Moral injury and moral repair in war veterans: A preliminary model and intervention strategy

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.

Introduction

Service members are confronted with numerous moral and ethical challenges in war. They may act in ways that transgress deeply held moral beliefs or they may experience conflict about the unethical behaviors of others. Warriors may also bear witness to intense human suffering and cruelty that shakes their core beliefs about humanity. What happens to service members who are unable to contextualize or justify their actions or the actions of others and are unable to successfully accommodate various morally challenging experiences into their knowledge about themselves and the world? Are they at risk for developing long-lasting psycho-bio-social impairment? Is there a distinct syndrome of psychological, biological, behavioral, and relational problems that arises from serious and/or sustained morally injurious experiences? Or, do existing disorders, such as posttraumatic stress disorder (PTSD), sufficiently explain the sequelae of what we term moral injury? And, can existing psychological treatments for combat and operational PTSD be effective or impactful?

In the first iteration of the PTSD construct (DSM-III) “guilt about surviving while others have not or about behavior required for survival (emphasis added)” was a symptom of PTSD. This was chiefly the result of the predominance of thinking about the phenomenology of Vietnam veterans and clinical care experience with veterans of war. Consequently, prior to the DSM-III-R, clinicians in VA settings arguably tackled moral conflict and guilt (e.g., Friedman, 1981). Since then, there has been very little attention paid to the lasting impact of moral conflict-colored psychological trauma among war veterans in the clinical science community. A possible reason for the scant attention is that clinicians and researchers who work with service members and veterans focus most of their attention on the impact of life-threat trauma, failing to pay sufficient attention to the impact of events with moral and ethical implications; events that provoke shame and guilt may not be assessed or targeted sufficiently. This explanation seems plausible given the emphasis on fear memories in evidence-based models of treatment (e.g., Foa, Steketee, & Rothbaum, 1989).

It is also possible that some clinicians believe that addressing ethical conflicts and moral violations is outside the realm of their expertise, preferring to recommend religious counseling instead. Care-providers may also not hear about moral injury because service members' or veterans' shame and concern about adverse impact or repercussions (e.g., being shunned, rejected, misunderstood) prevent disclosure. Mental health professionals may contribute to this; they may unknowingly provide non-verbal messages that various acts of omission or commission in war are too threatening or abhorrent to hear. Some may believe that treatment would excuse illegal or immoral behavior in some way. Others may veer from the topic to avoid the very thorny question about whether perpetration of violence should lead to diagnosable and potentially compensable PTSD.

Whatever the reasons for the scant attention paid to moral and ethical conflicts (after DSM-III), we argue that serious exploration is indicated because, in our experience, service members and veterans can suffer long-term scars that are not well captured by the current conceptualizations of PTSD or other adjustment difficulties. We are not arguing for a new diagnostic category, per se, nor do we want to medicalize or pathologize the moral and ethical distress that service members and veterans may experience. However, we believe that the clinical and research dialogue is very limited at present because questions about moral injury are not being addressed. In addition, clinicians who observe moral injury and are motivated to target these problems are at a loss because existing evidence-based strategies fail to provide sufficient guidance. Consequently, our goal is two-fold: We want to stimulate discourse and empirical research and, because we are sorely aware of the clinical care vacuum and need (especially in the Department of Defense), we offer specific treatment recommendations based on our conceptual model and a pilot study we are conducting in the Marine Corps.

Below, we first describe the potential morally injurious experiences in war, using the current wars in Iraq and Afghanistan as examples. Second, we review and summarize the research pertaining to events that have the potential to be morally injurious. Third, we discuss why existing conceptualizations of PTSD may not fully capture the different aspects of moral injury. Finally, we propose a working conceptual model, a set of assumptions that guide our treatment approach, and details about the treatment model.

There are three sets of important questions we will not be covering in detail in this article: (1) What military training, deployment length, battlefield context, leadership, rules of engagement, group processes, and personality factors moderate and mediate war-zone transgression?; (2) What aspects of military training (primary and secondary prevention strategies) help service members assimilate and accommodate various moral and ethical challenges, roles, and experiences?; and (3) What are the learning history, personality, religious beliefs, and social and cultural variables that moderate and mediate moral injury afterward? These complex research questions require an interdisciplinary approach (e.g., military, biological, philosophical, sociological and social psychological, legal, religious, mental health perspectives), and our intention is to offer a basic framework that can be used as a point of departure for future theory-building and research.