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.