to leave comments below or on our Facebook page, and we’ll pass them along to the authors.
By Sonya B. Norman, Ph.D. and Moira Haller, Ph.D.
Guest columnists
During the COVID-19 pandemic, people across the U.S. and around the world have faced agonizing and ethically difficult situations where they feel like they cannot do enough or are unable to live up to their own standards. Some examples include not being able to be there in person to care for an infected family member, worrying about exposing others to infection, being unable to provide for their family due to job loss, or being unable to adequately care for children and their education during school closures. While everyone can be impacted in these ways, healthcare workers and first responders on the front lines of helping COVID-19 patients may face additional challenges, such as feeling like they cannot do enough for patients, having to make decisions about resources, comforting patients dying in isolation, or being unable to save patients’ lives.
Such traumatic or very stressful scenarios are sometimes conceptualized as morally injurious events; that is, events where someone’s values and morals are violated by acting, failing to act, or witnessing events that go against deeply held values and morals (Litz et al., 2009). Many who experience a morally injurious event will be fine or feel only transient distress that they overcome on their own, but some go on to experience long lasting and debilitating distress termed “moral injury”. A cornerstone of moral injury is strong reactions of guilt and shame. Guilt results from negatively evaluating one's actions or inactions during an event (e.g., “I did something bad;” Kubany et al., 2004). Guilt can turn into shame if the negative beliefs turn into more global condemnation of the self (e.g., “I am bad;” Tangney et al., 2006). Those who continue to feel distress from guilt, shame, and moral injury often experience greater severity of posttraumatic stress disorder (PTSD), depression, suicidal ideation, problematic substance use, and poorer functioning and quality of life (Browne et al., 2015; Bryan et al., 2013; Griffin et al., 2019; Norman et al., 2018). Without intervention, guilt and shame may persist decades after the initial stressful event (Browne et al., 2015; Bryan et al., 2013; Griffin et al., 2019; S. B. Norman et al., 2018).
During the COVID-19 pandemic, Veterans may be especially vulnerable to the negative outcomes associated with experiencing guilt, shame, and moral injury. Prior trauma history increases risk of developing mental health problems from subsequent exposure to extremely difficult or traumatic events (Tangney et al., 2006). Trauma exposure is almost universal among Veterans, particularly among those who served in combat. Rates of exposure to traumatic events are 87% among U.S. Veterans, 91% among combat Veterans, and a staggering 97.5% among Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) combat Veterans (Thomas et al., 2017; Pietrzak, 2020; Wisco et al., 2014). Evidence of the potential negative mental health impact of COVID-19 on Veterans comes from a study of 312 Veterans who lived through Hurricane Andrew (Bauwens & Tosone, 2014). Those who had previous combat trauma were more likely to experience mental health problems after the hurricane. While guilt and shame are common responses after extremely stressful events (Miller et al., 2013), they are even more likely following COVID-19, given the many morally difficult situations occurring in the context of the pandemic. For these reasons, Veterans may be particularly likely to experience negative outcomes from pandemic-related morally injurious events. Actual data may not be available for some time yet, though. Although quite a few studies and commentaries have proposed guilt and moral injury to be common reactions during COVID-19 (e.g., Borges et al., 2020; Dean et al., 2020; Maguen & Price, 2020; Williams et al., 2020) and have proposed that certain populations may be particularly vulnerable to negative outcomes, no studies yet have documented prevalence or what percent of people may need further intervention.
