Moral Injury
Psychotherapies that May be Helpful for Moral Injury
There are currently no medications or psychotherapies that have been specifically and uniquely developed and tested to treat moral injury, either caused by a self- or other-transgression and only. This is for at least five reasons: (1) a lack of an empirical method for defining a clinical case of moral injury (who needs clinical care); (2) the very recent development a measure of moral injury as a clinical outcome with treatment validity; (3) a trend in the field not to treat moral injury as a cohering, potentially clinical (abnormal) syndrome; (4) a tendency in the field to conceptualize moral injury through the narrow lens of severe, low-base rate, atrocious acts or killing; and (5) a tendency for clinical researchers to regard treatments for existing problems, most typically PTSD, as necessary and sufficient to address moral injury.
Cognitive Processing Therapy (CPT)
CPT (Resick et al., 2016) is a manualized cognitive therapy for PTSD and comorbid symptoms that is based on the theory that maladaptive cognitions about the traumatic event are preventing the incorporation of the trauma memory into preexisting beliefs about the self, others, and the world. These beliefs are explored through Socratic questioning and dialogue to establish new beliefs that are more realistic and balanced. Though not specifically designed to treat MI, in the case of non-erroneous MI-related cognitions, CPT focuses on the acceptance of reality and the associated emotions using Socratic dialogue to alleviate moral pain (Wachen et al., 2016). CPT is typically 12 sessions administered once or twice per week. It can be delivered in an individual or group format, with sessions of the former designed to be 50-60 minutes and the later 90-120 minutes. One putative case study of moral injury showed a significant 52-point reduction in PCL-5 scores from pre- to post-treatment (Held et al., 2018).
Cognitive Therapy for PTSD
Ehlers and colleagues have adapted a cognitive therapy for PTSD treatment to address moral injury (Murray & Ehlers, 2021).
Impact of Killing (IOK)
IOK is a treatment module designed to be delivered after cognitive-behavioral therapy (CBT) for PTSD (Maguen et al., 2017). The intervention uniquely focuses on the act of killing and other moral struggles that may arise during war, placing great emphasis on self-forgiveness and making amends. IOK is a manualized, six-to-eight session intervention that includes salient between-session assignments. IOK employs a traditional CBT framework, focusing on the correction of maladaptive killing-related cognitions. The Killing Cognitions Scale, developed for this purpose, is used to guide treatment targets. Despite this focus, the intervention manual also specifies that some beliefs may be accurate and need to be acknowledged. This in mind, the last stage of the intervention involves writing a forgiveness letter and creating an amends plan that emphasizes behavioral changes. IOK (n=17) was compared to a waitlist control group (n=16) in a randomized control trial (Maguen et al., 2017). Two participants failed to complete treatment, one from each group. The IOK group had significantly greater reductions in PCL total scores compared to the control group (p=0.03). All participants were male Veterans who had completed a form of CBT for PTSD prior to participation.
Trauma-informed Guilt Reduction (TrIGR)
TrIGR is a type of CBT created to reduce guilt resulting from combat trauma through four modules: psychoeducation, appraisal of cognitive errors, personal value identification, and plan development (Norman et al., 2010; 2013). The putative cognitive errors particularly explored by this treatment are hindsight-bias, lack of justification, responsibility, and wrongdoing. TrIGR also focuses on employing personal values for meaning-making and recovery. The intervention is manualized and can be administered within four to seven 90-minute sessions, with homework between sessions. A pilot study of 14 participants (Norman et al., 2014) showed a significant decrease in CAPS scores from pre- to post-TrIGR treatment (p<0.05), with 10 participants completing treatment. Later, a randomized control trial examined TrIGR (n=74) in comparison to Supportive Care Therapy (n=71; Norman et al., 2022). 63 of the TrIGR participants completed treatment compared to 61 of the control group participants. TrIGR participants also showed a significantly greater decrease in guilt (p=0.001), CAPS-5 PTSD symptom severity (p=0.01), and depression (p=0.006) from pre- to post-treatment compared to control group participants.
