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Development of Moral Injury (Katie Carlson)

The development of moral injury has been inextricably tied to the psychological consequences of war. To understand the development of the construct of moral injury, it is necessary to examine the history of violence and it psychological consequences. Throughout history, humans have been killing each other, and have shown great reluctance in doing so. Literature on warfare emphasizes the moral anguish soldiers feel in combat, from modern military service members to ancient warriors. Ethical and moral challenges are expected from warfare. Soldiers in the line of duty may witness catastrophic suffering and severe cruelty, causing their fundamental beliefs about humanity and their worldview to be shaken.

Research has begun to look at the concept of moral injury to understand the impact that combat may have on soldiers, and their mental health afterwards. Currently, no systematic reviews or meta-analyses exist on the construct of moral injury. However, the literature reflects that moral injury was developed as a response to the inadequacy of mental health diagnoses to encapsulate the moral anguish service members were experiencing after returning home from war (Litz et al., 2009). Service members are routinely exposed to death, injury, and violence. Military service members represent the population with the highest risk of developing Posttraumatic Stress Disorder (PTSD) (APA, 2013). PTSD was first included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders, the manual classifying mental health disorders published by the American Psychiatric Association, to begin to address the symptoms that Vietnam veterans exhibited after their wartime experiences (Litz et al., 2009). As PTSD has developed as a diagnosis, it requires that individuals are either directly exposed to death, threatened death, serious injury, or sexual violence, witness it in person, learn about it occurring indirectly to a close relative or friend, or are repeatedly exposed to aversive details of traumatic events. PTSD includes four symptom clusters, including intrusion, avoidance, and negative mood and thoughts, and changes in arousal and reactivity. Individuals with PTSD may experience intrusive thoughts as they re-experience the traumatic events, as well as avoiding stimuli that reminds them of the traumatic event, and have increasingly negative thoughts and moods. Additionally, individuals with PTSD may exhibit irritable or aggressive, self-destructive behavior, and hypervigilance, amongst other arousal-related symptoms.

While these symptoms can have devastating effects, in the first review of moral injury, Litz and co-authors argued that service members may experience long-term pain and suffering stemming from their time in combat that is not encapsulated or represented by a diagnosis of PTSD. Unlike PTSD’s focus on fear-related symptoms, moral injury focuses on symptoms related to guilt, shame, anger, and disgust. A diagnosis of PTSD in the DSM-III listed an individual experiencing guilt for behaviors that required for their survival as a symptom. However, conceptualizations of PTSD in each subsequent DSM has dropped guilt as a symptom.

            With current diagnoses’ inability to account for moral anguish, research has begun to search to encapsulate moral conflict in warriors (Drescher et al., 2011). The phrase ‘moral injury’ was defined by Liz. et al (2009) as “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long term, emotionally, psychologically, behaviorally, spiritually, and socially" (p. 695). Treating moral injury is often thought of as “soul repair” due to the nature of moral anguish (Brock & Lettini, 2012). As someone wrestles with the impact of what they did or failed to do, it can seem like their entire guiding principles for life have been altered or removed. The consequences of moral injury can be disastrous. An individual with a moral injury can experience severe distress, including major depression, and suicidality (Litz et al., 2009). While moral injury can be experienced by people other than military service members, current research has paid special attention to morally injury in military populations (Litz et al., 2009).

Moral Injury and Military Culture (Marissa Bannister)

Although moral injury does not only exist among military populations, the exposure to violence that occurs during war times make military and veteran population at a higher risk of developing moral injury. It has been reported that 32% of service members deployed to Iraq and Afghanistan were responsible for the death of an enemy and 60% stated that they had witnessed both women and children who were either ill or wounded that they were unable to provide aid to (Litz et al., 2009). Additionally, 20% reported being responsible for the death of a non-combatant (Litz et al., 2009). These statistics were taken in 2003 and an updated survey of the number of service members who have been directly responsible for the death of an enemy, a non-combatant, or having to leave sick and wounded women and children behind can shed light onto the magnitude of the issue of moral injury among service members.

During times of war a service member’s personal ethical code may clash with what is expected of them during war. Approximately 27% of deployed soldiers have reported having an ethical dilemma to which they did not know how to respond (Gaudet, Sowers, Nugent & Boriskin, 2015). Research has shown that longer and more frequent deployments can result in an increase in unethical behaviors on the battlefield. This is problematic considering deployment lengths have increased for the war in Iraq and Afghanistan (Litz et al., 2009; MHAT-V, 2008). During times of war the military promotes an ethical pardon on the killing of an enemy, going against the typical moral code for many service members (Litz et al., 2009). While a service member is deployed, killing of the enemy is expected and often rewarded. Despite this, when a service member returns home the sociocultural expectations are largely different from when they were deployed (Litz et al., 2009). The ethical code back home has not changed, making the transition from deployment to home difficult for some service members (Gaudet et al., 2009). This clash in a personal ethical code and the ethical code and expectations of the military can further increase a service member’s deep seeded feelings of shame and guilt for their actions abroad.

