Moral Injury in the Context of War
What is moral injury?
Like psychological trauma, moral injury is a construct that describes extreme and unprecedented life experience including the harmful aftermath of exposure to such events. Events are considered morally injurious if they “transgress deeply held moral beliefs and expectations” (1). Thus, the key precondition for moral injury is an act of transgression, which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or culture-based, organizational, and group-based rules about fairness, the value of life, and so forth.
Moral injury in war
In the context of war, moral injuries may stem from direct participation in acts of combat, such as killing or harming others, or indirect acts, such as witnessing death or dying, failing to prevent immoral acts of others, or giving or receiving orders that are perceived as gross moral violations (2). The act may have been carried out by an individual or a group, through a decision made individually or as a response to orders given by leaders.
- Unintentional errors: Military personnel are well trained in the rules of engagement and do a remarkable job making life or death decisions in war; however, sometimes unintentional error leads to the loss of life of non-combatants, setting the stage for moral injury.
- Transgressive acts of others: Service members can be morally injured by the transgression of peers and leaders who betray expectations in egregious ways.
What is the aftermath of moral injury?
In terms of the aftermath of moral injuries, transgressive acts may result in highly aversive and haunting states of inner conflict and turmoil. Emotional responses may include:
- Shame, which stems from global self-attributions (for example “I am an evil terrible person; I am unforgivable”)
- Anxiety about possible consequences
- Anger about betrayal-based moral injuries
Behavioral manifestations of moral injury may include:
- Anomie (for example alienation, purposelessness, and/or social instability caused by a breakdown in standards and values)
- Withdrawal and self-condemnation
- Self-harming (for example suicidal ideation or attempts)
- Self-handicapping behaviors (for example alcohol or drug use, self-sabotaging relationships, etc.)
Additionally, moral injury has been posited to result in the re-experiencing, emotional numbing, and avoidance symptoms of PTSD (1). In addition to grave suffering, these manifestations of moral injury may lead to under- or unemployment, and failed or harmed relationships with loved ones and friends.
Can killing cause moral injury?
Several studies demonstrate an association between killing in war and mental and behavioral health problems, which may be proxies for moral injury (3-8).
- Across eras (for example Vietnam, Operations Desert Storm and Desert Shield, Operation Iraqi Freedom [OIF], Operation Enduring Freedom [OEF]) those who kill in war are at greater risk for a number of mental health consequences and functional difficulties, including PTSD, after accounting for a number of demographic variables and other indicators of combat exposure (3-5).
- In returning OIF Veterans, even after controlling for combat exposure, taking another life was a significant predictor of PTSD symptoms, alcohol abuse, anger, and relationship problems (3).
- Vietnam Veterans who reported killing were twice as likely to report suicidal ideation as those who did not, even after accounting for general combat exposure, PTSD and depression diagnoses (9). In OIF Veterans, the relationship between killing and suicidal ideation was mediated by PTSD and depression symptoms (10).
- Killing in war may be an important indicator of risk for developing frequent and severe PTSD symptoms. Three-quarters of individuals who killed were in the two most severe PTSD symptom classes, and those who killed had twice the odds of being in the most symptomatic PTSD class, compared to those who did not kill. Those who endorsed killing a non-combatant or killing in the context of anger or revenge were more likely to belong to the most symptomatic PTSD class, compared to those who did not kill (11).
Although killing may be a precursor to moral injury, it is important to note that not all killing in war results in adverse outcomes for military personnel. As noted earlier, certain elements need to be present for moral injury to occur, including a perceived transgression that goes against individual or shared moral expectations.
For example, a military member who kills an enemy combatant in self-defense may perceive that the death was justified. If however, a civilian was perceived to be armed and consequently killed, with military personnel later discovering that the individual was in fact unarmed, this may set the stage for the development of moral injury.
Are moral injury and PTSD the same?
More research is needed to answer this question. At present, although the constructs of PTSD and moral injury overlap, each has unique components that make them separable consequences of war and other traumatic contexts.
- PTSD is a mental disorder that requires a diagnosis. Moral injury is a dimensional problem – there is no threshold for the presence of moral injury, rather, at a given point in time, a Veteran may have none, or mild to extreme manifestations.
