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Moral Injury in Veterans of War v23n1

Moral Injury in Veterans of War v23n1

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Moral Injury in Veterans of War v23n1
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 advancing science and promoting understanding of traumatic stress
Research Quarterly 
 VOLUME 23/NO. 1
ISSN: 1050-1835
2012
Published by:
National Center for PTSD VA Medical Center (116D)215 North Main StreetWhite River Junction Vermont 05009-0001 USA(802) 296-5132FAX (802) 296-5135Email:ncptsd@va.gov All issues of the PTSD ResearchQuarterly are available online at:www.ptsd.va.gov 
Editorial Members:
Editorial DirectorMatthew J. Friedman, MD, PhDScientic EditorFran H. Norris, PhDManaging EditorHeather Smith, BA EdCirculation ManagerSusan Garone 
National Center Divisions:
ExecutiveWhite River Jct VTBehavioral ScienceBoston MADissemination and TrainingMenlo Park CAClinical NeurosciencesWest Haven CTEvaluationWest Haven CTPacic IslandsHonolulu HIWomen’s Health SciencesBoston MA
Continued on page 2
Shira Maguen, Ph.D.
Research Psychologist, San Francisco VA Medical Center; Assistant Professor, University of California, San Francisco,School of Medicine
Brett Litz, Ph.D.
Director, Mental Health Core, Massachusetts VeteransEpidemiological Research and Information Center, VA Boston Healthcare System; Professor, Boston UniversitySchool of Medicine
Moral Injuryin Veterans of War
Military personnel serving in war are confrontedwith ethical and moral challenges, most of whichare navigated successfully because of effectiverules of engagement, training, leadership, andthe purposefulness and coherence that arise incohesive units during and after various challenges.However, even in optimal operational contexts,some combat and operational experiences caninevitably transgress deeply held beliefs that undergirda service member’s humanity. Transgressions canarise from individual acts of commission oromission, the behavior of others, or by bearingwitness to intense human suffering or the grotesqueaftermath of battle. An act of serious transgressionthat leads to serious inner conict because theexperience is at odds with core ethical and moralbeliefs is called
 moral injury 
.More specically, moral injury has been dened as“perpetrating, failing to prevent, bearing witness to,or learning about acts that transgress deeply heldmoral beliefs and expectations” (Litz et al., 2009). Various acts of commission or omission may set thestage for the development of moral injury. Betrayalon either a personal or an organizational level canalso act as a precipitant. On a conceptual level,moral injury is different from long-establishedpost-deployment mental health problems. Forexample, whereas PTSD is a mental disorder thatrequires a diagnosis, moral injury is a dimensionalproblem. There is no threshold for establishing thepresence of moral injury; rather, at a given point intime, a Veteran may have none, or have mild toextreme manifestations. Furthermore, transgressionis not necessary for a PTSD diagnosis nor doesPTSD sufciently capture moral injury, or the shame,guilt, and self-handicapping behaviors that oftenaccompany moral injury. Although the idea that war can be morallycompromising is not new, empirical research aboutmoral injury is in its infancy, and there are moreunanswered questions than denitive answers atthis point. Below we review key studies that fallunder the umbrella of moral injury, noting thelimitations of current knowledge and suggestingfuture research directions.For those interested in learning more about thetopic of moral injury, Litz et al. (2009) provide acomprehensive review, complete with workingdenitions, prior research in related areas, apreliminary conceptual model, and interventionsuggestions. The conceptual model posits thatindividuals who struggle with transgressions ofmoral, spiritual, or religious beliefs are haunted bydissonance and internal conicts. In this framework,harmful beliefs and attributions cause guilt, shame,and self-condemnation. Forgiveness is also animportant mediator of outcome. The moral injuryframework posed by Litz et al. suggests thatalthough moral injury is manifested as PTSD-likesymptoms (e.g., intrusions, avoidance, numbing),other outcomes are unique and include shame, guilt,demoralization, self-handicapping behaviors(e.g., self-sabotaging relationships), and self-harm(e.g., parasuicidal behaviors). This frameworkhighlights the importance of thinking in a multi- orinter-disciplinary fashion about helping repair themoral wounds of war. Litz et al. argue that existingPTSD treatment frameworks may not sufcientlytarget moral injury. As a rst step to validating the construct ofmoral injury, Drescher et al. (2011) conductedinterviews with a diverse group of health andreligious professionals who work with active-duty
 Authors’ Addresses:
Shira Maguen, PhD,
is affiliated with the University of California, San Francisco, School ofMedicine, and with the San Francisco VA Medical Center, 4150 Clement St. (116-P), San Francisco, CA 94121.
Brett Litz, PhD,
is affiliated with the Boston University School of Medicine and with the Mental Health Core,Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System (116-B5),150 S. Huntington Avenue, Boston, MA 02130. Email Addresses: shira.maguen@va.gov; brett.litz@va.gov.
U.S. Department of Veterans Affairs
 