It has been proposed that some of the negative impacts of exposure to pandemic-related morally injurious events may be mitigated through self-care and support from colleagues, family, and leaders (Greenberg et al., 2020). The National Center for PTSD suggests strategies workers, colleagues, and leaders can take to help themselves and each other. These can be found here: https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury_hcw.asp
For those who do continue to feel significant guilt and shame and related distress after the morally injurious event, intervention may be warranted. Trauma-Informed Guilt Reduction (TrIG; (Norman et al., 2019) therapy is promising for reducing guilt, shame, and moral injury from COVID-19-related events (Haller et al., 2020). TrIGR is a cognitive-behavioral intervention that was developed for the purpose of addressing trauma-related guilt and shame. It is a transdiagnostic intervention in that it is not designed to treat a specific diagnosis but rather the guilt and shame that may contribute to a variety of diagnoses. A model of non-adaptive guilt and shame (NAGS; Norman et al., 2014) underlies TrIGR, with the idea that guilt can be adaptive if it helps someone change behavior to be more consistent with values. For example, feeling guilty for possibly exposing someone to COVID-19 may lead someone to social distance going forward, which then reduces the guilt. In contrast, non-adaptive guilt results when distress is taken as evidence of wrongdoing (e.g., “I feel bad, so I must have done something very wrong.”). Such distress is often accompanied with avoidance of thinking about the actual cause of distress. Unfortunately, avoidance keeps people from evaluating their actual role in the event and coming to an accurate perspective. In this way, avoidance contributes to worsening guilt and distress, as distress continues to be taken as evidence of wrongdoing, and beliefs about wrongdoing contribute to further distress. The guilt may become shame if someone comes to believe that their role in the stressful event speaks negatively about them as a person (the “I am bad” belief). The NAGS model proposes that guilt and shame contribute to symptom severity and functional problems. One way this may happen is that guilt and shame can interfere with people’s healthy expression of values. They may believe they don’t deserve to be happy because of what they did or because of who they now believe they are. In fact, we see many people with guilt, shame, and moral injury from trauma who come to therapy but show their ambivalence about getting better by only partly engaging in treatment, not completing assignments, or having inconsistent attendance. This may also be a reason why guilt, shame, and moral injury are associated with worse functioning and more self-destructive behaviors such as substance use.
The goal of TrIGR is to help people accurately appraise their role in the stressful or traumatic event and find positive ways to express important values going forward, so that they no longer need to express values through guilt and shame. This process is proposed to reduce guilt, shame, and related distress. To help people accurately appraise their role in a stressful event (since according to the NAGS model, such appraisal has been avoided), people are encouraged to examine four types of cognitions (Kubany et al., 2004). First, we look at hindsight bias (e.g., “I knew at the time that I was about to make a big mistake”) by helping people remember what they really knew and were really capable of doing at the time. We then examine what options the person really had during the event, and how every realistic option may have played out. People often realize during this exercise that there were no good options available to them, and that all options could have led to some bad outcome. We then help people consider the full context of what happened and the many factors that contributed to the outcome. Finally, we help people consider whether they purposely intended the bad outcome that occurred.
In the latter part of the therapy, TrIGR helps people find ways to express their values in more positive ways than by feeling guilt and shame, and helps people set goals to do activities that are consistent with their values. For instance, someone who feels guilt about possibly exposing others to infection may recommit to practicing social distancing, wearing a mask, and other safety measures.
In summary, the pandemic has created numerous situations that can be the cause of guilt, shame, and moral injury. For many, these feelings will be transient, but for some, they may be long-lasting, distressing, and associated with functional problems and mental health problems. TrIGR is a promising intervention for COVID-19-related guilt and shame, as it can help people accurately appraise their choices in the context of the pandemic and help them express values in a way that does not involve suffering through guilt and shame. Pilot data for TrIGR with combat Veterans is encouraging (Norman et al., 2014), and results from a randomized clinical trial with Veterans are forthcoming. Data collection with TrIGR on COVID-19 and pandemic-related guilt, shame, and moral injury will begin soon.
Finally, some helpful resources can be found here:
More information about moral injury: https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp
More information about moral injury in healthcare workers: https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury_hcw.asp
More information on TrIGR: https://www.amazon.com/Trauma-Informed-Guilt-Reduction-Therapy/dp/0128147806
The opinions in CDP blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Dr. Norman is Director of the PTSD Consultation Program through the Executive Branch of the National Center for PTSD and a Professor of Psychiatry at the University of California, San Diego (UCSD).
Dr. Haller is an Associate Clinical Professor of Psychiatry in the UCSD School of Medicine and a staff psychologist at the VA San Diego Health System.
