“There can be no doubt that this resistance to killing one’s fellow man is there and that it exists as a result of a powerful combination of instinctive, rational, environmental, hereditary, cultural, and social factors. It is there, it is strong, and it gives us cause to believe that there just may be hope for mankind after all.”
-David Grossman, On Killing
A Vietnam Veteran walked into my office at one of the VA’s top inpatient residential posttraumatic stress disorder (PTSD) programs as a last-ditch effort to save his marriage. He said very little in our initial interactions, and the stress of the years working hard to provide for his family alongside many sleepless nights had settled into dark patches under his eyes and grime beneath his fingernails. His outpatient therapist referred him to the program to receive an evidence-based treatment for PTSD. He was quickly assigned to the Cognitive Processing Therapy (CPT) group and to supplemental individual CPT sessions with me.
Like most new residents, he spent many days assessing the safety of the group and staff. Within our individual sessions he expressed concern about disclosing his experiences, especially to a young, female, civilian with no prior service, and probably of similar age to his daughter. Safety and rapport were established through patience and authenticity, as well as through his observations of me leading other trauma-processing groups on the unit. Trust was earned and built collaboratively, not freely given.
During session four of CPT, when he was asked to remember and read aloud his full trauma account, I noticed his otherwise steady hands started to tremble and sweat began to bead above his brow. He courageously finished and we both paused, allowing for the emotion in the room to exist undisturbed. He broke the silence with a proclamation that he is “a monster.” The experience he shared was not the first ambush he had survived in Vietnam, nor was it the first time he had to “kill or be killed.” It was, however, the first time he had to kill someone in such close physical proximity to himself. It was the first time he discovered a picture of a loved one in the pocket of someone he had killed. It was the first moment he realized the humanity in those labeled “enemy” and came to the conclusion that “they were just like us.”
His feelings of guilt since Vietnam were intense and enduring. CPT has conceptualized guilt as a manufactured emotion or a secondary emotion, meaning that it is a product of our thinking and interpretation of events. As a therapist sitting with a patient struggling with guilt, there is something enticing about CPT’s interventions to challenge guilt-related stuck points and to differentiate the feeling of guilt from being guilty. Within CPT, emotions are likened to a fire, which will burn out naturally if it is not fed, and guilt-related thoughts are considered the fuel that keeps the fire burning indefinitely. By changing thoughts and interpretations, the individual takes away the fuel which allows more natural emotions to be processed and for the fire to burn out quickly. Therefore, CPT considers guilt an individual appraisal often unrealistic to be dismantled within the therapy and contextualized within the parameters of war. As Finlay (2015) pointed out, a common motto in CPT is that “guilt is a feeling, not a fact.”
Psychology has historically pathologized guilt (Ellis, 1958; Freud, 1975) and our current conceptualizations of PTSD continue with this framework. Finlay (2015), challenged the field’s existing model of guilt and also collusion with the “political and ideological import of treating combat-related guilt.” In the article, the author highlights that by keeping war-related guilt within the individuals who go to war (i.e., by understanding guilt as manufactured and due to faulty interpretations that can be corrected with treatment), society as a whole is absolved of reconciling some tough emotions. In other words, instead of the impact of war being the responsibility of the collective, guilt and psychological suffering is to be carried by and corrected within the warrior. Thus, there is a function to our current conceptualizations maintaining guilt and guilt-related cognitions as a symptom of the individual with PTSD.
However, what happens to those Veterans and Service members whose guilt does not decrease with Socratic questioning? Whose wounds reach beyond the fear response or erroneous beliefs about the traumatic events? What happens to those who are unable to accommodate morally violating experiences into their beliefs about themselves or the world? Over the past ten years, researchers have begun to explore the lasting impacts of trauma that are not quite captured in the existing explanations of PTSD.