PAGE 2 PTSD RESEARCH QUARTERLY
Continued from cover 
military personnel and Veterans in order to better categorizewar-zone events that may contribute to moral injury. Emergingthemes included
 betrayal
(e.g., leadership failures, betrayal bypeers, failure to live up to one’s own moral standards, betrayal bytrusted civilians),
disproportionate violence
(e.g., mistreatment ofenemy combatants and acts of revenge),
 incidents involvingcivilians
(e.g., destruction of civilian property and assault), and
within-rank violence
(e.g., military sexual trauma, friendly re, andfragging). The authors suggest that an important next step wouldbe to directly interview Veterans about their experiences to helpexpand this list.The authors also interviewed providers about signs or symptomsof moral injury, and the results of this inquiry t nicely with theaspects of the model described in Litz et al. (2009): socialproblems, trust issues, spiritual/existential issues, psychologicalsymptoms, and self-deprecation. Study participants also madeimportant suggestions about ways to repair moral injury; thesecan be categorized into spiritually directed, socially directed, andindividually directed interventions. This last point emphasizes thatin addition to traditional individual-based therapies, interventionsfor moral injury should be considered across multiple disciplines(e.g., involving spiritual leaders), and that collaborative work acrossmultiple systems may lead to the best results (i.e., multidisciplinaryeffort that also considers social systems in which the individual isbased and can receive help and support). A number of studies have empirically demonstrated the potentialmoral injuries of war. For example, several articles havedocumented the relationship between killing in war and a numberof adverse outcomes. Fontana & Rosenheck (1999) found thatkilling and injuring others was associated for PTSD even whenaccounting for other exposures to combat within a larger model.Subsequent studies have expanded upon these ndings,demonstrating a relationship between killing and a host of othermental health and functioning variables. In Vietnam Veterans, aftercontrolling for exposure to general combat experiences, killingwas associated with posttraumatic stress disorder symptoms,dissociation, functional impairment, and violent behaviors(Maguen et al., 2009). Furthermore, the association with eachoutcome was stronger among those who reported killingnon-combatants. In returning OIF Veterans, even after controllingfor combat exposure, Maguen et al. (2010) found that takinganother life was a signicant predictor of PTSD symptoms,alcohol abuse, anger, and relationship problems. In Gulf War Veterans, killing was a signicant predictor of posttraumaticstress symptoms, frequency and quantity of alcohol use, andproblem alcohol use, even after statistical control for perceiveddanger, exposure to death and dying, and witnessing killing offellow soldiers (Maguen, Vogt et al., 2011).Beckham and colleagues (1998) focused on exposure to atrocitiesand found that after controlling for general combat, atrocitieswere associated with PTSD symptoms, guilt, and maladaptivecognitions. Marx et al. (2010) found that combat-related guiltmediated the association between participation in abusiveviolence and both PTSD and MDD. In analyses to further explorewhich components of PTSD were most important, Beckham andcolleagues (1998) demonstrated that the strongest associationbetween atrocities and PTSD was with the re-experiencingcluster. Other studies have also found that atrocities are mostassociated with re-experiencing and avoidance, rather than withhyperarousal symptoms of PTSD, which follows logically giventhat morally injurious events are more guilt- and shame-basedthan fear-based. Taken as a whole, this body of research suggeststhat morally injurious acts such as killing and atrocities areassociated not only with PTSD (particularly re-experiencing andavoidance, rather than hyperarousal), but also with a host ofother mental health problems and debilitating outcomes.The link between guilt and suicide, a putative outcome stemmingfrom moral injury, is also an important area of inquiry. Fontana et al.(1992) highlighted how different trauma types can lead to diversemental health and functional outcomes. They found that beingthe target of killing or injuring in war was associated with PTSDand being the agent of killing or failing to prevent death or injurywas associated with general psychological distress and suicideattempts. In a related study, Hendin and Haas (1991) found thatcombat guilt was the most signicant predictor of both suicideattempts and preoccupation with suicide, suggesting that guiltmay be an important mediator. The authors also reported that fora signicant percentage of the suicidal Veterans, the killing ofwomen and children occurred while feeling emotionally out ofcontrol due to fear or rage. This suggests that killing of womenand children—arguably morally injurious events—may beassociated with guilt feelings. A more recent study of servicemembers who have recently returned from war suggests that therelationship between killing and suicide may be mediated byPTSD and depression (Maguen, Luxton et al., 2011).The Interpersonal-Psychological Theory of Suicide (reviewed bySelby et al., 2010) offers an important backdrop within which todigest some of these ndings. The theory also ts well with themodel of moral injury. According to the theory, three factors areassociated with suicide: feelings that one does not belong withother people, feelings that one is a burden on others or society,and an acquired capability to overcome the fear and painassociated with suicide. The authors suggest that of all factors,acquired capability may be the most associated with militaryexperience because combat exposure and training may causehabituation to fear of painful experiences, including suicide.Consequently, killing behaviors, through a series of other mediators,result in more easily being able to turn the weapon of destructiononto oneself. Interestingly, ndings from Killgore at al. (2008)suggest that suicide is not the only high-risk outcome of concern;indeed a variety of arguably morally injurious combat actionscan lead to multiple risky behaviors. More specically, greaterexposure to violent combat, killing another person, and contactwith high levels of human trauma were associated with greaterpost-deployment risk-taking in a number of different domains.There is also a series of articles that point to important potentialmediators within the context of moral injury. Beckham andcolleagues (1998) highlighted the role of cognitions related tohindsight bias and wrongdoing among those endorsing atrocities.Witvliet et al. (2004) examined forgiveness of self and others andfound that difculty with any kind of forgiveness was associatedwith PTSD and depression and that difculty with self-forgivenesswas associated with anxiety. Religious coping seemed to beassociated with PTSD symptoms but the authors cautioned thatthis relationship should be explored in greater detail. Indeed, thisand other studies have highlighted that the religious and spiritualcauses and consequences of moral injury are complex and needto be explored. For example, many of the pre-existing morals andvalues that are transgressed in war stem from religious beliefsand faith practices. Religion and spirituality are critical components
 
