Approaching Moral Problems in Mental Health Treatment
John Peteet, MD, Harvard Medical School, Boston, MA
The recent adoption of “Moral Problem” as a Z code by the American Psychiatric Association (APA)’s Steering Committee for DSM5-TR recognizes a growing body of research on the clinical importance of moral injury, moral distress and moral dilemmas (Koenig and Zeben, 2021). Defined as moral because they are related to an experience that disrupts one’s understanding of right and wrong, or one’s sense of the goodness of oneself, others, or institutions, these problems can present in witnesses, victims and/or perpetrators.
Clinicians who work with survivors of trauma have been the primary contributors to the literature on approaching moral problems in treatment. In her classic book Trauma and Recovery (1992), Judith Herman points out that a therapist may need to provide “a context that is at once cognitive, emotional, and moral” in order to help the survivor reconstruct a coherent system of meaning and belief that encompasses the story of the trauma. Barr et al. (2022) advocate a “dual track” approach to the treatment of traumatic illness - addressing in addition to dysregulation of fear and memory systems, disturbances in value and character domains, e.g. “through reflection, self-forgiveness, repentance and restoration”. Similarly, Litz (2023) has argued for a “Yes, …and” rather than a “Yes,… but” approach, going beyond traditional behavioral approaches such as CBT that assume a normally operating conscience and address distorted beliefs associated with guilt and shame through contextualization, to suggest that therapists may also need to deal directly with issues of guilt, forgiveness, and making amends. Spiritually Integrated Cognitive Processing Therapy, developed by Pearce et al. (2018) has emerged as a one method of doing so, and Judith Herman in her recent book Truth and Repair (2023) points out the importance to survivors of abuse of pursuing justice.
However, clinicians have lacked consensus on how to approach the many other instances in which distressed patients question the goodness of the self, of others and of the world. Here we consider clinical examples of four contexts in which moral problems may present: complex PTSD, demoralization, depression, and adjustment with moral dilemmas. We then discuss a therapeutic framework for approaching them: validating the patient’s moral concerns; engaging in a “dual process” of addressing their psychological and moral dimensions; and identifying challenges the patient is encountering in accomplishing the basic tasks of developing moral commitments, implementing these commitments, making moral decisions, assessing one’s behavior, dealing with moral failure, and acquiring virtues (Peteet, 2004). These highlight the role of a transcendent ground of ideals, the virtues preferred by different traditions (Peteet, 2014), and the role of faith communities in supporting them.
Finally, we consider clinical and ethical challenges involved in addressing moral problems directly: For example: How can a clinician best weigh the patient’s, and the clinician’s personal, tradition specific, and professional values? How can a clinician avoid exerting undue influence? Deal with differences between the patient’s and the clinician’s values?
Recognizing distressing moral problems as legitimate subjects of clinical attention offers the opportunity to help patients recover belief in goodness, and the possibility of hope.
References
Barr N, Atuel H, Saba S, Castro CA. Toward a dual process model of moral injury and traumatic illness. Frontiers in psychiatry. 2022 Aug 24;13:883338.
Herman JL. Trauma and Recovery: The Aftermath of Violence – From Domestic Abuse to Political Terror, New York, Basic Books, 1992.
Herman JL. Truth and Repair: How Trauma Survivors Envision Justice. New York: Basic Books, 2023.
Koenig HG, Al Zaben F. Moral Injury: An Increasingly Recognized and Widespread Syndrome. J Relig Health. 2021 Oct;60(5):2989-3011. doi: 10.1007/s10943-021-01328-0. Epub 2021 Jul 10. PMID: 34245433; PMCID: PMC8270769.
Litz BL. The future of moral injury and its treatment. Journal of Military, Veteran and Family Health Volume 9 Issue 2, April 2023, pp. 1-5.
Pearce M, Haynes K, Rivera NR, Koenig HG. Spiritually Integrated Cognitive Processing Therapy: A New Treatment for Post-traumatic Stress Disorder That Targets Moral Injury. Glob Adv Health Med. 2018 Feb 20;7:2164956118759939.
