Comment of Litz et al. and Moral Injury Parts 1 & 2

Part 1

In their influential discussion of the psychological effects of war, Litz et al. (2009) offer the term “moral injury” to describe the destructive effects of the moral and ethical challenges (that is, horrors) of war. That they are raising the subject to academics, many of whom consider the emotional problems related to trauma essentially fear based, is a valuable service. They also usefully summarize research on the effects of moral conflict and violation of life principles on warriors. So, perhaps it will be considered quibbling if I raise a few concerns about their presentation, nonetheless:

1. Litz et al. assert that since DSMIII “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.” If by “the clinical science community” they mean non-practicing clinicians, they might be right, however,

2. when they go on, in their Introduction, to say that:

“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…”

it looks to me as if they are demonstrating their lack of knowledge about the work practicing clinicians actually do with combat veteran clients. The clinicians I have known, over my 35+ year career working with combat veterans in a VA treatment center and in providing consultation to therapist in many VA treatment centers, have continually tried mightily to help veterans with profound destructive non-fear related emotions.

Litz et al. offer no support for their claim about how clinicians act in this matter, but, as the above quote indicated they do offer speculative reasons why this imaginary phenomena might have “occurred”. Their assertion in the above quote that clinicians have been attending primarily to fear based emotions because they are influenced by evidence based methods appears to dismiss years of evidence cited by Karlin and Cross ( 2014), VA colleagues of Litz et al., who conclude that evidence based methods have been practiced in research settings and “…have not crossed the bridge into community practice settings in public and private mental health care systems.” (p19)

3. In their review of the clinical practices available for treating “moral injury” Litz et al. erroneously find no evidence based methods that explicitly address this issue. This failure appears to be inexplicable ignorance of EMDR, one of the few widely accepted evidence based treatments for PTSD ( e.g. VA/DoD, ISTSS guidelines), and one that explicitly acknowledges the non-fear based psychologically destructive effects of war and other traumatic experience. It is inexplicable, because this group of authors have certainly been aware of EMDR and its scientific standing.

Very early in Shapiro’s development of EMDR she conceptualized one source of distress as related to how clients held themselves responsible for events, whether or not they were reasonably to blame. So, in the cognitive therapy like (actually, it seems most specifically similar to, but not the same as, Ellis’ REBT) portion of EMDR treatment, she had clients develop what might become an understanding of the events and their regretted behavior that would conceivably not be associated with debilitating level of emotions, such as guilt, shame or despair they feel ( e.g. A client might remember a traumatic event and think “I am worthless”, or” I am evil”. The therapist then works with the client to develop a plausible potential belief, such as “ I can learn from this.” or “ I did the best I could under the circumstances”, or “I can find forgiveness.”) These or many other possible ways of understanding the events are discussed with the client as goals to find emotional resonance that is worked toward with EMDR. It must be noted that these understandings could include spiritual and/or philosophical beliefs, and evocation of the internalized beliefs of figures the client respects. Litz et al propose similar activity in the later stages of their 8 step “moral injury” intervention. There are some other overlaps, which we cannot call borrowing by Litz et al. because there is not indication in their work that they are aware of EMDR, but it is at least the failure to fully consider the precedent literature.

It should also be mentioned that in Shapiro’s (& Forest, 1997) book, describing a variety of cases, that there is an extensive report of her successful treatment of a combat veteran for the debilitating guilt related to the death of a prisoner being held by his unit.

For the authors to miss EMDR in surveying the field before offering their own treatment approach seems to reflect a lack of a required openness to precedent, which makes it difficult to consider their work a result of true scientific inquiry.

In a future post I hope to present some ideas on the question of the use of the term “injury” in this context. Litz et al. do say they do not want to medicalize these issues, however, I don’t know if you can use their terminology and not do so. It is a complex and difficult issue, on which which I hope to be able to share useful thoughts.

Karlin, B.E. & Cross, G. (2014) From the laboratory to the therapy room. American Psychologist, 60 (1), 19 – 33

Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P, Silva, C.& Maguen, Shira (2009) Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695 – 706

Shapiro, F. & Forest, M. (1997) EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress, and Trauma. New York: Basic Books.