Prolonged Exposure (PE)
PE (Foa et al., 2007) is a cognitive behavioral therapy specifically designed for PTSD that relies on emotion processing theory, or the revisiting the traumatic memory to process the associated thoughts, behaviors, and emotions. The intervention utilizes psychoeducation, in vivo exposure, and imaginal exposure with emotional processing. While not specifically manualized to address MI, Held et al. (2018) suggest that the exposure employed in PE allows for memory activation that highlights discrepancies in putatively maladaptive cognitions related to guilt and shame, which, coupled with psychoeducation, can integrate the context of the trauma and improve negative affect. PE for PTSD typically consists of eight to fifteen 90-minute sessions delivered once or twice per week with homework between sessions. There have been two case studies specifically investigating PE for MI, one of which showed a 30-point drop in PCL-5 scores from pre- to post-treatment (Held et al., 2018), while the other reported a 10-point drop in PCL-5 scores from the baseline to one-month follow up assessment (Evans et al., 2021).
Acceptance and Commitment Therapy (ACT)
ACT (Hayes et al., 2012) is a behavioral intervention based on relational frame theory (Hayes et al., 2001) that emphasizes changing one’s relationship to pain and its function in daily life. Instead of focusing on the traumatic event, ACT focuses on the avoidance of internal experience through maladaptive attempts to control one’s symptoms. While not designed to treat MI specifically, ACT employs the acceptance of past events and moral pain to increase psychological flexibility though openness, awareness, and engagement. This is accomplished through six core processes: acceptance, cognitive diffusion, contact with the present moment (i.e., mindfulness), self-as-context, values, and committed action (Hayes et al., 2006). Nieuwsma et al. (2015) suggest that MI can be uniquely addressed within the ACT framework as the treatment stresses feeling one’s natural emotions about a morally injurious event (i.e. guilt, shame, or betrayal) in a way that acknowledges the normative nature of human suffering while also identifying and acting upon one’s own values. ACT is typically administered in 12 sessions, but has also been done in five to six sessions (Strosahl et al., 2012). Meta-analyses have supported its effectiveness in treating many psychological disorders, including PTSD (A-Tjak et al., 2015).
One pilot study using group treatment ACT for MI has been conducted (Farnsworth et al., 2017) in which 11 Veterans completed six, 75-minute sessions, but the outcome data has yet to be published. A self-help workbook has been created that situates ACT within the context of MI for those who may be experiencing MI symptoms (Evans et al., 2020). Recently, ACT for MI has been dubbed ACT-MI (Borges, 2019), although this treatment does not involve any specific modifications to ACT. A case study of a telehealth delivery of ACT-MI (Borges, 2019) found the intervention to be highly acceptable, with scores on the Cognitive Fusion Questionnaire – Moral Injury and the Expressions of Moral Injury Scale decreasing from baseline to the one-month follow up appointment (significance level not reported).
Adaptive Disclosure (AD)
AD (Litz et al., 2017) is a manualized individual psychotherapy designed to flexibly target life-threat, traumatic loss, and moral injury-related traumas, each with distinctly different evidence-based cognitive behavioral and experiential strategies. The AD book is a therapy manual that teaches providers about the military culture and the warrior ethos, the uniquely powerful bonds between unit members, the non-malleable responsibility that leaders and unit members have for ensuring the protection of others, the unique moral glue that informs service members’ beliefs about their sacrifice and duty, and the double-edged sword that these enculturated professional features represent when mistakes are made, unit members die, leaders or the leadership betray trust, and when individuals betray these principles. AD was originally a brief, six 90-minute session intervention when it was piloted in the Marine Corps but has been expanded to 8 (Litz et al., 2021). In an open, uncontrolled trial of the 6-session AD active-duty Marines with PTSD reported significant improvements in PTSD and depression symptom severity, posttraumatic cognitions, and posttraumatic growth (Gray et al., 2012). To bolster evidence of its effectiveness, a non-inferiority trial was conducted in which an 8 session AD was compared to 12 sessions of CPT-C, a first-line evidence-based therapy used in the VA. The findings indicated that AD was not inferior to CPT-C in terms of changing PTSD and depression severity, and physical and mental health functioning (Litz et al., 2021). AD was recently expanded to 12-sessions and modified to incorporate letter-writing, compassion training in the form of loving kindness meditation and mindfulness, and an emphasis on generating a flexible individualized behavioral healing and repair plan (Yeterian et al., 2017).
For references, see the Bibliography page.
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