References
Bauwens, J., & Tosone, C. (2014). Posttraumatic growth following Hurricane Katrina: The influence of clinicians’ trauma histories and primary and secondary traumatic stress. Traumatology, 20(3), 209–218. https://doi.org/10.1037/h0099851
Borges, L. M., Barnes, S. M., Farnsworth, J. K., Bahraini, N. H., & Brenner, L. A. (2020). A commentary on moral injury among health care providers during the COVID-19 pandemic. Psychological Trauma: Theory, Research, Practice and Policy, 12(S1), S138–S140. https://doi.org/10.1037/tra0000698
Breslau, N., & Peterson, E. L. (2010). Assaultive violence and the risk of posttraumatic stress disorder following a subsequent trauma. Behaviour Research and Therapy, 48(10), 1063–1066. https://doi.org/10.1016/j.brat.2010.07.001
Browne, K. C., Trim, R. S., Myers, U. S., & Norman, S. B. (2015). Trauma‐related guilt: Conceptual development and relationship with posttraumatic stress and depressive symptoms. Journal of Traumatic Stress, 28(2), 134–141. https://doi.org/10.1002/jts.21999
Bryan, C. J., Morrow, C. E., Etienne, N., & Ray‐Sannerud, B. (2013). Guilt, shame, and suicidal ideation in a military outpatient clinical sample. Depression and Anxiety, 30(1), 55–60. https://doi.org/10.1002/da.22002
Dean, W., Jacobs, B., & Manfredi, R. A. (2020). Moral injury: The invisible epidemic in COVID health care workers. Annals of Emergency Medicine. Advance online publication. https://doi.org/10.1016/j.annemergmed.2020.05.023
Greenberg, N., Docherty, M., Gnanapragasam, S., & Wessely, S. (2020). Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ (Clinical research ed.), 368, m1211. https://doi.org/10.1136/bmj.m1211
Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz, M., Villierme, C., Walsh, J., & Maguen, S. (2019). Moral injury: An integrative review. Journal of Traumatic Stress, 32(3), 350–362. https://doi.org/10.1002/jts.22362
Haller, M., Norman, S. B., Davis, B. C., Capone, C., Browne, K., & Allard, C. B. (2020). A model for treating COVID-19-related guilt, shame, and moral injury. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1), S174-S176. http://dx.doi.org/10.1037/tra0000742
Kubany, E. S., Abueg, F. R., Owens, J. A., Brennan, J. M., Kaplan, A. S., & Watson, S. B. (1995). Initial examination of a multidimensional model of trauma-related guilt: Applications to combat veterans and battered women. Journal of Psychopathology and Behavioral Assessment, 17(4), 353–376. https://doi.org/10.1007/BF02229056
Kubany, E. S., Hill, E. E., Owens, J. A., Iannce-Spencer, C., McCaig, M. A., Tremayne, K. J., & Williams, P. L. (2004). Cognitive Trauma Therapy for Battered Women with PTSD (CTT-BW). Journal of Consulting and Clinical Psychology, 72(1), 3–18. https://doi.org/10.1037/0022-006X.72.1.3
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706. https://doi.org/10.1016/j.cpr.2009.07.003
Maguen, S., & Price, M. A. (2020). Moral injury in the wake of coronavirus: Attending to the psychological impact of the pandemic. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1), S131-S132. http://dx.doi.org/10.1037/tra0000780
Miller, M. W., Wolf, E. J., Kilpatrick, D. G., Resnick, H. S., Marx, B. P., Holowka, D. W., Keane, T. M., Rosen, R. C., & Friedman, M. J. (2013). The prevalence and latent structure of proposed DSM-5 posttraumatic stress disorder symptoms in U.S. national and veteran samples. Psychological Trauma: Theory, Research, Practice, and Policy, 5(6), 501–512. https://doi.org/10.1037/a0029730
Norman, S. B., Haller, M., Kim, H. M., Allard, C. B., Porter, K. E., Stein, M. B., Venners, M. R., Authier, C. C., Rauch, S. A. M., & Progress Team. (2018). Trauma related guilt cognitions partially mediate the relationship between PTSD symptom severity and functioning among returning combat veterans. Journal of Psychiatric Research, 100, 56–62. https://doi.org/10.1016/j.jpsychires.2018.02.003
Norman, S. B., Wilkins, K. C., Myers, U. S., & Allard, C. B. (2014). Trauma informed guilt reduction therapy with combat veterans. Cognitive and Behavioral Practice, 21(1), 78–88. https://doi.org/10.1016/j.cbpra.2013.08.001
Schock, K., Böttche, M., Rosner, R., Wenk-Ansohn, M., & Knaevelsrud, C. (2016). Impact of new traumatic or stressful life events on pre-existing PTSD in traumatized refugees: Results of a longitudinal study. European Journal of Psychotraumatology, 7, Article 32106. https://doi.org/10.3402/ejpt.v7.32106