- Transgression is not necessary for PTSD to develop nor does the PTSD diagnosis sufficiently capture moral injury (shame, self-handicapping, guilt, etc.).
Consequently, it is important to assess mental health symptoms and moral injury as separate manifestations of war trauma to form a comprehensive clinical picture, and provide the most relevant treatment. One example of a moral injury specific measure is the Moral Injury Events Scale (12).
Can evidence-based treatments for PTSD be used to treat moral injury in Veterans of war?
Moral injury is not explicitly addressed in the evidence-based treatments (EBTs) for PTSD supported by VA, namely Prolonged Exposure Therapy (PE) and Cognitive Processing Therapy (CPT). This is in part due to the fact that extant EBTs were primarily developed to target life-threat or danger-based posttraumatic memories and beliefs among victims of trauma. As such, they may not be sufficient for Servicemembers and Veterans who suffer from the moral injuries of war, especially killing-based transgressions (13, 14). Although the PE and CPT manuals do not mention moral injury, recently, these approaches have suggested strategies for addressing guilt and shame,, and helping the patient to contextualize, rather than over accommodate perceived culpability (15, 16). Whether these strategies can sufficiently reduce the sequelae of war-related moral injury is unknown.
Current research for treatment of moral injury
In service of broadening the discourse, we generated and are currently testing interventions that specifically target moral injury among Veterans of war.
The first intervention is a six-session module called Impact of Killing in War (IOK), developed to augment existing EBTs for PTSD (for example, IOK is used in conjunction with existing EBT for PTSD interventions, in those who have conflict related to killing in war). Pilot testing is currently underway. Preliminary data from pilot testing demonstrated significant improvements for participants on overall psychiatric symptoms, anxiety, and depression, compared to a control group, as well as greater community involvement and increased ability to share personal thoughts/feelings with others (17, 18).
IOK contains the following elements, presented within a cognitive-behavioral framework:
- Education about the complex interplay of the biopsychosocial aspects of killing in war that may cause inner conflict and moral injury.
- Identification of meaning elements and cognitive attributions related to killing in war.
- Self-forgiveness (which entails cognitive therapy and for some the promotion of spirituality or faith-based religious practices).
- Making amends tailored to the individual (this may include writing forgiveness letters and an action plan to start the process of making amends).
The second treatment is called Adaptive Disclosure (AD), an eight-session intervention that takes into account unique aspects of the phenomenology of military service in war in order to address difficulties such as moral injury and traumatic loss that are not explicitly addressed in extant EBTs (19). At its core, AD is an experiential exposure-based approach.
- Exposure is used to uncover core features of focal combat and operational trauma and as a means of articulating the meaning and implication of these events.
- If the focal combat event is fear and life-threat-based, exposure is the sole approach.
- If the focal trauma is loss-based, patients are also asked to have an imaginary emotionally evocative real-time dialogue with the lost person.
- For moral injury, patients are guided through a dialogue with a forgiving and compassionate moral authority about the transgression.
The added experiential strategies are designed to expose patients to corrective information about the meaning and implication of their war experiences. In an open trial, 44 Marines received AD in garrison. Participating Marines demonstrated significant reductions in PTSD symptoms, depression symptoms, and negative posttraumatic appraisals; AD was also associated with increases in posttraumatic growth (20).
- Litz, B.T., Stein, N., Delaney, E., Lebowitz, 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.
- Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schutz, A., & Litz, B.T. (2011). . An exploration of the viability and usefulness of the construct of moral injury in war Veterans. Traumatology, 17, 8-13. doi: 10.1177/1534765610395615
- Maguen, S., Metzler, T.J., Litz, B.T., Seal, K.H., Knight, S.J., & Marmar, C.R. (2009). The impact of killing in war on mental health symptoms and related functioning. Journal of Traumatic Stress, 22, 435-443. doi: 10.1002/jts.20451
- Maguen, S., Lucenko, B.A., Reger, M.A., Gahm, G.A., Litz, B.T., Seal, K.H., Knight, S.J., & Marmar, C.R. (2010). The impact of reported direct and indirect killing on mental health symptoms in Iraq War Veterans. Journal of Traumatic Stress, 23, 86-90.