Peteet JR. Doing the Right Thing: An Approach to Moral Issues in Mental Health Treatment. Washington, DC: American Psychiatric Publishing, 2004.
Peteet JR. What is the place of clinicians' religious or spiritual commitments in psychotherapy? A virtues-based perspective. J Relig Health. 2014 Aug;53(4):1190-8.
Clinicians who work with survivors of trauma have been the primary contributors to the literature on approaching moral problems in treatment. In her classic book Trauma and Recovery (1992), Judith Herman points out that a therapist may need to provide “a context that is at once cognitive, emotional, and moral” in order to help the survivor reconstruct a coherent system of meaning and belief that encompasses the story of the trauma. Barr et al. (2022) advocate a “dual track” approach to the treatment of traumatic illness - addressing in addition to dysregulation of fear and memory systems, disturbances in value and character domains, e.g. “through reflection, self-forgiveness, repentance and restoration”. Similarly, Litz (2023) has argued for a “Yes, …and” rather than a “Yes,… but” approach, going beyond traditional behavioral approaches such as CBT that assume a normally operating conscience and address distorted beliefs associated with guilt and shame through contextualization, to suggest that therapists may also need to deal directly with issues of guilt, forgiveness, and making amends. Spiritually Integrated Cognitive Processing Therapy, developed by Pearce et al. (2018) has emerged as a one method of doing so, and Judith Herman in her recent book Truth and Repair (2023) points out the importance to survivors of abuse of pursuing justice.
However, clinicians have lacked consensus on how to approach the many other instances in which distressed patients question the goodness of the self, of others and of the world. Here we consider clinical examples of four contexts in which moral problems may present: complex PTSD, demoralization, depression, and adjustment with moral dilemmas. We then discuss a therapeutic framework for approaching them: validating the patient’s moral concerns; engaging in a “dual process” of addressing their psychological and moral dimensions; and identifying challenges the patient is encountering in accomplishing the basic tasks of developing moral commitments, implementing these commitments, making moral decisions, assessing one’s behavior, dealing with moral failure, and acquiring virtues (Peteet, 2004). These highlight the role of a transcendent ground of ideals, the virtues preferred by different traditions (Peteet, 2014), and the role of faith communities in supporting them.
Finally, we consider clinical and ethical challenges involved in addressing moral problems directly: For example: How can a clinician best weigh the patient’s, and the clinician’s personal, tradition specific, and professional values? How can a clinician avoid exerting undue influence? Deal with differences between the patient’s and the clinician’s values?
Recognizing distressing moral problems as legitimate subjects of clinical attention offers the opportunity to help patients recover belief in goodness, and the possibility of hope.
References
Barr N, Atuel H, Saba S, Castro CA. Toward a dual process model of moral injury and traumatic illness. Frontiers in psychiatry. 2022 Aug 24;13:883338.
Herman JL. Trauma and Recovery: The Aftermath of Violence – From Domestic Abuse to Political Terror, New York, Basic Books, 1992.
Herman JL. Truth and Repair: How Trauma Survivors Envision Justice. New York: Basic Books, 2023.
Koenig HG, Al Zaben F. Moral Injury: An Increasingly Recognized and Widespread Syndrome. J Relig Health. 2021 Oct;60(5):2989-3011. doi: 10.1007/s10943-021-01328-0. Epub 2021 Jul 10. PMID: 34245433; PMCID: PMC8270769.
Litz BL. The future of moral injury and its treatment. Journal of Military, Veteran and Family Health Volume 9 Issue 2, April 2023, pp. 1-5.
Pearce M, Haynes K, Rivera NR, Koenig HG. Spiritually Integrated Cognitive Processing Therapy: A New Treatment for Post-traumatic Stress Disorder That Targets Moral Injury. Glob Adv Health Med. 2018 Feb 20;7:2164956118759939.
Peteet JR. Doing the Right Thing: An Approach to Moral Issues in Mental Health Treatment. Washington, DC: American Psychiatric Publishing, 2004.
Peteet JR. What is the place of clinicians' religious or spiritual commitments in psychotherapy? A virtues-based perspective. J Relig Health. 2014 Aug;53(4):1190-8.