Guest Perspective: Moral Injury and the Need for Innovative Treatment

Guest Perspective: Moral Injury and the Need for Innovative Treatment

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.

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 author.

By Shira Maguen, Ph.D
Guest Columnist

As a researcher and clinician who has worked with military personnel and Veterans for over 15 years, one of my most important priorities is providing the best assessment and treatment possible to those experiencing post-deployment mental health problems. While excellent, evidence-based treatments exist for posttraumatic stress disorder (PTSD), many military personnel and Veterans continue to meet diagnostic criteria for PTSD after psychotherapy,1 highlighting an imperative need for innovative treatments.  Designing, improving and implementing these treatments is a major focus of my research.

An important key to creating novel interventions is better understanding the specific traumatic war zone exposures that increase risk for PTSD. For example, in a sample of Veterans from the Iraq and Afghanistan combat theaters, we found that killing in combat may be an important risk factor for developing frequent and severe PTSD symptoms.2 We also found that killing in combat was not only uniquely associated with PTSD, but also with a number of other important mental health and functional outcomes across several war eras (e.g., Vietnam, Gulf War, and Operation Iraqi Freedom), even after accounting for a number of demographic variables and other indicators of combat exposure.3-4  Consequently it is important to acknowledge that different war zone stressors may have varying impacts on mental health and functioning.5 For example, one study found that among military personnel, transgressions committed by a Service member, such as killing in war, were more strongly associated with hopelessness, pessimism, and anger, and transgressions committed by other Service members were more strongly associated with traditional PTSD symptoms.5

One helpful construct for conceptualizing why killing in war, its ripple effects, and other associated exposures may be particularly traumatic for returning military personnel is moral injury, which is conceptually distinct from PTSD. Events are considered morally injurious if they transgress deeply held moral beliefs and expectations.6 Rather than focusing on fear-based aspects of trauma, moral injury focuses more on the shame, self-handicapping behaviors, guilt, etc. associated with the perceived transgression. Moral injury may also include spiritual components of moral transgressions that may have occurred and treatments may therefore involve a spiritual component and building bridges with spiritual communities.

Indeed, preliminary evidence suggests that complementing evidence-based PTSD treatments with treatments focused on alleviating moral injury can contribute to healing. Such treatments can address an otherwise unmet need among some PTSD patients. More specifically, through focus groups with Veterans of all eras and consultation with mental health professionals that work closely with military personnel and veterans, we developed a treatment called Impact of Killing in War (IOK) that can be used in conjunction with trauma-focused treatments and focuses on the mental health impact of killing in war by those who continue to be affected by these war zone experiences. The IOK treatment is a 6-8 session, weekly, individual, cognitive behavioral treatment, lasting 60-90 minutes, and focused on key themes including physiology of killing responses, moral injury, loss, self-forgiveness, and improved functioning. The treatment also involves out of session assignments that focus on evaluation of killing-related cognitions, writing assignments aimed at better understanding the meaning of killing and working towards self-forgiveness (e.g., letter writing described more below), and assignments aimed at better functioning through connection with individuals and community.

In a randomized, controlled pilot trial, we found that compared to controls, the IOK group experienced a significant improvement in PTSD symptoms and general psychiatric symptoms, including depression symptoms, anxiety symptoms, phobic anxiety, obsessive compulsive symptoms, and interpersonal sensitivity. The IOK group also experienced significant improvements in functional measures such as participation in community events and being able to be more intimate with a partner, as well as a reduction in cognitions related to suffering due to killing. Veterans who received IOK treatment reported that it was acceptable and feasible; they also reported gains in self-forgiveness, self-compassion, and self-acceptance.  These results provide evidence that Veterans can benefit from a treatment focused on the impact of killing following initial trauma therapy. As evidence concerning the effectiveness of pairing moral injury interventions with PTSD treatment strategies continues to emerge, the focus should remain on improved functioning in multiple areas of life and understanding that healing is an ongoing process. IOK is one of several innovative treatments (e.g., Adaptive Disclosure7) that are at various phases of being developed and tested to address moral injury in an effort to expand current treatments.

