Moral injury refers to the “the lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations” (Litz, et al. 2009, p. 697). In my recent article in the Journal of Traumatic Stress (Farnsworth, 2019), I argue that understanding moral injury and its relationship to PTSD can be assisted by distinguishing between what is and what ought to be. Drawing on both ethics and the philosophy of science, I suggest that beliefs in response to potentially morally injurious events can be separated into descriptive cognitions (thoughts about the way the world is) and prescriptive cognitions (thoughts about how the world should or ought to be).
Take for instance a situation in which a car fails to stop at a traffic light and, entering the intersection, strikes an oncoming vehicle. What punishment should the driver of the car receive? The person considering this hypothetical situation might thoughtfully respond that determining an appropriate response to the driver would depend greatly upon the factual, or descriptive, details of the event. Learning that the driver had been intoxicated at the wheel might garner a very different response than if the driver had suffered a stroke while driving. Furthermore, our response to the driver might also be impacted by the severity of the outcome. How much property damage was caused by the driver’s vehicle? Was anyone killed or injured? Thus, an example as common as a motor-vehicle accident is enough to demonstrate that our prescriptive beliefs about what ought to happen are influenced by our descriptive beliefs about what is.
Exploring both descriptive and prescriptive cognitions represents complementary tasks that treatment of moral injury must address in order to be comprehensive. Much like a puzzle being dropped onto the floor, traumas often shatter our perceptions of ourselves, others and the world in which we live. In the case of morally injurious events, the perceptions that are shattered involve beliefs about right and wrong and how our own or others’ behaviors live up to those expectations. Attending to both descriptive and prescriptive cognitions can help providers systematically address these concerns. For example, it is often the case that the cognitions developed in the midst or soon after the trauma are so extreme and disturbing (i.e., The event was my fault, People will betray you the first chance they get) that the individual avoids revisiting the descriptive evidence for these thoughts. Sadly, a byproduct of such avoidance is that such beliefs are not exposed to contradictory information that might challenge these conclusions.
The symptom criteria for PTSD explicitly state that negative PTSD-related cognitions must be “distorted” or “exaggerated.” Accordingly, several current evidence-based treatments for PTSD are built around the importance of challenging such erroneous descriptive cognitions and use techniques such as Socratic dialog and behavioral experiments to help the client revisit and revise their descriptive beliefs about morally injurious events. This process is akin to helping the individual sit down with the pieces of belief shattered during the morally injurious event and re-assembling the puzzle. In the course of revisiting the context of the event and the beliefs they had formed about it, clients have the opportunity to integrate into the puzzle new information uncovered in this process, critically assess the likely causes and consequences the morally injurious event, and decide whether the descriptive beliefs they formed in response to it are indeed accurate.
Once the puzzle pieces have been assembled, the client is now in a position to better evaluate the prescriptive meaning of the morally injurious event. This process is similar to the client sitting back from the assembled puzzle and interpreting the meaning of the picture they see. In this second stage, the client makes prescriptive judgements about which persons were or were not at moral fault for the morally injurious event and weigh the different moral values that have been affected. With the benefit of focused attention and an awareness of additional factual details, clients will often change or lessen many of their self-condemning prescriptive beliefs. However, in other cases, even after descriptively reviewing the objective facts of the event, clients may come to the conclusion that actions taken by themselves or others were indeed prescriptively wrong.
Just as there are therapeutic techniques that are well-designed to address descriptive cognitions, there are also therapeutic techniques that are better suited for addressing prescriptive cognitions. Rather than being based on objective evidence as in the case of descriptive beliefs, prescriptive beliefs are instead based on the personal values of the client and so cannot be challenged through empirical evidence. Therefore, working with prescriptive beliefs associated with a moral injury may involve different techniques such as enhancing awareness of personal values, developing greater acceptance of past wrongs, seeking greater compassion for self and others, and implementing values-consistent behavior going forward. In sum, improving our ability to distinguish, assess and intervene with descriptive and prescriptive cognitions can help give researchers and providers more precise ways to differentiate PTSD and moral injury and improve care for clients struggling with moral distress in the wake of trauma.
Farnsworth, J. K. (2019). Is and Ought: Descriptive and Prescriptive Cognitions in Military-Related Moral Injury. Journal of Traumatic Stress.
Advance online publication. doi: 10.1002/jts.22356
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
, 695-706. doi: 10.1016/j.cpr.2009.07.003
Farnsworth, J. K. (2019). Is and Ought: Descriptive and Prescriptive Cognitions in Military‐Related Moral Injury. Journal of Traumatic Stress.
Jacob K. Farnsworth, PhD is an independently licensed clinical psychologist with the Veteran Affairs Eastern Colorado Health Care System, specializing in the treatment of posttraumatic stress disorder (PTSD) and substance use disorders. He is a co-author of Acceptance and Commitment Therapy for Moral Injury (ACT-MI). His primary professional interests involve theoretical development of the moral injury construct and researching innovative and effective treatments for trauma-related moral distress.
- Identify a recent psychotherapy case or real-world traumatic event which caused moral distress. Taking this scenario, identify the descriptive beliefs that were formed about the event and the people involved in it (What happened? Who caused it to happen? What facts does the event imply?). In an adjacent space, identify the prescriptive beliefs that were formed in reaction to this event (What should have happened? What do specific individuals deserve to have happen as a result of the trauma?). How might you work directly with the descriptive beliefs? How might you work directly with the prescriptive beliefs?
- Reflect on your own training and education and the specific attention paid to working with descriptive and/or prescriptive cognitions. Which did your training emphasize more? Which do you feel more comfortable working with? Why do you think that is the case?
- If you feel uncomfortable working with either descriptive or prescriptive cognitions, how might you develop greater comfort and competency? Which other providers or professionals might you consult with or what experiences might you benefit from?