Staff Perspective: No Consensus on Definition, Measure, or Treatment of Moral Injury
The June 2019 issue of the Journal of Traumatic Stress (JTS) was devoted to Moral Injury (MI). As a clinical psychologist working at a military training hospital where nearly all patients are Warfighters, I was curious about current recommendations regarding the accepted definition of MI, what measure to use, and how to treat it.
Regarding a definition, before reading this special issue if one of my residents had asked me to define Moral Injury (MI). I’d have said something about it being the consequence of having to decide between two irreconcilable choices, each of which violates strongly held values. I’d give them the example of a Soldier at a forward operating base (FOB) facing down a young child in billowy clothing approaching an exterior check point (ECP.) Believing the youth had been outfitted as a walking IED, the Solider was faced with shooting the child, or risking the lives of himself and other Soldiers. Either choice would violate a strongly held value such as "don’t harm the innocent" and "protect your fellow Soldiers." In a sense, I’d previously thought MI was the result of a "damned if you do, damned if you don’t" situation that involved one’s deepest convictions.
The editors of the JTS special issue were Brett Litz, author of several articles on MI, and Patricia Kerig, a noted trauma researcher and one of the developers of the Moral Injury Scales for Youth. In their editorial introduction (Litz & Kerig, 2019), they note that the definition of MI is now much broader and more widely applicable than initially considered in John Shay’s (1994) Achilles in Vietnam in that it includes “…[morally] transgressive harms and the outcomes from those experiences…” (pg. 341) “…applicable to any human endeavor or context.” (pg. 342).
In the first research article of the JTS special issue, Griffin and colleagues (2019) note that there is no consensus definition for MI. Due to this and perhaps because it is not yet a bona fide diagnosis, there is no related DoD or VA policy.
In their closing commentary, Neria and Pickover (2019) briefly review the various MI measures that exist, but make no recommendations on which to use. Elsewhere in the issue, a lack of a gold standard measure is repeatedly mentioned (Litz & Kerig, 2019; Griffin et al., 2019).
So how might clinicians screen for MI among Warfighters? They may do well to be on the lookout for the most difficult decisions Warfighters have had to make; ones that involved deeply-held values or convictions. I typically ask patients about their “Oh sh#t!” moments, especially if they’ve deployed. That’s usually the point at which one realizes things are not going as planned, expected, or desired. I will also try to work in a question about the patient’s biggest regrets in any area of their life. This will sometimes illuminate an event in which they or someone else violated a deeply held value.
A third method to discern whether someone has experienced a MI is by examining their prime emotions subsequent to the trauma. Whereas trauma related to a diagnosis of PTSD typically involves fear, MI involves shame, guilt, hopelessness, and/or a loss of meaning (Currier et al., 2017; Koenig et al., 2018). The consequent emotion of guilt – especially as it pertained to behavior required for survival – was included in the original DSM-III definition of PTSD (APA, 1980). So if a Warfighter is expressing intense feelings of shame and guilt, therapists may do well to backtrack to the precipitating event(s) and see whether one or more moral values were transgressed.
With regard to treatment options for MI, in this JTS special issue, Griffin and colleagues (2019) review the debate over the applicability of Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) to MI, as well as several alternatives to these EBPs. They note that Smith, Duax, and Rauch (2013) have recommendations for how to apply PE to MI. Additionally, for CPT-trained providers, modifications have been made to deal with the existential, religious, or spiritual complications of MI (Koenig et al., 2017; Wade, 2016). Held and colleagues (2018) address their use of CPT in two case examples of Warfighters with MI.
In addition to PE and CPT, I have used EMDR to treat traumatized Warfighters. While I could find no RCTs using EMDR specifically to address MI, the late Francine Shapiro – who developed EMDR (Shapiro, 2001) – wrote about the treatment of an Operation Iraqi Freedom (OIF) medic with MI (Shapiro, 2017). More recently, retired Army Colonel E.C. Hurley (2018) reported successfully treating a group of 30 Veterans’ PTSD and MI using EMDR in both weekly and massed practice formats.
Shapiro and Laliotis (2015) identify several aspects of EMDR that Warfighters with MI may find attractive. These include honoring the dead, being in control of the process, leaving some aspects of the event unspoken, and preparing for the future.