There are multiple clinical examples of individuals that may benefit from treatments that focus on moral injury. For example, one of the Veterans referred to IOK had been through evidence-based treatment for PTSD but was still continuing to have multiple mental health symptoms, functional impairment, specifically in the domain of relationships and forging connections with others, and stated that he continued to be bothered by memories of those he had killed in war. For him, the focus on self-forgiveness in IOK was critical, as were the writing assignments focused on this task. It was important that he acknowledge that a transgression occurred, and balance this acceptance with moving forward with healing, beginning the process of self-forgiveness by writing a letter to those he killed in war. Part of the process was realizing that he felt that he did not deserve to have fruitful relationships because he had killed others, and by working on this directly, he was able to recognize that moving forward meant being able to heal partially through these connections with others. For many who remain symptomatic after evidence-based treatment, having another treatment option expands what we can offer for those in need, doing so in a way that goes beyond traditional treatments by adding additional components that particular veterans may find helpful.

Another Veteran who participated in IOK treatment also continued to have symptoms after PTSD treatment. For him, his Native-American culture played a large role in his understanding of his transgression in war, and it was critical that we worked within his cultural frame of what killing and self-forgiveness meant within that culture. He was able to incorporate rituals from his culture to heal, leveraging his own unique spiritualty to achieve this goal. In this way, while IOK has particular themes and targeted sessions, it can intentionally be tailored to each particular Veteran and his or her unique situation.

As the availability of new treatment continues to grow, it is important to also consider the multiple dimensions of trauma that are unique to war, and how these may be differentially associated with mental health symptoms, so that we can think creatively about how to support those most in need. For example, it may be that an area for growth is better assessment of the unique stressors that any given individual is exposed to in war. If we can best understand which exposures are most distressing, match these to specific symptoms, and then match specific treatments to these outcomes, we may best be able to tailor existing treatments. For example, those with more traditional fear-based exposures and symptoms may receive a different treatment trajectory than those who continue to be bothered by killing in war and have more self-handicapping symptoms and functional difficulties. By tailoring assessment and treatment in this way, we can continue to acknowledge that one size does not fit all with respect to healing from war zone injuries, and that multiple treatments and ongoing research is needed to best understand who is best helped by which types of treatments. More research is also needed about why certain individuals drop out of treatments or do not benefit, so we can understand what is most healing for those who may be most vulnerable.

Another specific area for growth is greater involvement of the spiritual community and other communities in healing from trauma and moral injury. There is growing evidence that spiritual well-being can serve as a protective factor against maladaptive mental health risks such as suicide.8 This is particularly important given that Veterans who killed in war were found to have twice the odds of suicidal ideation, even after adjusting for the effects of general combat and multiple mental health conditions.9 Further evidence for the importance of the role of spirituality was found in one study demonstrating the complex relationships between war zone exposures, faith, and seeking treatment. More specifically, researchers found that Veterans’ experiences of killing others and failing to prevent death decreased their religious faith, both directly and through guilt feelings, and that decreased faith and guilt were associated with more use of mental health services.10 Consequently, building bridges with the spiritual community can help expand resources and help clinicians and spiritual leaders work together towards the health and healing of military personnel and Veterans. While some efforts are already underway, best understanding how to support these collaborations is critical from both the perspective of military personnel and Veterans as well as clinicians and spiritual leaders.

By acknowledging that we may need to expand the ways in which we conceptualize trauma assessment and treatment to include the moral injury framework, we can continue to provide the best care possible to our military personnel and Veterans. Ideally, we may need to consider multiple treatment trajectories based on our conceptualizations of war zone stressors and matching treatments to trauma type. We need more research to understand who can best benefit from what types of treatments, as well as the unique needs of those that continue to be impacted by moral injury.

Shira Maguen, Ph.D., is Mental Health Director of the OEF/OIF Integrated Care Clinic, Staff Psychologist on the Posttraumatic Stress Disorder Clinical Team (PCT) at the San Francisco VA Medical Center (SFVAMC), and Associate Professor in the Dept. of Psychiatry, UCSF School of Medicine. She is also the San Francisco site lead for the VA Women’s Practice Based Research Network (PBRN) and co-director of the SFVAMC MIRECC Postdoctoral Research Fellowship. Dr. Maguen completed her internship and postdoctoral training at the National Center for PTSD at the VA Boston Healthcare System after receiving her doctorate in Clinical Psychology from Georgia State University. She is involved with both the research and clinical components of the PTSD program.


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  2. Maguen S, Madden E, Bosch J, Galatzer-Levy I, Knight S J, Litz B T, Marmar, C R, & McCaslin S.E. Killing and latent classes of PTSD symptoms in Iraq and Afghanistan Veterans. J Affect Disord. 2013;145:344-348.
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  4. Maguen S, Lucenko BA, Reger MA, Gahm GA, Litz BT, Seal KH, Knight SJ, Marmar CR. The impact of reported direct and indirect killing on mental health symptoms in Iraq war veterans. J Trauma Stress. 2010;23:86-90.
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