Treating Moral Injury (Marissa Bannister)

            There is little that is known about the treatment of moral injury. Gaudet et al. (2015) suggest that current interventions are lacking and new treatment interventions specific to moral injury are necessary. It is not enough to treat moral injury in the same way that depression or PTSD are commonly treated (Litz et al., 2009). In spite of the lack of research on the treatment of moral injury, factors such as humility, gratitude, respect and compassion have shown to either be protective or provide for hope for service members.

Although there is a delineation between PTSD and moral injury, the shame that many individuals face as a result of moral injury may predict symptoms of Posttraumatic Stress Disorder (PTSD) (Gaudet et al., 2015). When considering the impact of shame in PTSD, shame is known to be highly correlated with each cluster of symptoms of PTSD (Gaudet et al., 2009). Although no definitive treatment for moral injury has been found, it is hypothesized that treating the underlying shame that is often associated with service member’s symptoms of PTSD is necessary (Gaudet et al., 2015). Additionally, it has been shown that allowing feelings of shame to go untreated can have deleterious effects (Gaudet et al., 2015). This can often make the identification of moral injury in a service member difficult because shame tends to increase slowly over time (Litz et al., 2009). Shame has been linked to complications such as interpersonal violence, depression, and suicide (Gaudet et al., 2015). Although there are no systematic reviews or meta-analyses on the treatment of moral injury, Litz et al., (2009) have hypothesized a modified version of CBT that addresses three key areas of moral injury: “life-threat trauma, traumatic loss, and moral injury Marines from the Iraq and Afghanistan wars.” Although a significant amount of research on moral injury and specifically the treatment of it is still lacking, these proposed treatments and protective factors provide researchers with a starting foundation.

Moral Injury: Moral injury can occur through perpetrating, failing to prevent, or witnessing acts that violate a person’s deeply held moral beliefs (Litz et al., 2009). Violation of moral beliefs may wreak havoc on an individual’s long-term health, from psychological and spiritual to social behaviors (Litz et al., 2009). Moral injury has emerged recently as a psychological construct to conceptualize the type of trauma that occurs when a violation of moral beliefs takes place.

Moral Injury Article Outline - Improving an Existing Article
 * 1) Expand on Definition of Moral Injury
 * 2) Citation : A Review of PTSD and Shame in Military Veterans & Moral injury and moral repair in war veterans: A preliminary model and intervention strategy
 * 3) History (brief and new!) of Moral Injury
 * 4) Pioneers in the literature
 * 5) Citation : Moral injury and moral repair in war veterans: A preliminary model and intervention strategy
 * 6) Editing follow sections of the article:
 * 7) Cultural Perspective
 * 8) Psychological Perspective
 * 9) Spiritual Perspective  The literature does not show that moral injury should be separated into these categories. We will write a cohesive narrative of moral injury, paying special attention to the history of moral injury within the field of psychology.
 * 10) Citations : Moral injury and moral repair in war veterans: A preliminary model and intervention strategy
 * 11) Moral Injury and Military Service Members
 * 12) Moral injury in the context of war
 * 13) Citations : A Review of PTSD and Shame in Military Veterans
 * 14) Difference between Moral Injury and PTSD
 * 15) Current research/treatment of Moral Injury

Article Evaluation

"Transgenerational Trauma"

The article on transgenerational trauma was neutral, but lacked sufficient detail. The main component of the article was the "history" section. Within this section, although the material was relevant, the presentation was distracting and difficult to follow. For example, the third paragraph in the "history" section of the article is only two sentences. The author could have broken up the run on sentence in order to make the information more cohesive.

The article was rated as a "B-class," meaning that this article is in need of maintenance. This evaluation is consistent with the lack of information in the article. Although the history portion gives some detailed information, that is essentially the only component of the article. Other areas that could be expanded upon are things such as treatment options, populations at a higher risk, potential resilience factors, etc. The article briefly touches on how current research in transgenerational trauma may be transferred epigenetically, but fails to explore why this is and how this view differs from prior research.

In the "talk" section of the article, there are not many people discussing the article and no activity since 2014. In one of the conversations, a commenter called the article "bullshit psychological theory." Another author suggested to add a reference and provided a quote from the reference.