Tangney, J. P., Stuewig, J., & Mashek, D. J. (2006). Moral emotions and moral behavior. Annual Review of Psychology, 58(1), 345–372. https://doi.org/10.1146/annurev.psych.56.091103.070145
Thomas, M. M., Harpaz-Rotem, I., Tsai, J., Southwick, S. M., & Pietrzak, R. H. (2017). Mental and physical health conditions in US combat veterans: Results from the National Health and Resilience in Veterans Study. The Primary Care Companion for CNS Disorders, 19(3). https://doi.org/10.4088/PCC.17m02118
Williams, R. D., Brundage, J. A. & Williams, E. B. (2020). Moral injury in times of COVID-19. Journal of Health Service Psychology, 46, 65–69. https://doi.org/10.1007/s42843-020-00011-4
Wisco, B. E., Marx, B. P., Wolf, E. J., Miller, M. W., Southwick, S. M., & Pietrzak, R. H. (2014). Posttraumatic stress disorder in the US veteran population: Results from the National Health and Resilience in Veterans Study. The Journal of Clinical Psychiatry, 75(12), 1338–1346. https://doi.org/10.4088/JCP.14m09328
Editor’s Note: As part of the Center for Deployment Psychology’s ongoing mission to provide high-quality education on military- and deployment-related psychology, we are proud to present our latest “Guest Perspective.” Intermittently, we will be presenting blogs by esteemed guests and subject matter experts from outside the CDP. This allows us to offer more insight and opinions on a variety of topics of interest to behavioral health providers.
As these blog entries are written by outside authors, one important disclaimer: all of the opinions and ideas expressed in them are strictly those of the author alone and should not be taken as those of the CDP, Uniformed University of the Health Sciences (USUHS), or the Department of Defense (DoD).
That being said, we’re very happy to offer a platform where we can feature these individuals and the information they have to share. We’d like to make this an ongoing dialogue. If you have questions, remarks, or would like more information on a topic, please feel free to leave comments below or on our Facebook page, and we’ll pass them along to the authors.
By Sonya B. Norman, Ph.D. and Moira Haller, Ph.D.
Guest columnists
During the COVID-19 pandemic, people across the U.S. and around the world have faced agonizing and ethically difficult situations where they feel like they cannot do enough or are unable to live up to their own standards. Some examples include not being able to be there in person to care for an infected family member, worrying about exposing others to infection, being unable to provide for their family due to job loss, or being unable to adequately care for children and their education during school closures. While everyone can be impacted in these ways, healthcare workers and first responders on the front lines of helping COVID-19 patients may face additional challenges, such as feeling like they cannot do enough for patients, having to make decisions about resources, comforting patients dying in isolation, or being unable to save patients’ lives.
Such traumatic or very stressful scenarios are sometimes conceptualized as morally injurious events; that is, events where someone’s values and morals are violated by acting, failing to act, or witnessing events that go against deeply held values and morals (Litz et al., 2009). Many who experience a morally injurious event will be fine or feel only transient distress that they overcome on their own, but some go on to experience long lasting and debilitating distress termed “moral injury”. A cornerstone of moral injury is strong reactions of guilt and shame. Guilt results from negatively evaluating one's actions or inactions during an event (e.g., “I did something bad;” Kubany et al., 2004). Guilt can turn into shame if the negative beliefs turn into more global condemnation of the self (e.g., “I am bad;” Tangney et al., 2006). Those who continue to feel distress from guilt, shame, and moral injury often experience greater severity of posttraumatic stress disorder (PTSD), depression, suicidal ideation, problematic substance use, and poorer functioning and quality of life (Browne et al., 2015; Bryan et al., 2013; Griffin et al., 2019; Norman et al., 2018). Without intervention, guilt and shame may persist decades after the initial stressful event (Browne et al., 2015; Bryan et al., 2013; Griffin et al., 2019; S. B. Norman et al., 2018).