Part 2

Hamlet (to Polonius) Good my lord, will you see the players well bestowed?…
Polonius: My lord, I will use them according to their desert.
Hamlet: Use every man after his desert, and who should ’scape whipping?
Hamlet II 2

What is wrong with the phrase “moral injury”?
If we are to have a label for the category of problems related to the destructive psychological effects following harming or believing you have harmed others, it should not be “moral injury”. As Shakespeare’s quote suggests the injury would apply to us all, thus not of much use. If we consider “moral injury” as only applying to some, then, perhaps the difference is between those who know it and those who don’t. We could then divide the world between Poloniuses (who don’t know it) and Hamlets (who know it). And, then subdivide the Hamlets between pre/not-symptomatic and symptomatic. In Hamlet’s case the symptoms would have to be considered to have started after the father-murdered/mother-remarried trauma.

Furthermore, in that the designation “moral injury” is being applied in psychotherapeutic practice, specifically to people looking for help because of depression or symptoms usually considered part of PTSD, then the “moral injury” label is likely to be counter-productive. As a therapist, I have often tried to help people whose feelings of guilt over destructive actions (or inaction) have interfered with their being able to lead productive lives, and even potentiated the negative effects of their regretted behavior. But, I think categorizing them as having been morally injured would make many think I was treating them as the primary victim of their behavior, which they would find grossly insensitive.

What is the alternative?
If you are going to attack a term that has a use, as how “moral injury“ helps make the portion of mental health professionals stuck exclusively in the fear based understanding of the destructive psychological effects of trauma, then you are responsible for offering an improvement.

I have not been able to come up with anything that has the aesthetic fluidity of ”moral injury”, so far the best I can do is “trauma potentiating guilt”. I think it does not judge whether or not regretted acts should be considered an injury to the actor, but rather makes the focus helping people do what is worthwhile, given their experience. Psychotherapy relating to these issues is complex and I will not try to describe in detail here. It alluded to in the previous post in the discussion of EMDR and in some detail in EMDR and Psychotherapy Integration.  I plan on updating and elaborating on those ideas in a later post.

War Heros: A Poem

War Heroes

As taught by 500 veterans who have been tormented by their war.
Part 1 How to know you are a war hero
(pick some from the list below)

Believe you didn’t do enough
Believe the real heroes are dead
Have pride in what you did
Despise what you did
Not give a shit about what you did

Believe you should have died
Think you must figure out the secret reason you didn’t die
Be angry at the people who weren’t there
Think of everything you can to keep your kids from going
Love anyone else for going
Think you only did what you had to do
Think you didn’t have to do everything you did
Think this is not how heroes think and feel

Part II How to get over being a war hero

Grieve everything and everyone you lost
Grieve all the yous you think you could have been
Go through the grief until you recognize the impossibility of the other selves

Learn we have an obligation to find serenity
Learn that nobody in their right mind needs you to suffer anymore
Learn that living your life well is the only way to honor the dead
Learn that trying to carry other people’s pain would be an insult, if insults could exist
Stop pretending you are not going to die

Learn that knowing something once is not enough, we must keep coming back to it
We don’t pray once

Part III Where you learned the definition of the word hero

Maybe when you were a kid you learned to look up to someone as a hero
You thought that person had all the answers, all the power, all the skill, and none of your kind of fear
Then you grew up, but still never noticed
that the hero didn’t feel what you thought he felt

Now we know that the courageous are scared,
and the skillful aren’t always courageous

Part IV Summary

There was a new recruit from Maine
who thought he would earn him some fame.
He got in the fight,
and Lord it got tight,
but you better not call him a hero because now he knows
it is much more complex than that, and besides all the heroes are dead

Howard Lipke
(1/6/16 version)

North Chicago Conflict Resolution Institute (NCCRI)

North Chicago Conflict Resolution Institute
(a work in progress)

The nccri is a semi-fictional organization created to help people peacefully resolve internal conflicts and conflicts with others. Sometimes it teaches skills they need to accomplish this, but often times it just reminds them to use what they already know. Of course, the principles can be just simply stated for people to use if they choose, but when ideas are attached to a structure or organization, and practice is encouraged we often find it easier to use them when we need them.

So, the nacre was created as an entity to provide that structure, and is called an institute instead of a club, because of the educational component. The value of this general approach can be demonstrated with an example involving my friend William. He came across a kitten stuck in a tree. He was in a hurry to get where he was going, and was tempted to walk on, however, he remembered he was a member of the Help-A-Treed-Kitten Club (HATKC) and stopped to help poor tabby down.

The nccri was formed out of a concern as serious as the HATKC’s (I hope I don’t get in trouble for saying this) is frivolous. It was developed to help veterans meet the goal of preventing combat solutions to non-combat problems. The military teaches skills for violent resolution of conflict, and the American military does it particularly well. The lessons learned in the military, before and during combat, helped veterans survive there, and may even help veterans survive violent situations in civilian settings. However, when people are so well trained for and experienced in combat, that kind of solution can come out automatically, before other solutions are considered, especially when there is stress involved. It should be said that it is not just the military that teaches aggression, and employs anger to block hurt, many parents and others involved in child raising teach or foster a similar martial approach, which gets absorbed and can dominate reactions to stress.

