Staff Perspective: Moral Injury – What’s New and How Far Have We Come?
The concept of moral injury (MI) has become much more of a mainstream construct in mental health treatment over the last decade. In my research for this article, I reviewed my colleague’s observations and perspectives on the theoretical development, assessment and treatment. There has been rigorous examination, discussion and research on the construct of MI, its causes and remedies. There is a great deal of discussion about how MI is or is not part of PTSD and weather the treatments for PTSD are effective or not effective in alleviating the symptoms associated with MI. Rather than rehash these topics, I’ll point you to the perspectives of my colleagues Laura Copeland (Recognition of Moral Injury) and Paula Domenici (Identification and Assessment of Moral Injury) for a review of this information.
In this entry, I want to discuss some of the more recent additions to the field, specifically, the addition of the concepts from Acceptance and Commitment Therapy (ACT) that have been applied to the treatment of MI. Up to this point, there have been several treatment models proposed including: Adaptive Disclosure (Gray et al., 2012; Litz et al., 2009), Impact of Killing (Maguen et al., 2017) with the overall trend of the research of these treatments is generally positive, but there is still a lot we don’t understand and more gaps to be filled in.
The ACT-based treatment process for MI was developed within the Palo Alto VAMC and implemented at the Denver VAMC as a 12-session group format by Farnsworth, J.K., Borges, L. M., Drescher, K. D., & Walser, R. D (2019). The authors of this treatment program describe ACT-MI as having several factors that are advantageous over other treatment modalities, which are unique to the core principles of ACT. Because of this, ACT is well positioned to address moral emotions and the need for moral healing. Specifically, the authors suggest that ACT’s focus on the Social Functional Theory of Moral Emotions is particularly relevant. Emotions are moral in nature when they regulate the interests of a higher level of social organization (Giner-Sorolla, R. 2018). The distinction of moral emotions is an important concept to MI as it is distinguished from PTSD. Symptoms of PTSD are more commonly related to fear and anxiety, while MI symptoms are more aligned with shame and guilt, with shame and guilt being much more associated with violations of societal norms. The ACT-MI process emphasizes moral healing through acceptance of behaviors and situations while developing values consistent behaviors.
The initial study focused on measures of acceptance, values of living, and cognitive fusion rather than symptom specific measures that are commonly used when assessing PTSD outcomes. The good news is the pilot study indicated improvements in all of the outcome measures. So what does this mean when it comes to sitting down with a client who is suffering from Moral Injury and/or PTSD? I believe the concept of MI and the concepts of ACT adds a great deal of context to the process that is occurring with individuals that experience traumatic and morally injurious events. It helps us move from looking only at the fear network and dysfunctional thought patterns to including the reality that the individual has witnessed or been involved in something that violates our common social values. The concepts of ACT applied to MI (along with the other treatments intended to address MI) work towards integrating this perceived violation into our sense of self and the world.
The argument can be made that this is similar to the concept of working towards accommodation as outlined in the Cognitive Processing Therapy (CPT) treatment protocol. My view on the difference is the assumption in CPT is that dysfunctional thoughts are at the root of the inability to accommodate the experience. If we incorporate the notion of moral emotions and moral healing, we work towards making space for what happened while living a value based life rather than focusing on challenging dysfunctional beliefs. I do not believe these are conflicting concepts, but rather complementary. My experience has been that these treatment needs exist simultaneously, which can be challenging when trying to implement an evidence based protocol with fidelity. It’s important to focus on fidelity to treatment while balancing the reality of what you are seeing with your client/patient. I would expect that the field will evolve towards a more integrated approach that accounts for both constructs. Until then, we do the best we can based on what we know so far.
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.
Jeff Mann, Psy.D. is a Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences (USU) in Bethesda, Maryland.
References:
Farnsworth, J. K., Drescher, K. D., Nieuwsma, J. A., & Walser, R. D. (2014). The role of moral emotions in military trauma: Implications for the study and treatment of moral injury. Review of General Psychology, 18(4), 249-262.
Farnsworth, J. K.*, Borges, L. M.*, Drescher, K. D., & Walser, R. D. (2019). Acceptance and commitment therapy for the treatment of moral injury (ACT-MI). Unpublished treatment manual. *Both authors contributed equally to this manual.
Farnsworth J.K., Drescher K.D., Evans W.R., & Walser, R. D. (2017). A functional approach to understanding and treating military-related moral injury. Journal of Contextual Behavioral Science, 6(4), 391-397.
Gray, M. J., Schorr, Y., Nash, W., Lebowitz, L., Amidon, A., Lansing, A., …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.
Hayes S. C., Strosahl K. D., & Wilson K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change, second edition. Guildford Press: New York, NY.
Hayes, S. C. & Sanford, B. T. (2014). Cooperation came first: Evolution and human cognition. Journal of the Experimental Analysis of Behavior, 101(1), 112-129.
Jordan, A. H., Eisen, E., Bolton, E., Nash, W. P., & Litz, B. T. (2019). Distinguishing war-related PTSD resulting from perpetration and betrayal-based morally injurious events. Psychological Trauma: Theory, Research, Practice, & Policy, 9(6), 627-634.
Litz, B. T., Stein, N., Delaney, E., Lebowtiz, 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.
Maguen, S., Burkman, K., Madden, E., Dinh, J., Bosch, J., Keyser, J., Schmitz, M., & Neylan, T. C. (2017). Impact of killing in war: A randomized, controlled pilot trial. Journal of Clinical Psychology, 73(9), 997-1012.
Giner-Sorolla, R. (2018). A functional conflict theory of moral emotions. In K. Gray & J. Graham (Eds.), Atlas of moral psychology (p. 81–87). The Guilford Press.