Warfighters who want to remember their deceased comrades should have no fear that EMDR will erase their memory. That’s not how the process works. Indeed, positive memories of fallen comrades can be strengthened, if that is what’s desired. For example, I’ve had several patients who wanted to more strongly connect to their memories of deceased friends, such as when they partied, traveled, or celebrated together.
Control of the EMDR process is facilitated by encouraging the use of a stop signal. If a patient feels overwhelmed at any point they can look away, hold up their hand, and say, “Stop.” Additionally, other facets of EMDR can be used to help prepare a Warfighter for reprocessing a traumatic event. The Safe Place exercise (Shapiro, 2001) is basically a guided imagery protocol that directs the Warfighter to imagine a safe, calm, or good place while engaging in the standard bilateral eye movements, taps, or tones. The Safe Place can be used any time the Warfighter feels overwhelmed, wants to take a break, or at the end of a session to get centered before heading back into the world.
Korn and Leeds (2002) Resource Development and Installation (RDI) is another EMDR process that can be used to help Warfighters deal with any apprehensions about engaging in trauma reprocessing, whether the feared event has happened or not. The RDI protocol basically takes the Warfighter through imagining what they need to think, feel, and do in order to cope with the feared situation. Then they identify several different internal resources where they thought, felt, and did those things. Using the bilateral stimulation they then increase, anchor and experience those positive resources while imagining going through the feared situation. The end result is typically greater confidence in going forward towards the feared situation as well as reduced distress when imagining facing the feared situation. Leeds (2006) notes that RDI is beneficial for assisting with intense shame, depersonalization, angry outbursts, self-injurious behaviors, obsessive, self-critical thoughts, misery, and substance abuse.
Many Warfighters may have certain aspects of their experiences they do not wish to speak about. As a treatment for PTSD and MI, EMDR does not require one to reveal each and every aspect of a trauma. So long as the event can be vividly recalled the process can work.
Finally, a core component of the later phase of EMDR is preparing for the future. This entails imagining whatever behaviors one believes they need in order to cope effectively with any feared future scenario, whether a reminder of the trauma or successfully engaging in a fulfilling life.
In summary, the JTS special issue on MI does not identify a gold standard definition, measure or treatment. Busy clinicians treating traumatized Warfighters are encouraged to use the skills they already have to address MI, clinical acumen and established treatments for PTSD.
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.
Dave Reynolds, Ph.D., is the Military Internship Behavioral Health Psychogist with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Dr. Reynolds is currently located at Malcolm Grow Medical Clinics and Surgery Center (MGMCSC), Joint Base Andrews, Maryland.
REFERENCES
American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders (3 ed.). Washington, DC: APA Press.
Currier, J. M., Smith, P. N., & Kuhlman, S. (2017). Assessing the unique role of religious coping in suicidal behavior among U.S. Iraq and Afghanistan veterans. Psychology of Religion and Spirituality, 9, 118–123. doi: 10.1037/rel0000055
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, 350-362. doi: 10.1002/jts.22362
Held, P., Klassena, B. J., Brennana, M. B., & Zaltaa, A. K. (2018). Using Prolonged Exposure and Cognitive Processing Therapy to treat veterans with moral injury-based PTSD: Two case examples. Cognitive Behavioral Practice, 25(3), 377–390. doi:10.1016/j.cbpra.2017.09.003
Hurley, E. C. (2018). Effective treatment of Veterans with PTSD: Comparison between intensive daily and weekly EMDR approaches. Frontiers in Psychology, 9(1458), 1-10. doi: 10.3389/fpsyg.2018.01458
Koenig, H. G., Ames, D., Youssef, N. A., Oliver, J. P., Teng, E. J., Haynes, K., . . . Pearce, M. (2018). The Moral Injury Symptom Scale–Military Version. Journal of Religion and Health, 57, 249–265. doi: 10.1007/s10943-017-0531-9
Koenig, H. G., Boucher, N. A., Oliver, R. J. P., Youssef, N., Mooney, S. R., Currier, J. M., & Pearce, M. (2017). Rationale for spiritually oriented cognitive processing therapy for moral injury in active duty military and veterans with posttraumatic stress disorder. Journal of Nervous and Mental Disease, 205, 147–153. doi: 10.1097/NMD.0000000000000554
Korn, D. L., & Leeds, A. M. (2002). Preliminary evidence of efficacy for EMDR resource development and installation in the stabilization phase of treatment of complex posttraumatic stress disorder. Journal of Clinical Psychology, 58(12), 1465-1487.