The internal combat response does not only involve emotions, it also involves thinking patterns. The thinking pattern that becomes most likely to turn non-combat situations violent is rapidly thinking of others as enemies. This may save lives in war, but can be self defeating, increasing rather than limiting risk outside the combat zone.

This institute was originally established, about 25 or 30 years ago , in conjunction with the Stress Disorder Treatment Unit (SDTU) at what is now called the Lovell Federal Health Care Facility. nccri activities partially overlap with SDTU programs for both resident and non-resident participants. It is a principle of the Institute that successful study of peaceful conflict resolution, when appropriate, will go hand in hand with decreases in symptoms of PTSD for those who have these symptoms. However, the distress and disruption of meaningful and pleasurable functioning that may come with having been in war cannot be fully described in terms of psychiatric symptoms. They must also be considered from other points of view, spiritual, philosophical, educational, vocational, and social. These are more the purview of exploration and education than treatment.

To be a member of the nccri one only has to agree that making peaceful conflict resolution, when possible, is a goal. Membership in the Institute is completely voluntary. There is no list of members. However, the founder Howard Lipke, is the only one authorized to decide what is, or is not, an official activity of the nccri. A membership card is offered below, it can be downloaded and printed.

Howard Lipke, PhD
Revised 4/25/16

Don’t I Have the Right to Be Angry? A Podcast Interview

Podcast from the University of Buffalo School of Social Work

Listen to a 35 minute interview with Howard Lipke conducted by Dr. Nancy Smyth, dean of the School of Social Work. The basics and history of the development of the HEArt program are discussed, as are research, general ideas about anger prevention work and clinical practice with combat veterans.

Episode 180 – Dr. Howard Lipke: HEArt for Veterans: Identifying the Hidden Emotion. (2015, November 23). inSocialWork® Podcast Series. [Audio Podcast] Retrieved from


On Stigma

Below are two paragraphs from a paper on stigma, especially as it applies to veterans. (Actually there are two papers, one addressed to veterans and one more academically written for MH professionals) In the second paragraph it is suggested that if vets, or anyone with trauma related “symptoms,” is going to get down on themselves they should at least “Get it right.” which is the name of the academically oriented paper these quotes come from.

That stigma (being marked or believing one is marked as disgraced) is a primary barrier to veterans seeking help to overcome the destructive psychological effects of trauma is one of those cultural phenomena which is easy to see, widely acknowledged, and also supported by research (Hoge et al 2004) . As is often pointed out, the stigma has two manifestations, (e.g., Corrigan, 2004) the belief by others that the need for psychological help is a sign of essential inferiority, and the same belief held by the self. Both are important with the self-stigma clearly most damaging.

 Stigma terms

  1. Current stigma term: Crazy Vet 

More accurate term: Stuck Transferer

This is the stigma associated with re-experiencing symptoms. “Stuck Transferer” refers to the idea that flashbacks and reliving nightmares are a manifestation of unprocessed memory. In Horowitz’s terms (1976) memory has not moved (transferred) from short term to long term storage. In the version presented to veterans this is called moving from “reliving” to “historical” or “intellectual” memory.


The Definition of EMDR

Let’s start with a fairly circumscribed mild point. We need a new definition of EMDR, one that does not begin with “…evidence based …” or “…successful outcomes well documented …”, as occur in EMDRIA’s official definition. Those aren’t phrases you find in a definition, you find them in an evaluation or a press release. In addition, “evidence based” suggests that EMDR was developed from research demonstrating the effectiveness of its various aspects. It wasn’t, but more on that later.

I have a definition in which more is different from EMDRIA’s than just the absence of self praise. I don’t think my proposal is perfect, but so far it is the least bad one I know of. It should also be mentioned that a version of the one below was submitted to EMDRIA during the latest development of the EMDR definition and it was rejected. But, that doesn’t mean the discussion should be over, or that someone could not use mine if they needed one that focused on essential features.

And, here it is: Eye Movement Desensitization and Reprocessing (EMDR) is a method of psychotherapy in which aspects of a target associative network (usually a troubling memory) including visual images, thoughts, feeling, emotions, are identified, as are a preferred thought about the self when target memory is active. The believability of the preferred thought is rated, as is the level of distress felt as the troubling memory is activated before initiated eye movement.

