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.” Every Tuesday, 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.
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By Amy Amidon, Ph.D.
Moral Injury: What is it?
“Die woman, die!” These are the words of HM2 Jones (All patient material has been de-identified), a 30-year-old Navy FMF corpsman with two tours to Iraq, as he watches an Iraqi woman lay dying. She has just killed one of his Marines during a firefight, and he has just returned fire on her. Yet as the corpsman, his role now is to save her. “I wanted her to die. I was so angry. It bothers me that it doesn’t bother me, Doc. Is that wrong? Am I evil?” He continues to question his capacity for evil.
“These bullets weren’t made for him.” These are the words of SSgt Smith, a 31-year-old infantry Marine with two tours to Iraq and Afghanistan as he watches in horror as one of his Marines burns, trapped in his Humvee. His Corpsman is yelling at him to shoot and kill the Marine to put him out of his misery. “I shoot and I kill my friend and there’s a possible investigation. I don’t shoot and I watch and listen to his screams as he burns. How could I forgive myself for that?” He continues to struggle with the decision he made.
“We’re asked to ‘show our presence’ and clear the village we just cleared and knowing there’s nothing there, when he gets killed.” These are the words of Cpl Chavez, a 25-year-old Marine with one tour to Afghanistan. His anger with and mistrust of his command and authority has generalized from his direct command, to the military, to the government, to society.
What do all of these men have in common? They struggle with what researchers and clinicians in the field of Posttraumtic Stress Disorder (PTSD) call “moral injury.” For years, PTSD has been narrowly conceptualized as a fear-based construct, most commonly treated with a Neo-Classical Conditioning Model or a social-cognitive theory model. The former assumes by deconditioning the service member to the feared stimuli, symptoms will alleviate. The latter assumes that by modifying distorted thoughts or “stuck points,” symptoms will alleviate. And they do… sometimes. Yet within the field of PTSD, clinicians and researchers have increasingly seen a sense of guilt, loss, grief, and disillusionment to be at the core of combat Veterans’ distress rather than straight fear. Thus, there are times when traditional PTSD treatment needs to be supplemented or even other treatments need to be utilized.
Dr. Jonathan Shay’s groundbreaking book on moral injury, Achilles in Vietnam1, and Brett Litz, Ph.D., of Boston university and the Boston VA, retired navy Captain William P Nash, M.D. the Director of Psychological Health at United States Marine Corps, and Shira Maugen, Ph.D., of UCSF and the San Francisco VA and their research teams have been at the forefront of conceptualizing and researching ways to treat moral injury, with Naval Medical Center San Diego (NMCSD) being at the forefront of treating moral injury. Litz et al 20092 provides a comprehensive model of the development and consequences of moral injury, defining it as, “bearing witness to, failing to prevent, or perpetrating acts that transgress deeply held moral beliefs and expectations.” Or as my patients define it, “the !&*$ we did that we feel bad about or that people did that makes us angry.” In our treatment of moral injury at NMCSD, I more broadly define moral injury into three categories: 1) acts of perpetration (legitimate or otherwise), 2) acts of failure (self or others), and 3) acts that result in disillusionment (going from specific to broad). The three examples above highlight these three types, in order. Yet the reality is that a moral injury is rarely clean cut, and doesn’t often fall into just one type or category. For example, SSgt Smith not only struggles with failing to make the “right” decision, he is angry with command about why they were on the mission in the first place and for his direct command’s inability to respond appropriately amidst the chaos. Additionally, this is playing out amidst a firefight. Thus, moral injury is a complex construct, often intertwined amongst the classic fear aspects of traditional PTSD.
Causes of Moral Injury: Acts of Perpetration
What makes men and women do things in war they would never imagine doing? This is a question we explore in our moral injury treatment at NMCSD. Dr. Shay talks about the “berserk state” of having no restraint and being singularly focused. Our men and women talk of feeling “God-like.” These acts serve a survival purpose; with the obvious defensive acts as well as the less obvious offensive acts (“Every time I’d do it they wouldn’t bother us for a few days”). All of this is couched within the number one goal of the military, and on a personal level what each Marine, soldier, sailor, or Airman, was seeking: mission accomplishment (“All I cared about was getting my men home”). There are also acts of revenge or avenge, or as Dr. Shay states in Achilles in Vietnam, “Don’t get sad, get even.” Additionally, our men and women talk of “fighting ghosts” due to the nature of the type of warfare being used, often having no immediate person to take their anger out on. All the while, their anger builds until they can find someone to take it out on. There is the classic concept of group think. There are the unfortunate situations of collateral damage that are inevitable and part of the very fabric of war. And finally, it could be as straightforward as being in highly ambiguous situations with little time to make decisions—in our current wars, for instance, we have seen anything can be potentially dangerous.
