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For Therapists

This section is intended for therapists and mental health professionals who are tasked with supporting Veterans in recovering from serious moral transgressions. 

Topics on this page:

Potential War-time Morally Injurious Events

Moral Injury Implications

Interventions

Scales

Measurements

Additional Resources

  • When we are compassionate witnesses who listen with open hearts and minds, we provide a safe space for Veterans to learn to talk about their painful experiences in useful ways for adaptive coping.

  • When we hold space for their intense pain, we offer hope, and support them in making their way through the shame and self-hatred, separating the morally injurious event from the totality of who they truly are.

  • We can encourage the awareness that even if a particular act was unequivocally “bad” or “wrong” it is nonetheless possible to move forward and create a life of goodness and value. 

Potential MI events

Potential War-time Morally Injurious Events

  • Accidental or intentional killing of civilians

  • Torture

  • Sadistic killing (people or animals)

  • Overly aggressive or disproportionate violence

  • Mutilation of corpses

  • Sexual assault

  • Failure (real or perceived) to prevent death 

  • Destruction of homes 

  • Within ranks violence

  • Betrayal by leadership

  • Freezing or failing to act                                  

 

      (Litz et al., 2015)

Moral Injury Implications

One’s perspective is transformed when foundational beliefs about the goodness and trustworthiness of oneself, others, or the world have been shattered (Yeterian et al., 2019). The phenomenology of a moral injury touches on all aspects of human subjectivity—spiritual, emotional, behavioral, psychological, and social (Wiinikka-Lydon, 2021). The shameful and unforgivable feelings one experiences from moral injury are linked with depression, anxiety, suicidality, and substance dependence (Cenkner et al., 2021; Shay, 2014).

Moral injury can lead to alterations in self-perception, loss of meaning and loss of religious faith. Litz et. al, found that those who were haunted by something they did or witnessed had more activity in their left precuneus, a part of the brain that is related to sense of self (2009). Thus, we can support Veterans by helping them reconnect with their sense of Self. 

Interventions

Regardless of the intervention you use, consider this perspective, shared by a Veteran and LMFT:
"Forcing a speed of therapy is a form of violence. There is an inner healing intelligence driving this process upon which we can disclose and move through these (wounded) parts. And when we are forced to answer a lot of questions right at the gate, it can send those protective parts up and running. Being more flexible with how we think about assessment and building that therapeutic relationship is key" ~ Mark Cunnigham

We can Support Veterans by Encouraging them to:

​

  • Separate their morally injurious events from the totality of who they are

  • Accommodate and integrate their experiences

  • Make meta meaning of their horrific events

  • Reprocess rigid interpretations that create misery and impairment

  • Consider less self-depreciating appraisals

  • Allow powerful feelings to surface

  • Approach self-forgiveness or grace

  • Identify their self-worth and a sense of purpose

  • Reengage with values and actions that are aligned with their values 

  • Increase cognitive flexibility

  • Create corrective experiences that counter core beliefs of being unforgivable

  • Practice self-compassion, or loving-kindness

Also essential is for therapists to:​

  • Be fully present, engaged, and regulated

  • Develop a strong therapeutic alliance

  • Maintain a compassionate and non-judgmental stance​

"The process of re-organizing neural circuits to integrate a negative past event into a more complex and mature perspective is tied to cognitive flexibility.  This flexibility is a major aspect of the healing process for moral injury." ~Stefanie Faye

Adaptive Disclosure

Adaptive Disclosure

Adaptive Disclosure is a clinical  approach developed specifically to treat moral injury. I found it very helpful to have training in Prolonged Exposure (PE) first, as Adaptive Disclosure builds on concepts of PE. 

One aspect to this treatment modality is acknowledging the morally "bad" or "wrong" act and yet instilling hope that it is possible to create a meaningful life.  

adaptive disclosure.jfif

Litz, B. T., Lebowitz, L., Gray, M. J., Nash, W. P. (2015).
Adaptive Disclosure: A New Treatment for Military Trauma, Loss, and Moral Injury. United States: Guilford Publications.

Dr. Brett Litz discusses Adaptive Disclosure-Enhanced (AD-E):

"The aim is to help people do things that are repairing, and being exposed to reparative and healing things in their community. The compassion training really helped this process... AD-E is designed to help people feel valued and to value others, and to feel part of communities and humanity (kindred attachments). Having a sense of belonging is essential; in concrete terms and broadly, in terms of developing compassion for the self and others and feeling part of humanity."   

Acceptance & Commitment Therapy (ACT) 

ACT helps break patterns that maintain the suffering of a moral injury and empowers Veterans to build new patterns of behavior in response to their moral pain. These new behaviors are guided by their identified values rather than being limited to avoidance and control.

(Borges et al., 2022)

MI WB.webp

Evans, W. R., Walser, R. D., Drescher, K.D., & Farnsworth, J.K. (2020). The Moral Injury Workbook: Acceptance and Commitment Therapy Skills for Moving Beyond Shame, Anger, and Trauma to Reclaim Your Values. New Harbinger Publication

Client Handouts and Worksheets from ACT books by Dr. Russ Harris:

ACT

Scales

The following two scales can help you consider ways that Veterans may experience connectedness and self-compassion ~ or a lack thereof.  

The Watts Connectedness Scale: to measure a sense of connectedness to self, others, and the world.

connectedness scale.png

(Watts, et al., 2022) 

Scales

   Self-Compassion Scale–Short Form

(Raes, et al., 2011) 

HOW I TYPICALLY ACT TOWARDS MYSELF IN DIFFICULT TIMES
Please read each statement carefully before answering.
Indicate how often you behave in the stated manner, on a scale of 1 to 5, where 1 is Almost never and 5 is Almost always 

_1. When I fail at something important to me I become consumed by feelings of inadequacy. 
_2. I try to be understanding and patient towards those aspects of my personality I don’t like. 
_3. When something painful happens I try to take a balanced view of the situation.
_4. When I’m feeling down, I tend to feel like most other people are probably happier than I am. 
_5. I try to see my failings as part of the human condition. 
_6. When I’m going through a very hard time, I give myself the caring and tenderness I need.
_7. When something upsets me I try to keep my emotions in balance. 
_8. When I fail at something that’s important to me, I tend to feel alone in my failure 
_9. When I’m feeling down I tend to obsess and fixate on everything that’s wrong. 
_10. When I feel inadequate in some way, I try to remind myself that feelings of inadequacy are shared by most people.
_11. I’m disapproving and judgmental about my own flaws and inadequacies.
_12. I’m intolerant and impatient towards those aspects of my personality I don’t like.

Measurements
Additional Resources

Additional Resources

15 Things Veterans want you to know
(16 mins)

This work can be incredibly rewarding but also emotionally exhausting, it's a good idea to have your own self-compassion practice.

Self-Care Assessment:       
Professional Quality of Life Scale:

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