During the COVID-19 pandemic, Veterans may be especially vulnerable to the negative outcomes associated with experiencing guilt, shame, and moral injury. Prior trauma history increases risk of developing mental health problems from subsequent exposure to extremely difficult or traumatic events (Tangney et al., 2006). Trauma exposure is almost universal among Veterans, particularly among those who served in combat. Rates of exposure to traumatic events are 87% among U.S. Veterans, 91% among combat Veterans, and a staggering 97.5% among Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) combat Veterans (Thomas et al., 2017; Pietrzak, 2020; Wisco et al., 2014). Evidence of the potential negative mental health impact of COVID-19 on Veterans comes from a study of 312 Veterans who lived through Hurricane Andrew (Bauwens & Tosone, 2014). Those who had previous combat trauma were more likely to experience mental health problems after the hurricane. While guilt and shame are common responses after extremely stressful events (Miller et al., 2013), they are even more likely following COVID-19, given the many morally difficult situations occurring in the context of the pandemic. For these reasons, Veterans may be particularly likely to experience negative outcomes from pandemic-related morally injurious events. Actual data may not be available for some time yet, though. Although quite a few studies and commentaries have proposed guilt and moral injury to be common reactions during COVID-19 (e.g., Borges et al., 2020; Dean et al., 2020; Maguen & Price, 2020; Williams et al., 2020) and have proposed that certain populations may be particularly vulnerable to negative outcomes, no studies yet have documented prevalence or what percent of people may need further intervention.
It has been proposed that some of the negative impacts of exposure to pandemic-related morally injurious events may be mitigated through self-care and support from colleagues, family, and leaders (Greenberg et al., 2020). The National Center for PTSD suggests strategies workers, colleagues, and leaders can take to help themselves and each other. These can be found here: https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury_hcw.asp
For those who do continue to feel significant guilt and shame and related distress after the morally injurious event, intervention may be warranted. Trauma-Informed Guilt Reduction (TrIG; (Norman et al., 2019) therapy is promising for reducing guilt, shame, and moral injury from COVID-19-related events (Haller et al., 2020). TrIGR is a cognitive-behavioral intervention that was developed for the purpose of addressing trauma-related guilt and shame. It is a transdiagnostic intervention in that it is not designed to treat a specific diagnosis but rather the guilt and shame that may contribute to a variety of diagnoses. A model of non-adaptive guilt and shame (NAGS; Norman et al., 2014) underlies TrIGR, with the idea that guilt can be adaptive if it helps someone change behavior to be more consistent with values. For example, feeling guilty for possibly exposing someone to COVID-19 may lead someone to social distance going forward, which then reduces the guilt. In contrast, non-adaptive guilt results when distress is taken as evidence of wrongdoing (e.g., “I feel bad, so I must have done something very wrong.”). Such distress is often accompanied with avoidance of thinking about the actual cause of distress. Unfortunately, avoidance keeps people from evaluating their actual role in the event and coming to an accurate perspective. In this way, avoidance contributes to worsening guilt and distress, as distress continues to be taken as evidence of wrongdoing, and beliefs about wrongdoing contribute to further distress. The guilt may become shame if someone comes to believe that their role in the stressful event speaks negatively about them as a person (the “I am bad” belief). The NAGS model proposes that guilt and shame contribute to symptom severity and functional problems. One way this may happen is that guilt and shame can interfere with people’s healthy expression of values. They may believe they don’t deserve to be happy because of what they did or because of who they now believe they are. In fact, we see many people with guilt, shame, and moral injury from trauma who come to therapy but show their ambivalence about getting better by only partly engaging in treatment, not completing assignments, or having inconsistent attendance. This may also be a reason why guilt, shame, and moral injury are associated with worse functioning and more self-destructive behaviors such as substance use.