Leeds, A. M. (2006). Criteria for assuring appropriate clinical use and avoiding misuse of Resourced Development and Installation when treating complex posttraumatic stress syndromes. EMDR International Association Annual Conference. Sep 8, 2006.
Litz, B. T., & Kerig, P. T. (2019). Introduction to the special issue on moral injury: Conceptual challenges, methodological issues, and clinical applications. Journal of Traumatic Stress, 32, 341-349. doi: 10.1002/jts.22405
Neria, Y., & Pickover, A. (2019). Commentary on the special issue on moral injury: Advances, gaps in literature, and future directions. Journal of Traumatic Stress, 32, 459-464. doi: 10.1002/jts.22402
Shapiro, F. (2017, June 14). Clinician’s Corner: EMDR Therapy. [Blog post]. Retrieved from http://emdrlebanon.org/articles_16_clinicians-corner-emdr-therapy
Shapiro, F., & Laliotis, D (2015). EMDR for trauma-related disorders. In U. Schnyder & M. Cloitre (Eds.), Evidenced Base Treatments for Trauma-Related Psychological Disorders: A Practical Guide for Clinicians (pp 205-228). Switzerland: Springer.
Shapiro, F. ([1995] 2001). Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures (2 ed.). New York: Guilford Press.
Shay, J. (1994). Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York: Scribner.
Smith, E. R., Duax, J. M., & Rauch, S. A. (2013). Perceived perpetration during traumatic events: Clinical suggestions from experts in prolonged exposure therapy. Cognitive and Behavioral Practice, 20, 461–470. doi: 10.1016/j.cbpra.2012.12.002
Wade, N. R. (2016). Integrating cognitive processing therapy and spirituality for the treatment of post-traumatic stress disorder in the military. Social Work and Christianity, 43, 59–72.
The June 2019 issue of the Journal of Traumatic Stress (JTS) was devoted to Moral Injury (MI). As a clinical psychologist working at a military training hospital where nearly all patients are Warfighters, I was curious about current recommendations regarding the accepted definition of MI, what measure to use, and how to treat it.
Regarding a definition, before reading this special issue if one of my residents had asked me to define Moral Injury (MI). I’d have said something about it being the consequence of having to decide between two irreconcilable choices, each of which violates strongly held values. I’d give them the example of a Soldier at a forward operating base (FOB) facing down a young child in billowy clothing approaching an exterior check point (ECP.) Believing the youth had been outfitted as a walking IED, the Solider was faced with shooting the child, or risking the lives of himself and other Soldiers. Either choice would violate a strongly held value such as "don’t harm the innocent" and "protect your fellow Soldiers." In a sense, I’d previously thought MI was the result of a "damned if you do, damned if you don’t" situation that involved one’s deepest convictions.
The editors of the JTS special issue were Brett Litz, author of several articles on MI, and Patricia Kerig, a noted trauma researcher and one of the developers of the Moral Injury Scales for Youth. In their editorial introduction (Litz & Kerig, 2019), they note that the definition of MI is now much broader and more widely applicable than initially considered in John Shay’s (1994) Achilles in Vietnam in that it includes “…[morally] transgressive harms and the outcomes from those experiences…” (pg. 341) “…applicable to any human endeavor or context.” (pg. 342).
In the first research article of the JTS special issue, Griffin and colleagues (2019) note that there is no consensus definition for MI. Due to this and perhaps because it is not yet a bona fide diagnosis, there is no related DoD or VA policy.
In their closing commentary, Neria and Pickover (2019) briefly review the various MI measures that exist, but make no recommendations on which to use. Elsewhere in the issue, a lack of a gold standard measure is repeatedly mentioned (Litz & Kerig, 2019; Griffin et al., 2019).
