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PTSD and Moral Injury
Posted on: 03/28/18

In contrast to a burgeoning body of literature to support effective treatment for PTSD, moral injury, a partially overlapping, but discrete set of experiences, has received scant attention. Existing treatments for PTSD, which are exposure-based, may not successfully address the guilt and shame that fuels moral injury (Steinkamp, et al., 2011). In fact, existing treatments may even be unintentionally harmful; according to Litz and colleagues (2009), “repeated raw exposure to a memory of an act of transgression without a strategic therapeutic frame for corrective and countervailing attributions, appraisals, and without fostering corrective and forgiveness promoting experiences outside therapy would be counterproductive at best and potentially harmful.”

For nearly a decade, I worked with a very large caseload of Veterans as a frontline mental health psychologist. During this time, I developed and deployed multiple rounds of a well-received, highly effective group-based treatment for moral injury. The goal of this workshop will be to evaluate this treatment in light of current theory and research on moral injury.

This workshop will critically evaluate the current conceptualizations of moral injury as rooted in acts of commission or omission and will argue for an expanded understanding of moral injury insofar as it can accrue over time in relation to repeated action or inaction (to give an example, a veteran who carries shame for many decades for never contacting the family of a brother in arms who died in Vietnam).

Drawing on the ground-breaking research of Litz and colleagues, a clear and practical model will be offered to explain the maintenance of moral injuries. In addition, this model will be mapped onto Joiner’s interpersonal-psychological theory of suicidal behavior (Joiner, 2005) to explain how moral injury can lead to increased risk of suicide (Joiner, T. (2005). Why People Die by Suicide. Cambridge, MA: Harvard University Press).

Further this workshop will propose that effective treatment for moral injury – no matter what form it takes - achieves two primary objectives –

  1. Decrease shame
  2. Increase alignment with each patient’s personally-valued “warrior code”

The current model of treatment, which relies of expansion and adaptation of exposure-based treatment with a facilitated dialogue with an imaginary benevolent moral authority will be reviewed. While this treatment may be helpful for some Veterans, this writer proposes that greater gains are likely to be observed using the group-based method for a number of reasons that are supported by relevant research. To summarize this body of research, Jonathan Shay, who has been a staff Psychiatrist at the Boston VA, a leading researcher of the Commandant of the Marine Corps Trust Study (1999-2000) and a visiting scholar-at-large at the U.S. Naval War College (2001), has asserted: “The essential injuries in combat PTSD are moral and social and so the central treatment…actively encourages communalization of the trauma” (Shay, J. (1994). Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York, NY: Scribner Press).

This writer will outline the method used to treat moral injury (which involves letter-writing exercises to contain and give structure to communal processing of shame-inducing experiences, followed by mission-setting and practical action designed to realign each patient with his or her personal “warrior code”). We will also discuss some thought-provoking questions such as whether self-forgiveness and atonement are in fact necessary for recovery.

The potential limitations and relative benefits of both individual and group therapy will be weighed and thoughtfully considered in light of existing theory and research. For instance, this writer will draw from social psychology research to reflect on whether veteran patients are likely to feel decreased shame burden based on 1:1 therapy with a provider who has expertise in the treatment of moral injury or within the context of a group of veterans who have lived experience carrying their own burdens of shame.

Finally, in light of the empirical thrust of this conference, it is important to note that the group-based method described in this workshop has been evaluated by this writer. Over three iterations of the group, a drop of 20 points on average was observed in PCL-C scores (which in retrospect would have been a proxy measure relative to a more targeted outcome assessment, had well-validated tools to assess treatment gains been available at the time for moral injury). Moreover, this writer will share some of the narrative feedback from group participants. However, whether group-based therapy is more powerful than individual therapy remains an empirical question for further research.


Shauna Springer Ph.D.

Senior Director, TAPS Red Team 

In honor of my veteran patients who have lost brothers and sisters in arms


Tragedy Assistance Program For Survivors

3033 Wilson Blvd., Third Floor, Arlington, VA 22201 

Toll-Free: 800.959.8277 (TAPS)

Main: 202.588.8277 (TAPS)

Caring for the Families of America's Fallen Heroes since 1994.

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