 VOLUME 23/NO. 1
 
 
2012 PAGE 3
of moral injury. More research is needed to better understandhow these factors shape beliefs, attributions, and coping in theaftermath of a moral injury.Because there is sufcient evidence that morally injurious eventsproduce adverse outcomes, developing treatments that targetmoral injury is an important next step. Research investigating anew intervention for military personnel and Veterans that targetsmoral injury, life-threat trauma, and traumatic loss is underway(Gray et al., in press; Steenkamp et al., 2011). The treatment, Adaptive Disclosure, consists of eight 90-minute sessions, eachof which includes imaginal exposure to a core haunting combatexperience and uncovering beliefs and meanings in this emotionallyevocative context. In cases where traumatic loss or moral injuryare present, patients also engage in experiential exercises thatentail either a charged imaginal conversation with the deceasedor a compassionate and forgiving moral authority in the contextof moral injury. In an open trial, Adaptive Disclosure resultedin reductions in PTSD symptoms, depression symptoms, andnegative posttraumatic appraisals, and increased posttraumaticgrowth (Gray et al., in press).To summarize, the scientic discourse about moral injury is nascent,yet it provides an excellent springboard for future investigations. A preliminary model has been proposed (Litz et al., 2009), andseveral studies provide empirical support for this model, althoughmany more are needed to validate its proposed components.We are conducting the groundwork for constructing a measure ofmoral injury, which will help to examine the epidemiology of moralinjury. Other future research required entails studies that distinguishmoral injury from PTSD and other mental health outcomes,providing evidence for its unique attributes and construct validity.Longitudinal studies of moral injury are also needed in order tobetter understand changes over time and whether (or when)interventions are helpful.Further development of intervention studies that branch out fromthe traditional fear-based models of war-zone exposure and focuson guilt- or shame-based injuries that directly target moral injuryare also important. We are pilot-testing a treatment module thatfocuses on the impact of killing in war and can be incorporatedinto existing evidence-based treatment for PTSD. Researchinvolving larger systems that can facilitate recovery from moralinjury is also needed, particularly across disciplines that integrateleaders from faith-based and spiritual communities, as well asother communities from which individuals seek support. At thispoint in the development of the construct of moral injury thereare many unanswered questions that need further development.We hope this forum can serve as a starting point for continuedempirical work in this important area.
Beckham, J. C., Feldman, M. E., & Kirby, A. C. (1998).
 Atrocities exposurein Vietnam combat veterans with chronic posttraumatic stress disorder:Relationship to combat exposure, symptom severity, guilt, and interpersonalviolence.
 