The goal of TrIGR is to help people accurately appraise their role in the stressful or traumatic event and find positive ways to express important values going forward, so that they no longer need to express values through guilt and shame. This process is proposed to reduce guilt, shame, and related distress. To help people accurately appraise their role in a stressful event (since according to the NAGS model, such appraisal has been avoided), people are encouraged to examine four types of cognitions (Kubany et al., 2004). First, we look at hindsight bias (e.g., “I knew at the time that I was about to make a big mistake”) by helping people remember what they really knew and were really capable of doing at the time. We then examine what options the person really had during the event, and how every realistic option may have played out. People often realize during this exercise that there were no good options available to them, and that all options could have led to some bad outcome. We then help people consider the full context of what happened and the many factors that contributed to the outcome. Finally, we help people consider whether they purposely intended the bad outcome that occurred.
In the latter part of the therapy, TrIGR helps people find ways to express their values in more positive ways than by feeling guilt and shame, and helps people set goals to do activities that are consistent with their values. For instance, someone who feels guilt about possibly exposing others to infection may recommit to practicing social distancing, wearing a mask, and other safety measures.
In summary, the pandemic has created numerous situations that can be the cause of guilt, shame, and moral injury. For many, these feelings will be transient, but for some, they may be long-lasting, distressing, and associated with functional problems and mental health problems. TrIGR is a promising intervention for COVID-19-related guilt and shame, as it can help people accurately appraise their choices in the context of the pandemic and help them express values in a way that does not involve suffering through guilt and shame. Pilot data for TrIGR with combat Veterans is encouraging (Norman et al., 2014), and results from a randomized clinical trial with Veterans are forthcoming. Data collection with TrIGR on COVID-19 and pandemic-related guilt, shame, and moral injury will begin soon.
Finally, some helpful resources can be found here:
More information about moral injury: https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp
More information about moral injury in healthcare workers: https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury_hcw.asp
More information on TrIGR: https://www.amazon.com/Trauma-Informed-Guilt-Reduction-Therapy/dp/0128147806
The opinions in CDP blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Dr. Norman is Director of the PTSD Consultation Program through the Executive Branch of the National Center for PTSD and a Professor of Psychiatry at the University of California, San Diego (UCSD).
Dr. Haller is an Associate Clinical Professor of Psychiatry in the UCSD School of Medicine and a staff psychologist at the VA San Diego Health System.
References
Bauwens, J., & Tosone, C. (2014). Posttraumatic growth following Hurricane Katrina: The influence of clinicians’ trauma histories and primary and secondary traumatic stress. Traumatology, 20(3), 209–218. https://doi.org/10.1037/h0099851
Borges, L. M., Barnes, S. M., Farnsworth, J. K., Bahraini, N. H., & Brenner, L. A. (2020). A commentary on moral injury among health care providers during the COVID-19 pandemic. Psychological Trauma: Theory, Research, Practice and Policy, 12(S1), S138–S140. https://doi.org/10.1037/tra0000698
Breslau, N., & Peterson, E. L. (2010). Assaultive violence and the risk of posttraumatic stress disorder following a subsequent trauma. Behaviour Research and Therapy, 48(10), 1063–1066. https://doi.org/10.1016/j.brat.2010.07.001
Browne, K. C., Trim, R. S., Myers, U. S., & Norman, S. B. (2015). Trauma‐related guilt: Conceptual development and relationship with posttraumatic stress and depressive symptoms. Journal of Traumatic Stress, 28(2), 134–141. https://doi.org/10.1002/jts.21999
