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

ABSTRACT 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.

    • "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. · 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 · 0.89 Impact Factor
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    • "After a traumatic event, most of the psychological structures of the self— body image, images of others, and ideals and values— have been invaded and systematically broken down disturbing individual's sense of coherence (Herman, 1992). This inability was proposed to be a strong vulnerability factor for PTSD (Leskela, Dieperink, & Thuras, 2002; Litz et al., 2009) as a consequence of strong self-concept and identity disturbance (Van Vliet, 2008). However, no previous study has explored this hypothesis. "
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    ABSTRACT: This study explored the factors to which a sample of Portuguese war veterans attributed their recovery from posttraumatic symptoms related to their war experiences. Participants were a sample (n = 60) of war veterans with mental sequelae of the Portuguese Colonial war: 30 suffered from chronic PTSD (unrecovered) and 30 veterans with remission from PTSD (recovered). Two individual semistructured interviews were conducted. Analysis of the interviews was conducted using the Thematic and Categorical Analysis. Six themes were identified to which participants attributed their recovery: war zone stressors, stressful life events, mental and coping strategies, self-integration in personal schemas of morally incongruent experiences, self-awareness of mental states, and perceived social support. Recovered participants showed higher occurrence of integration of the morally incongruent events within existing personal schemas, self-awareness of mental states, and use of problem focused coping. Unrecovered participants showed higher occurrence of lack of self-awareness of mental states, use of acting out strategies and lack of social support. The authors discussed that reconciliation of morally discrepant experiences in their self- and relational-schemas, and development of higher self-awareness of their own mental states can play a pivotal role in recovery from PTSD among war veterans.
    Traumatology 03/2015; 21(1):22-31. DOI:10.1037/trm0000019
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