- Maguen, S., Vogt, D.S., King, L.A., King, D.W., Litz, B.T., Knight, S.J., & Marmar, C.R. (2011).The impact of killing on mental health symptoms in Gulf War Veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 3 21-26. doi: 10.1037/a0019897.
- Fontana, A., Rosenheck, R. & Brett, E. (1992). War zone traumas and posttraumatic stress disorder symptomatology. Journal of Nervous and Mental Disease, 180, 748-755.
- MacNair, R.M. (2002). Perpetration-inducted traumatic stress in combat Veterans.Peace and Conflict: Journal of Peace Psychology, 8, 63-72. doi: 10.1207/S15327949PAC0801_6
- Fontana, A. & Rosenheck, R. (1999). A model of war zone stressors and posttraumatic stress disorder. Journal of Traumatic Stress, 12, 111-26. doi: 10.1023/A:1024750417154
- Maguen, S., Metzler, T.J., Bosch, J., Marmar, C.R., Knight, S.J., & Neylan, T.C. (2012) Killing in combat may be an independently associated with suicidal ideation. Depression & Anxiety, 29, 918-23. doi: 10.1002/da.21954
- Maguen, S., Luxton, D.D., Skopp, N.A., Gahm, G.A., Reger, M.A., Metzler, T.J., & Marmar, C.R. (2011). Killing in combat, mental health symptoms, and suicidal ideation in Iraq War Veterans. Journal of Anxiety Disorders, 25, 563-567. doi: 10.1016/j.janxdis.2011.01.003
- Maguen, S., Madden, E., Bosch, J., Galatzer-Levy, I., Knight, S. J., Litz, B. T., Marmar, C. R., & McCaslin, S. E., (2013). Killing and latent classes of PTSD symptoms in Iraq and Afghanistan Veterans. Journal of Affective Disorders, 145, 344-348. doi: 10.1016/j.jad.2012.08.021
- Nash, W. P., Mariano Carper, T. L., Mills, M. A., Au, T., Goldsmith, A., & Litz, B. T., (2013). Psychometric evaluation of the Moral Injury Events Scale. Military Medicine, 178, 646-652. doi: 10.7205/MILMED-D-13-00017
- Steenkamp, M. M., Nash, W. P., Lebowitz, L., & Litz, B. T. (2013). How best to treat deployment-related guilt and shame: Commentary on Smith, Duax, and Rauch (2013). Cognitive and Behavioral Practice, 20, 471-475. doi: 10.1016/j.cbpra.2013.05.002
- Maguen, S., & Burkman, K. (2013). Combat-related killing: Expanding evidence-based treatments for PTSD. Cognitive and Behavioral Practice, 20, 476-479. doi: 10.1016/j.cbpra.2013.05.003
- Resick, P. A., Monson, C. M., & Chard, K. M. (2014). Cognitive processing therapy: Veteran/military version: Therapist’s manual. Washington, DC: Department of Veterans Affairs.
- Smith, E. R., Daux, J. M., & Rauch, S. M. (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
- Maguen, S., & Burkman, K. (2014, May 22). Killing in war and moral injury: Research and clinical implications. Invited lecture presented at 17th Annual VA Psychology Leadership Conference, San Antonio, TX.
- Burkman, K., Madden, E., Bosch, J., Dinh, J., Neylan, T., & Maguen, S. (2013, November 8). Preliminary findings from a pilot study of a novel treatment among Veterans with PTSD who have killed in war. Paper presented at the International Society for Traumatic Stress Studies 29th Annual Meeting, Philadelphia, PA.
- Steenkamp, M., Litz, B. T., Gray, M., Lebowitz, L., Nash, W., Conoscenti, L., Amidon, A., & Lang, A., (2011). A brief exposure-based intervention for service members with PTSD. Cognitive and Behavioral Practice, 18, 98-107. doi: 10.1016/j.cbpra.2009.08.006
- Gray, M.J., Schorr, Y., Nash, W., Lebowitz, L., Amidon, A., Lansiung, A. Maglione, M., Lang, A.J., 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. doi: 10.1016/j.beth.2011.09.001