 Journal of Traumatic Stress, 11
, 777−785. doi: 10.1023/A:1024453618638.   Vietnam combat veterans ( 
N
= 151) with chronic PTSD completed measuresof atrocities exposure, combat exposure, PTSD symptom severity, guilt andinterpersonal violence. PTSD symptom severity, guilt and interpersonal violencerates were similar to previously reported studies that examined treatment seekingcombat veterans with PTSD. Controlling for combat exposure, endorsement of
FEATURED ARTICLES
continued 
FEATURED ARTICLES
atrocities exposure was related to PTSD symptom severity, PTSD B (reexperiencing)symptoms, Global Guilt, Guilt Cognitions, and cognitive subscales of Hindsight-Bias/Responsibility and Wrongdoing. These results are discussed in the contextof previous research conducted regarding atrocities exposure and PTSD.Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schutz, K., & Litz, B. (2011).
 An exploration of the viability and usefulness of the construct of moral injuryin war veterans.
 
Traumatology, 17 
, 8-13.doi: 10.1177/1534765610395615. It is widely recognized that, along with physical and psychological injuries,war profoundly affects veterans spiritually and morally. However, research aboutthe link between combat and changes in morality and spirituality is lacking.
Moral injury 
is a construct that we have proposed to describe disruption in anindividual’s sense of personal morality and capacity to behave in a just manner. As a rst step in construct validation, we asked a diverse group of health andreligious professionals with many years of service to active duty warriors andveterans to provide commentary about moral injury. Respondents were given asemistructured interview and their responses were sorted. The transcripts wereused to clarify the range of potentially and morally injurious experiences in warand the lasting sequelae of these experiences. There was strong support for theusefulness of the moral injury concept; however, respondents chiey found ourworking denition to be inadequate.Fontana, A., & Rosenheck, R. (1999).
 A model of war zone stressors andposttraumatic stress disorder.
 
 Journal of Traumatic Stress, 12
, 111-126.doi: 10.1023/A:1024750417154.We present a theoretical model of eld placement,war zone stressors (ghting, death and injury of others, threat of death or injuryto oneself, killing others, participating in atrocities, harsh physical conditions andinsufciency of resources in the environment) and PTSD. Theater veterans fromthe National Vietnam Veterans Readjustment Study were divided randomly intotwo subsamples of 599 each. The model was developed on the rst subsampleand cross-validated on the second using structural equation modeling. The modelprovides a theoretically and empirically satisfactory description of the anatomy ofwar zone stressors and their role in the etiology of PTSD, but it leaves unansweredimportant questions regarding the etiological role of insufciency of resources inthe environment.Fontana, A., Rosenheck, R., & Brett, E. (1992).
War zone traumas andposttraumatic stress disorder symptomatology.
 
 Journal of Nervous andMental Disease, 180
, 748-755.The diagnosis and clinical understanding ofPTSD rests upon the explicit identication of traumatic experiences that giverise to a well-dened constellation of symptoms. Most efforts to investigatethe characteristics of these experiences have attempted to specify war zonestressors as objectively as possible. In this study, we add specication of thepsychological meaning of war zone stressors to their objective specication.Eleven traumas are organized in terms of four roles that veterans played in theinitiation of death and injury; namely, target, observer, agent, and failure. Theseroles can be ordered in terms of the degree of personal responsibility involvedin the initiation of death and injury. The relationships of these roles to currentsymptomatology were examined in combination with a set of objective measuresof war zone stressors. The sample consisted of the rst 1,709 Vietnam theaterveterans who were assessed in a national evaluation of the PTSD Clinical Teamsinitiative of the Department of Veterans Affairs. Results show that having been atarget of others’ attempts to kill or injure is related more uniquely than any otherrole to symptoms that are diagnostic criteria for PTSD. On the other hand, havingbeen an agent of killing and having been a failure at preventing death and injuryare related more strongly than other roles to general psychiatric distress andsuicide attempts. These results support the interpretation that roles involvinglow personal responsibility for the initiation of traumas may be connected mostdistinctively to symptoms diagnostic of PTSD, whereas roles involving highpersonal responsibility may be connected as much to comorbid psychiatricsymptoms, including suicidal behavior, as to PTSD.Gray, M. J., Schorr, Y., Nash, W., Lebowitz, L., Amidon, A., Lansing, A., et al.(in press).
 Adaptive Disclosure: An open trial of a novel exposure-basedintervention for service members with combat-related psychological stressinjuries.
 
Behavior Therapy.

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