So how might clinicians screen for MI among Warfighters? They may do well to be on the lookout for the most difficult decisions Warfighters have had to make; ones that involved deeply-held values or convictions. I typically ask patients about their “Oh sh#t!” moments, especially if they’ve deployed. That’s usually the point at which one realizes things are not going as planned, expected, or desired. I will also try to work in a question about the patient’s biggest regrets in any area of their life. This will sometimes illuminate an event in which they or someone else violated a deeply held value.
A third method to discern whether someone has experienced a MI is by examining their prime emotions subsequent to the trauma. Whereas trauma related to a diagnosis of PTSD typically involves fear, MI involves shame, guilt, hopelessness, and/or a loss of meaning (Currier et al., 2017; Koenig et al., 2018). The consequent emotion of guilt – especially as it pertained to behavior required for survival – was included in the original DSM-III definition of PTSD (APA, 1980). So if a Warfighter is expressing intense feelings of shame and guilt, therapists may do well to backtrack to the precipitating event(s) and see whether one or more moral values were transgressed.
With regard to treatment options for MI, in this JTS special issue, Griffin and colleagues (2019) review the debate over the applicability of Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) to MI, as well as several alternatives to these EBPs. They note that Smith, Duax, and Rauch (2013) have recommendations for how to apply PE to MI. Additionally, for CPT-trained providers, modifications have been made to deal with the existential, religious, or spiritual complications of MI (Koenig et al., 2017; Wade, 2016). Held and colleagues (2018) address their use of CPT in two case examples of Warfighters with MI.
In addition to PE and CPT, I have used EMDR to treat traumatized Warfighters. While I could find no RCTs using EMDR specifically to address MI, the late Francine Shapiro – who developed EMDR (Shapiro, 2001) – wrote about the treatment of an Operation Iraqi Freedom (OIF) medic with MI (Shapiro, 2017). More recently, retired Army Colonel E.C. Hurley (2018) reported successfully treating a group of 30 Veterans’ PTSD and MI using EMDR in both weekly and massed practice formats.
Shapiro and Laliotis (2015) identify several aspects of EMDR that Warfighters with MI may find attractive. These include honoring the dead, being in control of the process, leaving some aspects of the event unspoken, and preparing for the future.
Warfighters who want to remember their deceased comrades should have no fear that EMDR will erase their memory. That’s not how the process works. Indeed, positive memories of fallen comrades can be strengthened, if that is what’s desired. For example, I’ve had several patients who wanted to more strongly connect to their memories of deceased friends, such as when they partied, traveled, or celebrated together.
Control of the EMDR process is facilitated by encouraging the use of a stop signal. If a patient feels overwhelmed at any point they can look away, hold up their hand, and say, “Stop.” Additionally, other facets of EMDR can be used to help prepare a Warfighter for reprocessing a traumatic event. The Safe Place exercise (Shapiro, 2001) is basically a guided imagery protocol that directs the Warfighter to imagine a safe, calm, or good place while engaging in the standard bilateral eye movements, taps, or tones. The Safe Place can be used any time the Warfighter feels overwhelmed, wants to take a break, or at the end of a session to get centered before heading back into the world.
Korn and Leeds (2002) Resource Development and Installation (RDI) is another EMDR process that can be used to help Warfighters deal with any apprehensions about engaging in trauma reprocessing, whether the feared event has happened or not. The RDI protocol basically takes the Warfighter through imagining what they need to think, feel, and do in order to cope with the feared situation. Then they identify several different internal resources where they thought, felt, and did those things. Using the bilateral stimulation they then increase, anchor and experience those positive resources while imagining going through the feared situation. The end result is typically greater confidence in going forward towards the feared situation as well as reduced distress when imagining facing the feared situation. Leeds (2006) notes that RDI is beneficial for assisting with intense shame, depersonalization, angry outbursts, self-injurious behaviors, obsessive, self-critical thoughts, misery, and substance abuse.
Many Warfighters may have certain aspects of their experiences they do not wish to speak about. As a treatment for PTSD and MI, EMDR does not require one to reveal each and every aspect of a trauma. So long as the event can be vividly recalled the process can work.
Finally, a core component of the later phase of EMDR is preparing for the future. This entails imagining whatever behaviors one believes they need in order to cope effectively with any feared future scenario, whether a reminder of the trauma or successfully engaging in a fulfilling life.
