 Healing Hidden Wounds: Treating Moral Injuries in First Responders, Veterans, and CiviliansWritten by Hillary Gorin, PhD, LCPWhat is moral injury? “The lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations” (Litz et al., 2009, p. 697; as cited in Bryant, 2021). In other words, a moral injury takes place when one’s conduct is not perceived as moral or ethical or when one’s experience does not align with one’s moral viewpoint (Bryant, 2021).
How does this look for my clients who suffer from moral injuries? It appears to be a chronic, internal agony… A voice that starts off quiet but gets louder with time. It typically starts with a “If only I had done X,” but quickly evolves into a “I should have known, how did I not know? I am a failure. I am a terrible person.” I have seen Veterans sob, overwhelmed by the guilt and shame of the commands they were given and chose to follow through with. I have seen firefighters heartbroken over the car seat in the back of the burning car. I have seen nurses tormented by the question, “is there anything else I could have done to save them?” I have seen mothers sick with guilt because they think they could have prevented a catastrophic outcome related to their child. Many people in the helping fields, such as nurses, firefighters, and police officers, suffer from a moral injury when they are not able to save a member of a vulnerable population, such as a child. I have also seen that the impact of moral injuries worsen over time. This makes sense because the impact of PTSD generally increases the longer the PTSD remains untreated; in other words, time does not heal a wound that continues being opened by shame, guilt, and negative and harsh internal dialogue. So how can treatment help someone with moral-injury related PTSD? First, addressing shame, guilt, and self-blame is a critical component of the treatment of PTSD, especially when a moral injury has contributed to the development of the disorder. Therefore I see my role in treating your moral injury as helping you to understand that you did the best you could with the information you had at the time. If you had other information, you would have done something else. That is what many of the brave and courageous humans I treat who serve others don’t see. We are not perfect. We cannot be perfect, especially when having to make life altering decisions every day at work. The path that you chose was the path you believed would have the highest likelihood of success or you would not have chosen it. Many cognitive patterns contribute to the maintenance of the guilt and shame found in moral injuries. For example, research suggests that first responders have a tendency to believe that they should always be able to successfully save or help others, and that they therefore perceive it to be a failure when they can’t do so (as cited in Bryant, 2021). This assumption is another way that guilt and shame can be perpetuated. Additionally, during a moral injury, fundamental assumptions can be shattered. For example, if someone believes that good things happen to good people, and bad things happen to bad people, otherwise referred to as the “Just World Belief” (Resick et al., 2017), then they may not know how to interpret certain unfair tragedies, such as the death of a toddler. Therefore, treatment of moral-injury related PTSD typically entails challenging unhelpful thinking patterns and related beliefs. For example, an exercise that I encourage is thinking about what else could have happened? You could have made a different decision, sure. But how do you know the outcome would be better or different? For a healthcare worker, how do you know that a person would have lived if you provided different care? For a firefighter, how do you know that child would have survived the fire if you arrived sooner? You don’t. We do not get access to these unknown answers. I provide a treatment called Cognitive Processing Therapy to guide these exercises and thought challenging strategies, an evidence-based treatment for PTSD and moral injury-related PTSD (Litz et al., 2021). Treatment suggestions also include the following: Processing memories of the moral transgression, integrating corrective information that allows for a more evidence-based perspective, and self-forgiveness strategies, such as values-driven and reparative behavior (as cited in Litz et al., 2021). In my experience helping patients with moral-injury related PTSD, I have witnessed the effectiveness of these treatment strategies and watched my patients forgive themselves for the circumstances they could not control. I encourage you to reach out if you would like help healing from your moral injury. Call OakHeart at 630-570-0050 or 779-201-6440 or email us at [email protected]. We have counselors, psychologists, and social workers available to help you at one of our locations in North Aurora, IL, Sycamore, IL, and/or via Telehealth Online Therapy Services serving Kane County, DeKalb County, Dupage County, and beyond. References Bryant, R. A. (2021). Treating PTSD in First Responders: A guide for serving those who serve. American Psychological Association. Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva., C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clinical Psychological Review. 29(8), 695-706. https://doi.org.10.1016/j.cpr.2009.07.003 Litz, B. T., Rusowicz-Orazem, L., Doros, G., Grunthal, B., Gray, M., Nash, W. & Lang., A. J. (2021). Adaptive disclosure, a combat-specific PTSD treatment, versus cognitive-processing therapy, in deployed marines and sailors: A randomized controlled non-inferiority trial. Psychiatry Research, 297, 113761, https://doi.org.10.1016/j.psychres.2021.113761 Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive Processing Therapy for PTSD. The Guilford Press. |
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