The concept of “moral injury” (MI), most recently, dates back to the work of military psychiatrist Shay (1994) when he described a syndrome in Vietnam war Veterans. However, the concept dates much further back than that, at least to the writings of Euripides (416 BCE). Euripides had originally described the syndrome using the term “miasma,” signifying the ancient Greek concept of moral defilement or pollution, often resulting from unjust killing, but applicable to any transgression of moral values, whether applied to the perpetrator, the victim, or even the observer. In the Athenian tragedy Herakles (a theater play) authored by Euripides, Herakles describes the feeling of miasma as follows:
What can I do? Where can I hide from all this and not be found? What wings would take me high enough? How deep a hole would I have to dig? My shame for the evil I have done consumes me… I am soaked in blood-guilt, polluted, contagious… I am a pollutant, an offense to gods above. (Euripides, 416 BCE)
Definition of Moral Injury Syndrome
In that seminal paper by Litz et al., (2009), they defined MI as resulting from “an act of transgression that creates dissonance and conflict because it violates assumptions and beliefs about right and wrong and personal goodness…”. Following up on that, Brock and Letitini (2012) described MI as “a deep sense of transgression including feelings of shame, grief, meaninglessness, and remorse from having violated core moral beliefs” (p xiv). Transgressive and betrayal-based Moral Injury as described above is closely related to the term “moral distress”; Moral Injury Syndrome occurs when moral distress is experienced repeatedly and the effects are long-lasting.
More recently, Jinkerson (2016) updated the definition to emphasize the empirically and theoretically recognized symptoms of guilt, shame, spiritual/existential conflict, and loss of trust, with secondary symptoms of depression, anxiety, anger, self-harm, and social problems resulting from it.
Treatment of Moral Injury Syndrome
Adaptive Disclosure Therapy (ADT) for Moral Injury Syndrome
Adaptive Disclosure Therapy (ADT) is a manualized therapy designed to help Veterans and active duty military to integrate and resolve moral injuries experienced during wartime using emotion-focused cognitive behavioral strategies (Litz et al., 2017). This method involves discussing and processing of wartime memories and experiences, while at the same time challenging dysfunctional cognitions related to memories of the trauma and moral transgressions. The treatment consists of six 90-min one-on-one treatment sessions.
Healing through Forgiveness (HTF) for Moral Injury Syndrome
HTF is a 12-session 12-week program that largely utilizes CBT and PE strategies to not only focus upon the Veterans but actively includes family members (mostly the spouse) throughout most sessions (Grimsley & Grimsley, 2017). While largely secular in nature, HTF has a spiritual component. The sessions include (1) introduction and overview including pre-test MIQ-M assessment (veteran only), (2) remembering how to remember, (3) the conscious/unconscious PTSD and MI,
(4) dealing with guilt, (5) dealing with shame, (6) MI and the subconscious, (7) forgiveness and fear as trigger for anger and PTSD, (8) integration of spouses and significant others, (9) the family and PTSD, (10) lessons for living life together, (11) summarizing PTSD and traumatization exercises, and (12) spiritual disciplines of forgiveness. There is a six-month follow-up and post-session questionnaire. HTF does not exclusively focus upon MI but co-jointly considers PTSD as well.
Prolonged Exposure (PE) for Moral Injury Syndrome
PE has also been used to treat MI (Paul et al., 2014). Initially developed as a treatment for PTSD, PE involves repeatedly exposing the person to their traumatic memories through imagining the trauma or to real-life situations similar to the trauma (in vivo exposure). Repeated exposure of this type is conducted until habituation develops and the event no longer elicits distress.
This can also be done for morally compromising situations that cause symptoms of MI. PE for MI typically consists of nine 45-min weekly one-on-one sessions that focus on this imaginal or in vivo exposure. To our knowledge, only a few case reports have been published to support the efficacy of PE for MI, although the effectiveness of this approach makes sense (Held et al., 2018; Paul et al., 2014).
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