Moral injury and moral repair in war veterans: A preliminary model and intervention strategy

National Center for PTSD, VA Boston Healthcare System, United States.
Clinical psychology review (Impact Factor: 7.18). 08/2009; 29(8):695-706. DOI: 10.1016/j.cpr.2009.07.003
Source: PubMed


Throughout history, warriors have been confronted with moral and ethical challenges and modern unconventional and guerilla wars amplify these challenges. Potentially morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long-term, emotionally, psychologically, behaviorally, spiritually, and socially (what we label as moral injury). Although there has been some research on the consequences of unnecessary acts of violence in war zones, the lasting impact of morally injurious experience in war remains chiefly unaddressed. To stimulate a critical examination of moral injury, we review the available literature, define terms, and offer a working conceptual framework and a set of intervention strategies designed to repair moral injury.

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    • "The concept of moral injury [4] is a relatively recent addition to the mental health lexicon, but its antecedents can be evidenced in ancient concepts such as sin and karma, which expressed in the languages of their times the basic idea that a person's core self could be harmed by events that violated moral beliefs and expectations. For example, in ancient Greece the concept of miasma appealed less to the spiritual consequences of wrong action, and more to a personal moral stain on the wrongdoer – a stain which, it was believed, could even be transferred to friends or family by a process akin to infectious contagion. "
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    ABSTRACT: Moral injury and acceptance and commitment therapy (ACT) are both topics that have only quite recently been introduced into the mental health literature. Although inquiries into these two domains have been advanced independent from one another, both challenge various aspects of the traditional medical model for diagnosing, understanding, and treating psychiatric problems. This article explores complementary possibilities for using ACT to approach the care of persons with moral injury. Descriptions of moral injury and ACT are provided along with an overview of the developmental histories and relevant research literature in each of these domains. Specific possibilities for attending to moral injury are explored via examination of each of the six core processes in ACT: acceptance; cognitive defusion; contact with the present moment; self-as-context; values; and committed action. It is suggested that ACT has unique potential as an evidence-based psychotherapy for approaching numerous moral injury related issues. These include: understanding human suffering as normative, expectable, and potentially meaningful; balancing both verbal and experiential understandings of morality; fostering forgiveness in a manner that is not dismissive of guilt but employs it to orient towards values; holding and honoring morally injurious experiences in a way that respects and empathizes with ongoing suffering; identifying a sense of self from which to behaviorally enact valued actions; and inviting engagement from care providers and communities outside of the traditional mental health care system. Future conceptual and empirical work is needed, including studies examining the efficacy and effectiveness of ACT for moral injury.
    Current Psychiatry Reviews 08/2015; 11(3). DOI:10.2174/1573400511666150629105234
    • "Building on prior research that demonstrated that selfcompassion was primarily associated with the avoidance symptoms of PTSD among a civilian sample with trauma exposure (Thompson & Waltz, 2008), we examined the relations between self-compassion and the DSM-IV PTSD symptom clusters . Based on the literature on moral injury in war veterans (Litz et al., 2009), we expected that level of combat exposure would be negatively associated with self-compassion. In addition , we explored which aspects of combat exposure (e.g., being in the role of victim versus engaging in violence, involvement of civilians) were most strongly related to self-compassion. "
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    ABSTRACT: Mindfulness and self-compassion are overlapping but distinct constructs that characterize how people relate to emotional distress. Both are associated with PTSD and may be related to functional disability. While self-compassion includes mindful awareness of emotional distress, it is a broader construct that also includes being kind and supportive to oneself and viewing suffering as part of the shared human experience – a powerful way of dealing with distressing situations. We examined the associations of mindfulness and self-compassion with PTSD symptom severity and functional disability in 115 trauma-exposed Iraq/Afghanistan war veterans. Mindfulness and self-compassion were each uniquely, negatively associated with PTSD symptom severity. After accounting for mindfulness, self-compassion accounted for unique variance in PTSD symptom severity (f² = .25; medium ES). After accounting for PTSD symptom severity, mindfulness and self-compassion were each uniquely negatively associated with functional disability. The combined association of mindfulness and self-compassion with disability over and above PTSD was large (f² = .41). After accounting for mindfulness, self-compassion accounted for unique variance in disability (f² = .13; small ES). These findings suggest that interventions aimed at increasing mindfulness and self-compassion could potentially decrease functional disability in returning veterans with PTSD symptoms.
    Journal of Traumatic Stress 07/2015; in press. DOI:10.1002/jts.22045 · 2.72 Impact Factor
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    • "appraisal of the world as lacking meaning and predictability (Bryan et al., 2013; Marx et al., 2010). Veterans may suffer from a strong inner conflict as a result of a severe discrepancy between personal schemas and violent acts committed or witnessed in military duty, which may impair the integration of the event within existing personal schemas (Horowitz, 1992; Litz et al., 2009). Failure in the assimilation of new values and ideals in self-schemas could result in strong self-concept and identity disturbance (Herman , 1992; Lee, Scragg, & Turner, 2001). "
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    ABSTRACT: We analyzed the effects of 3 war components-combat exposure (CES), observation of abusive violence (OBS), and participation in abusive violence (PARTC)-and sense of coherence (SOC) on the development of both posttraumatic stress disorder (PTSD) and depression among a sample of war veterans. We also analyzed the role of SOC as a mediator of the effects of CES, OBS, and PARTC on both depression and PTSD symptoms. Sample was composed of 120 Portuguese Colonial War veterans. A binomial logistic regression analysis was performed to determine the effects of these variables on depression and PTSD diagnosis. Mediation test was performed by conducting several hierarchical regression analyses. Results showed that OBS and PARTC, and lower levels of SOC were associated with increased odds for exceeding the clinical cutoff scores for diagnosis of depression. All variables were associated with increased odds for exceeding the clinical cutoff scores for diagnosis of PTSD. In mediation analysis, at first step, PARTC was not a significant predictor of both PTSD and depression symptoms, and PARTC did not enter in subsequent analysis. SOC was a full mediator of the effects of OBS and CES on both depression and PTSD symptoms. We propose that treatment of war veterans should aim the reconciliation of traumatic incongruent experiences in veterans' personal schemas to strengthen veterans' sense of coherence, especially for those exposed to acts of abusive violence. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
    Psychological Trauma Theory Research Practice and Policy 04/2015; DOI:10.1037/tra0000043 · 2.31 Impact Factor
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