With the painful aspects of the problem memory again brought to awareness, the client is asked to free associate while moving her or his eyes following the therapist lead, in a repeated pattern for a period of time, determined by client response, but usually about 30 seconds. After the set of eye movement, the client is asked to report on the current content of consciousness, and then eye movement is reinitiated. This pattern is repeated until distress associated with the target network is resolved, and, hopefully, adaptive associations are connected to the targeted event. In its most complete form all aspects of the target memory(ies) are addressed, including related past events and possible future situations which may elicit related psychopathological responses.

Therapist comments between sets of eye movement are limited to brief instructions, unless the client is not progressing by either becoming aware of new material or not having decreased distress. In these cases a variety of interventions, many typical of other methods of psychotherapy may be made before eye movements are resumed.

There are many variations to specific aspects of the above activities, including on what the client is supposed to try to keep in mind as em begins. These variations are determined by client response, experience and research.

As in standard psychotherapy practice negotiation of treatment contract, client evaluation, history taking, building of rapport, explanation of method, and development of stress management strategies are part of treatment.

And now a short dictionary/elevator definition:

EMDR (Eye Movement Desensitization and Reprocessing) – a method of psychotherapy which usually involves recalling a troubling experience and engaging in therapist led repetitive back and forth eye movements or other sensory/motor activity. The rest is commentary.

I was just kidding about the commentary part. This subtle reference to Rabbi Hillel’s effort to explain his religion while standing on one leg obviously doesn’t belong in a definition. However, it should also note that Rabbi Hillel is reputed to have also suggested that the commentary should be studied.

Response to a potential objection:

I can foresee objection to the phrase: “including on what the client is supposed to try to keep in mind as eye movement begins”. The allowance of the loosening of the protocol comes from clinical practice. Let’s say before the first set of eye movement, when the therapist asks the client to put in mind a picture of the worst part of the target memory, the client has an immediate strong emotional reaction, and the therapist then begins the eye movement. Since the client has already been prepared for eye movement at this point most experienced therapists I have asked would just begin it. Would this not be EMDR because most of the Assessment phase was skipped over?

There will never be a fully satisfactory definition of EMDR, and this is a problem with almost all terms in the mental health field including such basic terms as “mental health” and “psychotherapy”. So we have to pick compromises that are most useful and least problematic.

Understanding Psychological Trauma Through Literature (draft)

As a psychology graduate student, in the 1970’s, I came across an edited volume, The Abnormal Personality Through Literature, by Alan A. and Sue Smart Stone (1966), which presented long passages of great works of fiction to describe psychiatric syndromes and psychotherapeutics. I thought it a great idea then, and still do. The work you are reading attempts to apply their method more specifically, to just the destructive psychological effects of trauma and efforts to overcome them. The other variations from Stone and Stone include the use of shorter passages, and comments on changes in the way trauma has been recognized over the years, since it has been officially acknowledged in the Diagnostic and Statistical Manual (DSM) as the official United States standard.

A reasonably clean rough draft:

Thinking and Feeling About Forgiveness

This is a paper based on work with combat veterans over many years and addresses some of the most difficult and painful concerns people can have, the difficulty of which is magnified by involvement in war. It includes discussion of forgiveness of others and the self, with the decision to forgive, not all or nothing, and not a foregone conclusion.

Recently the phrase “moral injury” has been applied to some of the issues addressed in this paper.  While I’m glad the moral and emotional reactions to participating in combat are being  more fully considered by psychologists who used to only talk about the fear related to traumatic experiences, I’m not sure that the injury metaphor is most useful way to consider them. The term moral injury appears to be about what is already considered when we talk about guilt. Guilt people feel related to trauma, whether  it seems justified to others or not, or necessary or not, has already been subject of much psychotherapeutic work, written about for a long long time and undoubtedly considered even longer.

Structured Questionnaire for Trauma History: The GLEQ

The Great Lakes Event Questionnaire (GLEQ):

The Great Lakes Event Questionnaire (GLEQ) is a one page trauma history questionnaire initiated in 2000 aid in psychotherapeutic work with combat veterans. It was subsequently developed and refined to its current form. Key features include:
– asking about broad categories of events in order to gently prompt consideration of both major trauma and significant less obviously destructive events.
– subjective units of disturbance ratings of the effects of events to
facilitate understanding of their relative impact and measure change.
– a format that indicates that specifics are verbalized and disclosed at client discretion.

A second page can be included to briefly ask about client values and positive aspects of client lives. Clinical suggestions about when and how to use the GLEQ are offered in the attached paper. The GLEQ is in the public domain and can be modified to fit therapist needs.