International Society for Traumatic Stress Studies

Can trauma cause a moral injury?

01/01/2019
by Brandon Griffin, Natalie Purcell, Kristine Burkman & Shira Maguen
There has been a growing interest in traumatic events that may violate people’s core moral beliefs. Exposure to these events sometimes results in psychological symptoms and functional difficulties called moral injury. While not exclusively a military-related issue, some service members and veterans attribute chronic and pervasive problems to potentially morally injurious deployment-related experiences such as injuring or killing enemy combatants or failing to prevent the suffering of fellow service members or civilians. Media outlets including The New York Times (Brody, 2016), Huffington Post (Wood, 2014), Washington Post (Kudo, 2013), The Atlantic (Puniewska, 2015), and Newsweek (Dokoupil, 2012) have highlighted the importance of this issue for the general public. In a recent special issue of the Journal of Traumatic Stress, Griffin and colleagues (2018) reviewed 116 scientific studies on moral injury.
 
Although interdisciplinary teams of clinicians and scholars have examined the experiences of individuals who sustain moral injuries, no consensus exists regarding precisely what type of traumatic event might cause a moral injury. The progenitor of the term, Jonathan Shay, suggested that potentially morally injurious events entail “betrayal of what’s right by someone who holds legitimate authority in a high stakes situation” (2014, p. 183). Litz and colleagues described potentially morally injurious events as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (2009, p. 697). In their review, Griffin and colleagues contend that both definitions can fit different veterans’ experiences, and they are not  mutually exclusive. For example, one could witness a warzone atrocity committed by their superiors (betrayal-based), but may also feel as though they failed to intervene on behalf of the victim (perpetration-based). These experiences can independently or jointly contribute to distress associated with moral injury.
 
The review compiles evidence from a growing body of literature to explore psychological and functional problems associated with moral injury. This may include feelings of guilt, shame, or anger. Those suffering from moral injury may also experience numbness toward positive emotions, such as warmth, happiness, and compassion and withdrawal from close relationships. Some feel abandoned or punished by God, and some lose a sense of purpose or hopefulness about their future. Importantly, these issues do not appear to be reducible to the sequelae of posttraumatic stress disorder (PTSD). While there is currently no-first line treatment for moral injury, several existing approaches to treatment show evidence of therapeutic effect, and the development of new treatments designed to promote moral repair is underway. 
 
The authors contend that moral injury is not solely a product of individual psychopathology and that recovery might involve more than psychotherapy. Specifically, a person’s beliefs are influenced by significant others including family members, friends, community and religious/spiritual organizations to which they belong. Oftentimes, moral injuries occur when one core value (e.g., loyalty to country) may conflict with others (e.g., thou shalt not kill). Individuals might therefore perceive that others will reject them if they disclose the events for which they condemn themselves. Research confirms the significance of community and interpersonal bonds in mitigating (or, if absent, amplifying) the most devastating consequences of moral injury, including suicidal thoughts and behaviors (Bryan, Griffith, Pace, Hinkson, Bryan, Clemans, & Imel, 2015). Thus, the authors advocate an affirmative community effort to understand and accept those burdened by moral trauma and to help them build healthy relationships, find meaning and purpose, and reconnect to positive aspects of themselves.

References:

Brody, J. E. (2016). War wounds that time alone can’t heal [Blog post]. Retrieved from
https://well.blogs.nytimes.com
 
Bryan, C. J., Griffith, J. E., Pace, B. T., Hinkson, K., Bryan, A. O., Clemans, T. A., & Imel, Z. E.
(2015). Combat exposure and risk for suicidal thoughts and behaviors among military
personnel and veterans: A systematic review and meta-analysis. Suicide and Life-
Threatening Behavior, 45, 633-649. doi: 10.1111/sltb.12163
 
Dokoupil, T. (2012, December 3). A new theory of PTSD and veterans: Moral injury. Newsweek. Retrieved from http://www.newsweek.com/new-theory-ptsd-and-veterans-moral-injury-63539
 
Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz, M., Villierme, C., Walsh, J., & Maguen, S. (in press). Moral injury: An integrative review. Journal of Traumatic Stress. Manuscript accepted for publication.
 
Kudo, T. (2013). I killed people in Afghanistan. Was I right or wrong? The Washington Post. Retrieved from https://www.washingtonpost.com.
 
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. doi: 10.1016/j.cpr.2009.07.003
 
Puniewska, M. (2015, July 3). Healing a wounded sense of morality. The Atlantic. Retrieved from
https://www.theatlantic.com

Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31, 182-191. doi: 10.1037/a0036090

Wood, D. (2014, March 20). Can we treat moral wounds [Blog post]. Retrieved from
http://projects.huffingtonpost.com/projects/moral-injury/healing

Reference Article:

Griffin, B. J., Purcell, N. , Burkman, K. , Litz, B. T., Bryan, C. J., Schmitz, M. , Villierme, C. , Walsh, J. and Maguen, S. (2019), Moral Injury: An Integrative Review. Journal of Traumatic Stress. doi:10.1002/jts.22362

Questions for Discussion:

  1. Unlike PTSD, moral injury is not a diagnosis. What are the benefits and drawbacks of potentially adding moral injury to medical classification systems, such as the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases?
  2. What role might forgiveness of others or oneself play in recovery from betrayal- and perpetration-based moral injuries? What barriers to forgiveness exist?

About the Authors

Brandon J. Griffin, PhD, is a Research Health Science Specialist at the San Francisco Veterans Affairs Health Care System. His interests include development and evaluation of interventions designed to enhance resilience and well-being among individuals and communities. Dr. Griffin’s current work focuses on the clinical application of self-forgiveness for combat veterans who experience self-condemnation associated with their warzone actions.
 
Natalie Purcell, PhD, is a sociologist and health services researcher at the San Francisco VA and an Assistant Professor in the Department of Social and Behavioral Sciences at the University of California, San Francisco.  She specializes in the study of violence, trauma, and pain across healthcare contexts, and uses mixed methods drawn from the social sciences and the humanities. Since joining the VA in 2011, her research has centered on understanding the impact of violence and combat trauma in the lives of US military veterans, identifying and evaluating care interventions to address violence-related trauma and pain among veterans, and identifying interventions to reduce violence directed against frontline healthcare workers.
 
Kristine Burkman, PhD, is an Assistant Clinical Professor in in the Department of Psychiatry, UCSF School of Medicine and a staff psychologist in the Substance Use and PTSD (SUPT) Clinic at the San Francisco VA Health Care System. She provides direct clinical service and supervision in the assessment and treatment of co-occurring trauma and substance abuse within a phase-based model of care. After serving as a study therapist on the Impact of Killing (IOK) pilot trial, Dr. Burkman’s work focuses on further developing the IOK manual and related training materials based on initial feedback from Veterans and providers.
 
Shira Maguen, PhD, is a Professor at the University of California, San Francisco School of Medicine, and the Mental Health Director of the Post-9/11 Integrated Care Clinic as well as Staff Psychologist on the PTSD Team at the San Francisco Veterans Affairs Health Care System. Her interests include risk and resilience factors in veterans with PTSD, evidenced-based treatments (EBT) for PTSD, the impact of killing in war and moral injury, and gender differences in mental health among Veterans. Dr. Maguen’s current work focuses on examining the effectiveness of EBTs through natural language processing and testing a novel treatment for moral injury called the Impact of Killing (IOK) for use with Veterans.
 

 

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