The concept of moral injury (MI) has become much more of a mainstream construct in mental health treatment over the last decade. In my research for this article, I reviewed my colleague’s observations and perspectives on the theoretical development, assessment and treatment. There has been rigorous examination, discussion and research on the construct of MI, its causes and remedies. There is a great deal of discussion about how MI is or is not part of PTSD and weather the treatments for PTSD are effective or not effective in alleviating the symptoms associated with MI. Rather than rehash these topics, I’ll point you to the perspectives of my colleagues Laura Copeland (Recognition of Moral Injury) and Paula Domenici (Identification and Assessment of Moral Injury) for a review of this information.
In this entry, I want to discuss some of the more recent additions to the field, specifically, the addition of the concepts from Acceptance and Commitment Therapy (ACT) that have been applied to the treatment of MI. Up to this point, there have been several treatment models proposed including: Adaptive Disclosure (Gray et al., 2012; Litz et al., 2009), Impact of Killing (Maguen et al., 2017) with the overall trend of the research of these treatments is generally positive, but there is still a lot we don’t understand and more gaps to be filled in.
The ACT-based treatment process for MI was developed within the Palo Alto VAMC and implemented at the Denver VAMC as a 12-session group format by Farnsworth, J.K., Borges, L. M., Drescher, K. D., & Walser, R. D (2019). The authors of this treatment program describe ACT-MI as having several factors that are advantageous over other treatment modalities, which are unique to the core principles of ACT. Because of this, ACT is well positioned to address moral emotions and the need for moral healing. Specifically, the authors suggest that ACT’s focus on the Social Functional Theory of Moral Emotions is particularly relevant. Emotions are moral in nature when they regulate the interests of a higher level of social organization (Giner-Sorolla, R. 2018). The distinction of moral emotions is an important concept to MI as it is distinguished from PTSD. Symptoms of PTSD are more commonly related to fear and anxiety, while MI symptoms are more aligned with shame and guilt, with shame and guilt being much more associated with violations of societal norms. The ACT-MI process emphasizes moral healing through acceptance of behaviors and situations while developing values consistent behaviors.
The initial study focused on measures of acceptance, values of living, and cognitive fusion rather than symptom specific measures that are commonly used when assessing PTSD outcomes. The good news is the pilot study indicated improvements in all of the outcome measures. So what does this mean when it comes to sitting down with a client who is suffering from Moral Injury and/or PTSD? I believe the concept of MI and the concepts of ACT adds a great deal of context to the process that is occurring with individuals that experience traumatic and morally injurious events. It helps us move from looking only at the fear network and dysfunctional thought patterns to including the reality that the individual has witnessed or been involved in something that violates our common social values. The concepts of ACT applied to MI (along with the other treatments intended to address MI) work towards integrating this perceived violation into our sense of self and the world.
The argument can be made that this is similar to the concept of working towards accommodation as outlined in the Cognitive Processing Therapy (CPT) treatment protocol. My view on the difference is the assumption in CPT is that dysfunctional thoughts are at the root of the inability to accommodate the experience. If we incorporate the notion of moral emotions and moral healing, we work towards making space for what happened while living a value based life rather than focusing on challenging dysfunctional beliefs. I do not believe these are conflicting concepts, but rather complementary. My experience has been that these treatment needs exist simultaneously, which can be challenging when trying to implement an evidence based protocol with fidelity. It’s important to focus on fidelity to treatment while balancing the reality of what you are seeing with your client/patient. I would expect that the field will evolve towards a more integrated approach that accounts for both constructs. Until then, we do the best we can based on what we know so far.
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.
Jeff Mann, Psy.D. is a Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences (USU) in Bethesda, Maryland.
References:
Farnsworth, J. K., Drescher, K. D., Nieuwsma, J. A., & Walser, R. D. (2014). The role of moral emotions in military trauma: Implications for the study and treatment of moral injury. Review of General Psychology, 18(4), 249-262.
Farnsworth, J. K.*, Borges, L. M.*, Drescher, K. D., & Walser, R. D. (2019). Acceptance and commitment therapy for the treatment of moral injury (ACT-MI). Unpublished treatment manual. *Both authors contributed equally to this manual.
Farnsworth J.K., Drescher K.D., Evans W.R., & Walser, R. D. (2017). A functional approach to understanding and treating military-related moral injury. Journal of Contextual Behavioral Science, 6(4), 391-397.
Gray, M. J., Schorr, Y., Nash, W., Lebowitz, L., Amidon, A., Lansing, A., …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.
Hayes S. C., Strosahl K. D., & Wilson K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change, second edition. Guildford Press: New York, NY.
Hayes, S. C. & Sanford, B. T. (2014). Cooperation came first: Evolution and human cognition. Journal of the Experimental Analysis of Behavior, 101(1), 112-129.
Jordan, A. H., Eisen, E., Bolton, E., Nash, W. P., & Litz, B. T. (2019). Distinguishing war-related PTSD resulting from perpetration and betrayal-based morally injurious events. Psychological Trauma: Theory, Research, Practice, & Policy, 9(6), 627-634.
Litz, B. T., Stein, N., Delaney, E., Lebowtiz, 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.
Maguen, S., Burkman, K., Madden, E., Dinh, J., Bosch, J., Keyser, J., Schmitz, M., & Neylan, T. C. (2017). Impact of killing in war: A randomized, controlled pilot trial. Journal of Clinical Psychology, 73(9), 997-1012.
Giner-Sorolla, R. (2018). A functional conflict theory of moral emotions. In K. Gray & J. Graham (Eds.), Atlas of moral psychology (p. 81–87). The Guilford Press.