In summary, the JTS special issue on MI does not identify a gold standard definition, measure or treatment. Busy clinicians treating traumatized Warfighters are encouraged to use the skills they already have to address MI, clinical acumen and established treatments for PTSD.
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.
Dave Reynolds, Ph.D., is the Military Internship Behavioral Health Psychogist with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Dr. Reynolds is currently located at Malcolm Grow Medical Clinics and Surgery Center (MGMCSC), Joint Base Andrews, Maryland.
REFERENCES
American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders (3 ed.). Washington, DC: APA Press.
Currier, J. M., Smith, P. N., & Kuhlman, S. (2017). Assessing the unique role of religious coping in suicidal behavior among U.S. Iraq and Afghanistan veterans. Psychology of Religion and Spirituality, 9, 118–123. doi: 10.1037/rel0000055
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, 350-362. doi: 10.1002/jts.22362
Held, P., Klassena, B. J., Brennana, M. B., & Zaltaa, A. K. (2018). Using Prolonged Exposure and Cognitive Processing Therapy to treat veterans with moral injury-based PTSD: Two case examples. Cognitive Behavioral Practice, 25(3), 377–390. doi:10.1016/j.cbpra.2017.09.003
Hurley, E. C. (2018). Effective treatment of Veterans with PTSD: Comparison between intensive daily and weekly EMDR approaches. Frontiers in Psychology, 9(1458), 1-10. doi: 10.3389/fpsyg.2018.01458
Koenig, H. G., Ames, D., Youssef, N. A., Oliver, J. P., Teng, E. J., Haynes, K., . . . Pearce, M. (2018). The Moral Injury Symptom Scale–Military Version. Journal of Religion and Health, 57, 249–265. doi: 10.1007/s10943-017-0531-9
Koenig, H. G., Boucher, N. A., Oliver, R. J. P., Youssef, N., Mooney, S. R., Currier, J. M., & Pearce, M. (2017). Rationale for spiritually oriented cognitive processing therapy for moral injury in active duty military and veterans with posttraumatic stress disorder. Journal of Nervous and Mental Disease, 205, 147–153. doi: 10.1097/NMD.0000000000000554
Korn, D. L., & Leeds, A. M. (2002). Preliminary evidence of efficacy for EMDR resource development and installation in the stabilization phase of treatment of complex posttraumatic stress disorder. Journal of Clinical Psychology, 58(12), 1465-1487.
Leeds, A. M. (2006). Criteria for assuring appropriate clinical use and avoiding misuse of Resourced Development and Installation when treating complex posttraumatic stress syndromes. EMDR International Association Annual Conference. Sep 8, 2006.
Litz, B. T., & Kerig, P. T. (2019). Introduction to the special issue on moral injury: Conceptual challenges, methodological issues, and clinical applications. Journal of Traumatic Stress, 32, 341-349. doi: 10.1002/jts.22405
Neria, Y., & Pickover, A. (2019). Commentary on the special issue on moral injury: Advances, gaps in literature, and future directions. Journal of Traumatic Stress, 32, 459-464. doi: 10.1002/jts.22402
Shapiro, F. (2017, June 14). Clinician’s Corner: EMDR Therapy. [Blog post]. Retrieved from http://emdrlebanon.org/articles_16_clinicians-corner-emdr-therapy
Shapiro, F., & Laliotis, D (2015). EMDR for trauma-related disorders. In U. Schnyder & M. Cloitre (Eds.), Evidenced Base Treatments for Trauma-Related Psychological Disorders: A Practical Guide for Clinicians (pp 205-228). Switzerland: Springer.
Shapiro, F. ([1995] 2001). Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures (2 ed.). New York: Guilford Press.
Shay, J. (1994). Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York: Scribner.
Smith, E. R., Duax, J. M., & Rauch, S. A. (2013). Perceived perpetration during traumatic events: Clinical suggestions from experts in prolonged exposure therapy. Cognitive and Behavioral Practice, 20, 461–470. doi: 10.1016/j.cbpra.2012.12.002
Wade, N. R. (2016). Integrating cognitive processing therapy and spirituality for the treatment of post-traumatic stress disorder in the military. Social Work and Christianity, 43, 59–72.