Causes of Moral Injury: Acts of “Failure”
Survivors’ guilt and the consequent lack of confidence in oneself is very common amongst combat Veterans. Why? Because the military works on the assumption of accountability, always. This can create unrealistic beliefs about oneself and others’ capabilities. Ask a combat Veteran in a leadership position and they are likely to tell you it is their sole mission to get all of their men and women home alive. And yet we know it is guaranteed men and women will die in war, even if they do everything right. That is hard to accept and harder to live with. Thus, Service members often take to blaming themselves rather than accepting the unpredictability of war, and lack of control in the world. Additionally, combat Veterans describe “twinship-like” relationships, meaning their buddies, and particularly their best buddy, almost becoming an extension of themselves. Combat Veterans often come to value the men and women they fight with above themselves. Thus, the loss and the sense of responsibility is that much more significant.
Causes of Moral Injury: Sources of Disillusionment
In my experience, this is by far the most commonly cited source of moral injury. In session two of our moral injury group, we talk about the causes of moral injury. Men and women will talk at length about what was done to them or the injustices of the world. Perhaps it is because these injustices are so painful. Perhaps it is because it is easier to look at what was done to them or what is wrong in the world than it is to look at their own perceived failure or shame. Dr. Shay talks of authority perceived as violating what is “right” or “fair,” keeping in mind the extreme dependence combat Veterans have upon one another for survival. As I noted earlier, authority can move from very specific (i.e. my direct chain of command) to very general (i.e. the government or society as a whole). On a broad level, our men and women talk about feeling handicapped by Rules of Engagement that are necessary and yet create an uneven playing field in combat. They talk of not having the very supplies they need to survive, particularly early on in the war. As they narrow in, they talk of unnecessary missions fought in order for someone higher to get a medal. They talk of perceived incompetence by commands. They talk of favoritism or feared retaliation amongst their unit. Particularly painful for them can be what is perceived as indifference or dismissiveness from their command. Other sources of disillusionment come from witnessing and experiencing intense suffering and evil, which can result in a sense of despair and hopelessness. Men and women struggle with accepting the unpredictability of and lack of control in the world. They struggle with knowing and coming to terms with one’s capacity for evil. Finally, on a very broad level of disillusionment, our men and women report anger over the naivety of civilians while they simultaneously grieve their own loss of innocence. “Stupid civilians,” is matched with, “sometimes I wish I could just be like them.” Similarly, there is frustration over the perceived lack of support, understanding, or indifference of civilians. Civilians’ complaints of waiting in line in Starbucks is frequently cited in our moral injury groups as one of the banal problems civilians are perceived to have, compared to what a combat Veteran has gone through.
Consequences of Moral Injury
Litz et al 2009 talk of the consequences of war as follows:
Treatment of Moral Injury—Stabilization and Safety, Trauma Processing, and Reintegration
A novel treatment for combat-related psychological stress injuries, to include moral injury, is Adaptive Disclosure therapy. Adaptive Disclosure therapy was developed by Dr. Brett Litz, Dr. William P Nash and their research team, and takes into account the military culture. This therapy demonstrates strong preliminary results in decreased symptoms of PTSD, depression, negative posttraumatic appraisal, and increased posttraumatic growth3. A follow-up study comparing CPT to Adaptive Disclosure Therapy is currently underway. For more on Adaptive Disclosure therapy, see Litz, Lebowitz, Gray, and Nash’s 2016 book4.
As first conceptualized by Judith Herman in Trauma and Recovery—The Aftermath of Violence—From Domestic Abuse to Political Terror5, trauma processing requires three phases: (1) stabilization and safety, (2) trauma processing, and (3) mourning, reconnection, and reintegration. I apply the same concepts with the treatment of moral injury (all moral injury is traumatic, but not all trauma is morally injurious). As part of NMCSD’s residential treatment program, OASIS, we spend the first weeks of treatment stabilizing patients. The moral injury group spends the first two sessions creating a safe and sacred environment, providing psychoeducation on the consequences and causes of moral injury to the patients (both to get patient buy in and because they are the true experts on moral injury), and building group rapport as a means of stabilization. Similarly, in our outpatient clinic in individual therapy, I spend the first sessions stabilizing a patient using relaxation techniques and coping skills. Great resources include Marsha Linehan’s DBT skills of mindfulness, distress tolerance and emotion regulation skills, Francine Shapiro’s EMDR resourcing skills and Calm Place and Container exercises, Donald Meichenbaum’s Stress Innoculation Training or Martin Seligman’s Positive Psychology techniques.