Bryan, C. J., Morrow, C. E., Etienne, N., & Ray‐Sannerud, B. (2013). Guilt, shame, and suicidal ideation in a military outpatient clinical sample. Depression and Anxiety, 30(1), 55–60. https://doi.org/10.1002/da.22002
Dean, W., Jacobs, B., & Manfredi, R. A. (2020). Moral injury: The invisible epidemic in COVID health care workers. Annals of Emergency Medicine. Advance online publication. https://doi.org/10.1016/j.annemergmed.2020.05.023
Greenberg, N., Docherty, M., Gnanapragasam, S., & Wessely, S. (2020). Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ (Clinical research ed.), 368, m1211. https://doi.org/10.1136/bmj.m1211
Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz, M., Villierme, C., Walsh, J., & Maguen, S. (2019). Moral injury: An integrative review. Journal of Traumatic Stress, 32(3), 350–362. https://doi.org/10.1002/jts.22362
Haller, M., Norman, S. B., Davis, B. C., Capone, C., Browne, K., & Allard, C. B. (2020). A model for treating COVID-19-related guilt, shame, and moral injury. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1), S174-S176. http://dx.doi.org/10.1037/tra0000742
Kubany, E. S., Abueg, F. R., Owens, J. A., Brennan, J. M., Kaplan, A. S., & Watson, S. B. (1995). Initial examination of a multidimensional model of trauma-related guilt: Applications to combat veterans and battered women. Journal of Psychopathology and Behavioral Assessment, 17(4), 353–376. https://doi.org/10.1007/BF02229056
Kubany, E. S., Hill, E. E., Owens, J. A., Iannce-Spencer, C., McCaig, M. A., Tremayne, K. J., & Williams, P. L. (2004). Cognitive Trauma Therapy for Battered Women with PTSD (CTT-BW). Journal of Consulting and Clinical Psychology, 72(1), 3–18. https://doi.org/10.1037/0022-006X.72.1.3
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706. https://doi.org/10.1016/j.cpr.2009.07.003
Maguen, S., & Price, M. A. (2020). Moral injury in the wake of coronavirus: Attending to the psychological impact of the pandemic. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1), S131-S132. http://dx.doi.org/10.1037/tra0000780
Miller, M. W., Wolf, E. J., Kilpatrick, D. G., Resnick, H. S., Marx, B. P., Holowka, D. W., Keane, T. M., Rosen, R. C., & Friedman, M. J. (2013). The prevalence and latent structure of proposed DSM-5 posttraumatic stress disorder symptoms in U.S. national and veteran samples. Psychological Trauma: Theory, Research, Practice, and Policy, 5(6), 501–512. https://doi.org/10.1037/a0029730
Norman, S. B., Haller, M., Kim, H. M., Allard, C. B., Porter, K. E., Stein, M. B., Venners, M. R., Authier, C. C., Rauch, S. A. M., & Progress Team. (2018). Trauma related guilt cognitions partially mediate the relationship between PTSD symptom severity and functioning among returning combat veterans. Journal of Psychiatric Research, 100, 56–62. https://doi.org/10.1016/j.jpsychires.2018.02.003
Norman, S. B., Wilkins, K. C., Myers, U. S., & Allard, C. B. (2014). Trauma informed guilt reduction therapy with combat veterans. Cognitive and Behavioral Practice, 21(1), 78–88. https://doi.org/10.1016/j.cbpra.2013.08.001
Schock, K., Böttche, M., Rosner, R., Wenk-Ansohn, M., & Knaevelsrud, C. (2016). Impact of new traumatic or stressful life events on pre-existing PTSD in traumatized refugees: Results of a longitudinal study. European Journal of Psychotraumatology, 7, Article 32106. https://doi.org/10.3402/ejpt.v7.32106
Tangney, J. P., Stuewig, J., & Mashek, D. J. (2006). Moral emotions and moral behavior. Annual Review of Psychology, 58(1), 345–372. https://doi.org/10.1146/annurev.psych.56.091103.070145
Thomas, M. M., Harpaz-Rotem, I., Tsai, J., Southwick, S. M., & Pietrzak, R. H. (2017). Mental and physical health conditions in US combat veterans: Results from the National Health and Resilience in Veterans Study. The Primary Care Companion for CNS Disorders, 19(3). https://doi.org/10.4088/PCC.17m02118
Williams, R. D., Brundage, J. A. & Williams, E. B. (2020). Moral injury in times of COVID-19. Journal of Health Service Psychology, 46, 65–69. https://doi.org/10.1007/s42843-020-00011-4
Wisco, B. E., Marx, B. P., Wolf, E. J., Miller, M. W., Southwick, S. M., & Pietrzak, R. H. (2014). Posttraumatic stress disorder in the US veteran population: Results from the National Health and Resilience in Veterans Study. The Journal of Clinical Psychiatry, 75(12), 1338–1346. https://doi.org/10.4088/JCP.14m09328