Moral Injury
Is Moral Injury a Separate Clinical Syndrome or is it Just PTSD?
Recent research by Litz and colleagues defined the outcomes uniquely associated with exposure to PMIEs (Yeterian et al., 2019). For MI to be a viable and useful clinical syndrome, features that are and are not MI need to be specified and reliably measured. Farnsworth and colleagues (2017) expressed concern that considering MI as a clinical condition would “medicalize” normal responses to moral conflicts (see also Farnsworth, et al., 2014; Nieuwsma et al., 2015). This concern can be addressed by applying the standard threshold that defines a clinical problem, namely impairment. When MI symptoms make it very difficult for the person to function at work, in relationships, at school, and in terms of self-care and leisure, these symptoms and problems merit clinical attention. There is enough evidence to support MI as a syndrome (i.e., a set of cohering, identifiable symptoms, and problems), which can adversely affect functional capacities. As advances are being made to treat MI (Farnsworth et al., 2017; Kopacz et al., 2016; Litz et al., 2016; Litz & Carney, 2018; Nieuwsma et al. 2015), it is important to be clear about the conditions that make MI a clinical problem and to reliably assess the MI syndrome. Some assume that MI is best construed as a form of PTSD and that evidence-based treatments for PTSD are sufficient to address MI. PTSD is relevant to MI in several ways: (1) given that MI is a stressor-linked problem, the PTSD symptoms of reexperiencing, avoidance, disinterest, detachment, and restricted range of affect are core outcomes (Litz et al., 2009); (2) traumatic events can be moral injuries and people can have PTSD as a result of these events (Held et al., 2018; Litz et al., 2018); (3) PTSD includes symptoms that overlap with MI, namely negative thoughts about oneself or the world and negative emotions, some of which are moral emotions (anger and shame). Similarly, the PTSD symptom of reckless or self-destructive behavior may help capture morally injurious outcomes and irritable and angry behavior fits other-related MI quite well.
PTSD falls short as a syndrome to explain and describe MI
This is for many reasons:
1. PTSD can only be applied formally to moral injuries that occur in the context of life threats, which unnecessarily and inappropriately limits the universe of PMIEs.
2. The PTSD symptoms of “persistent distorted negative beliefs and expectations about oneself or the world (e.g., “I’m bad,” “the world is completely dangerous”) and “persistent distorted blame of self or others for causing the traumatic event or for resulting consequences” are of limited relevance to MI. In the context of PTSD, these beliefs arise from pathological distortions of the experience and the implication of the experience. This can occur within MI, such as when one blames themself for being assaulted or being treated cruelly by an intimate or someone that should be trustworthy (like a leader or boss). However, this view neglects that role that frequent and high magnitude morally injurious events play in the development of MI. That is, MI can result from biological changes and accurate beliefs about the potential for inhumane acts. There are important therapeutic implications of this distinction. If beliefs are viewed as distorted, changing one’s thinking (e.g., through cognitive therapy) is appropriate. By contrast, some moral transgressions are existentially bad, meaning that negative appraisals are appropriate. In such cases, challenging thoughts as if distorted would be inappropriate and potentially harmful. Novel models of MI treatment are based on the idea repairing requires doing things or being exposed to things in the world to that counter the implication of morally injurious experiences to rebalance beliefs about one’s own or the world’s badness,. When people either do horrendous things, by choice or by mistake, or they are victimized or exposed to horrendous moral failures of others, healing may be better accomplished by taking action to reclaim or allowing goodness to offset the bad things that have been done.
3. The PTSD diagnosis lacks specificity about the presence of moral emotions. There are unique symptoms of MI not captured by PTSD, which we cover in the section titled “What are the symptoms of moral injury.”
Next: Moral Injury Symptomatology
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