In the second phase of our moral injury group at OASIS, each group member shares their moral injury stories over the course of several sessions, being given space and time that is just for them to share whatever is weighing heavy on their heart. This may be a single moral injury, or it may be a series of moral injuries. The only guideline is that what they share is something that is weighing heavy on their heart as a result of something that they did do, didn’t do, was done to them, or was witnessed. The patient is asked prior to sharing what their experiences have been like in sharing this event(s), and what they are needing and wanting from their peers (i.e. “Don’t just tell me it was ok… because it wasn’t”). The group emotionally “holds” that member as they share and then engage in processing the experience. Sometimes this is a form of Socratic questioning to better understand the situation; sometimes it is a group member sharing a similar experience as a means of relating; sometimes it is feedback about how they would have done the same thing; or sometimes, and equally powerful, it is “Man that was really *@#&!$ up, and I still love you.” In individual therapy, I tend to use Adaptive Disclosure therapy, and ask the patient to share their experience each session for “hot cognitive processing” and move into an experiential in which they “talk” with someone who will be helpful in moving forward (for example, the victim, a senior Service member, a benevolent figure, a junior Service member, their friend who died or a family member).
The third phase is repair, re-engagement, and reintegration and the concept of moral repair is really woven in throughout treatment, touching more lightly on it in the first phase and more heavily in the second phase. As the provider, the idea throughout treatment is to create a balance between acknowledging one’s capacity for evil with one’s ability to grow from their experiences and continue living a valued life. Moral repair, or doing things that in one’s heart you know to be “good” or “right” and bring you closer to the person you want to be, is focused on each session starting in session three in group and as appropriate in individual therapy. You really want to tailor their moral repair acts to their moral injury and to the current problems in their life (i.e. excessive violence/anger in combat—practice controlling their anger; injury involving children—practice being a better father; difficulties getting close to others—practice being vulnerable; depression—practice self-care). The core aspect of moral repair is that each action they choose brings them closer to who they want to be, pulling in Acceptance and Commitment Therapy constructs. Whether in a group or individual setting, I check in at the beginning of each session on what they have done for moral repair the previous week, discussing how this is bringing them closer to who they want to be. Throughout treatment, you can be helping them to identify how they want to “repair” or move forward. In the group, they spend two sessions writing specific assignments: a letter to a benevolent figure and a letter of apology or reconciliation. They then share them, which is similar to the experientials that are occurring throughout Adaptive Disclosure therapy in their individual therapy. Finally, the last session of group or individual therapy is used to process the experience and highlight continued moral repair growth they are moving towards.
We are at an exciting time in the field of PTSD, as we come to a better understanding how to treat combat PTSD, particularly the morally injurious aspects of trauma. In my work, I tend to take an integrated approach. In the above case of SSgt Smith, we used EMDR coping and resourcing techniques. We then moved into Prolonged Exposure Therapy, as his anxiety was the salient symptom. PE was very effective in decreasing his sense of fear and helplessness, but was less effective on the shame and guilt and may have even exacerbated these symptoms. Thus, we moved into Adaptive Disclosure therapy and the moral injury group which was very effective in decreasing moral injury symptoms. Finally, throughout treatment we utilized Positive Psychology and ACT to increase confidence, esteem, and insight into who he wanted to be. Further research is needed to determine how best to treat moral injury wounds.
Disclaimer - The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.
1. Shay, J. (1994). Achilles in Vietnam. New York, NY: Scribner. http://www.amazon.com/Achilles-Vietnam-Combat-Undoing Character/dp/0684813211/ref=sr_1_1?s=books&ie=UTF8&qid=1447865671&sr=1-1&keywords=achilles+in+vietnam
2. 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, 695-706. https://msrc.fsu.edu/system/files/Litz%20et%20al%202009%20Moral%20injury%20and%20moral%20repair%20in%20war%20veterans--%20a%20preliminary%20model%20and%20intervention%20strategy.pdf
3. Gray, M.J., Schorr, Y., Nash, W., Lebowitz, L, Amidon, A, Lansing, A., Maglione, M., Lang, A.J., & Litz, B.T. (2012). Adaptive Disclosure: An open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behavior Therapy, 43, 407-415. http://www.researchgate.net/publication/221968909_Adaptive_Disclosure_An_Open_Trial_of_a_Novel_Exposure-Based_Intervention_for_Service_Members_With_Combat-Related_Psychological_Stress_Injuries
4. Litz, B.T., Lebowitz, L., Gray, M.J., & Nash, W.P. (2016). Adaptive disclosure: A new treatment for military trauma, loss, and moral injury. New York, NY: The Guilford Press http://www.guilford.com/books/Adaptive-Disclosure/Litz-Lebowitz-Gray-Nash/9781462523290
5. Herman, J. (1997). Trauma and recovery: The aftermath of violence—from domestic abuse to polictical terror. New York, NY: Basic Books.
Amy Amidon, Ph.D., is a staff psychologist at Naval Medical Center San Diego. She was previously assigned to their residential treatment program, OASIS, and is currently a provider in their Naval Amphibious Base clinic. She received her doctorate in counseling psychology from The University of Texas at Austin.