Moral injury is a concept that is defined as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs” (Litz et al., 2009). Transgressions of these moral codes can result in negative moral emotions, such as meaninglessness, shame, guilt, grief, and remorse (Brock & Lettini, 2013). In many ways, moral injury is a nice addendum to our conceptualizations of PTSD that offers a deeper understanding of those “symptoms” that might fail to resolve with our current best practices. Still, it is not necessarily a popular term among military members. Some believe the term suggests that actions in combat were immoral and so a more neutral term of “inner conflict” was proposed (Maguen and Litz, 2015). However, inner conflict lacks specificity and also contains the feeling of guilt within the individual, separate from the broader moral, ethical, spiritual, and philosophical contexts with which they are embedded.
Although the military has been slow to embrace the concept of moral injury, the military itself actually adheres to a strict moral and ethical code and cultivates specific positive moral emotions (e.g., loyalty, fidelity, cohesiveness) in preparation for armed conflict (Farnsworth et al., 2014). In addition to the use of moral emotions to promote individual and group survival, issues with morality have become salient in the wars in Vietnam and the Middle East, which have involved more unconventional tactics (e.g., guerilla warfare, using women and children to carry out attacks, etc.). The most recent conflicts have also required longer and more frequent deployments. Thus, Service members have likely been faced with more morally ambiguous situations and some may have experienced challenges to ethical decision making as deployments have grown in frequency, intensity, and duration. Therefore, it is worthwhile for the military and mental health professionals working with military-connected individuals to consider the role of moral injury and moral emotions in the recovery process.
Not every soldier with PTSD experiences moral injury; however, there is a subset of soldiers with PTSD whose experiences deeply transgress moral beliefs. The subsequent negative moral emotions (e.g., shame, guilt, etc.) that may arise from these transgressions are currently considered symptoms. Although there is merit for challenging more neurotic guilt (Shapiro & Stewart, 2011), guilt in general is considered socially adaptive. Numerous studies have found strong correlations between guilt-proneness and perspective taking, empathy, and pro-social interpersonal behaviors (Joireman, 2004; Tangney, 1991; Baumeister, Stillwell, & Heatherton, 1994). Thus, there is a significant limitation to how CPT and other evidence-based interventions for PTSD address guilt and guilt-related cognitions.
After all, it was the Vietnam Veteran’s experience of guilt and remorse that was, in fact, the antithesis to his understanding of self as “a monster”. It was also true that he had killed and efforts made to contextualize the event or challenge guilt-related cognitions using a CPT framework fell short. His beliefs about killing were his own. The changes in his cognitions following his trauma were also not necessarily symptoms (e.g., challenging the purpose of war, the supposed differences between races of people, and the role of government). In many ways, it was his guilt and guilt-related cognitions that enriched his worldview. It was an honor to witness the complexity of his understanding of the human condition and his compassion for others, all of which seemed birthed from guilt. What his guilt did strip him of, though, was his compassion for self.
Under the social-functionalist framework, positive moral emotions, such as self-compassion, can be used to alleviate suffering from moral injury. Self-compassion has been described as being open to one’s own experience of suffering and generating a desire to heal oneself through kindness (Neff, 2003). If we shift our understanding of guilt from pathological to socially functional, we can start to bolster self-compassion as a mechanism for moral repair (Kearney et al., 2013). From the social functional framework, moral systems (and moral emotions) have developed overtime to promote group survival through the encouragement/discouragement of individual actions to make cooperative social life feasible (Farnsworth, et al., 2014). If guilt were to be viewed as a functional emotion that enhances our species survival, mental health professionals might actually be able to meet such emotions head-on in therapy.
Our current approach to moral emotions decontextualizes the most instinctive of human responses that have evolved for the purpose of species enhancement. We may alienate and invalidate the experiences of our patients if we continue to categorize guilt-related cognitions as stuck points to be challenged. As mental health professionals, do we really want to challenge cognitions related to negative moral emotions, and how much of our existing paradigm is driven by an increasingly individualistic culture? Alternatively, understanding moral emotions from a social-functionalist perspective will aid in our individual interventions, encourage more comprehensive approaches to care (e.g., collaborating with important community members), and depathologize the very reactions that indicate hope for humanity.
The opinions in CDP Staff Perspective 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.
Kaleigh E. DeSimone, Psy.D., is the Center for Deployment Psychology's Military Internship Behavioral Health Psychologist at Tripler Army Medical Center, Honolulu, HI.
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