Treatments for Moral Injury in Veterans with PTSDS
Moderator -
Harold Koenig, M.D., Professor, Duke University Medical Center
Panelists -
John R. Peteet, M.D., Associate Professor of Psychiatry, Harvard Medical School
Warren Kinghorn, M.D., ThD., Associate Research Professor of Psychiatry and Pastoral and Moral Theology, Duke University Medical Center and Duke Divinity School
Kerry Haynes, MDiv, BCC, Mental Health Chaplain, San Antonio VAMC
PTSD is the most common mental disorder among Iraq and Afghanistan Veterans and is a major risk factor for suicide. Inner conflict (also called “moral injury”) is common in PTSD, and if not addressed, may help to explain why only 20-30% of persons with PTSD achieve anything close to remission with existing treatments. Psychological therapies, such as Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), are evidence-based treatments widely used in PTSD. These therapies, however, do not typically focus on inner conflict related to moral injury, spiritual struggles, or attempt to utilize spiritual resources as part of the treatment. A spiritually-oriented therapy is needed for inner conflict/moral injury (ICMI) in Veterans with PTSD and subthreshold PTSD. We believe that ICMI lies directly on the etiologic pathway from distressing combat-related events to PTSD symptoms and co-morbid psychological and social disorders.
Since the 1980’s, war-time experiences such as violence, direct or indirect killing of enemy combatants and non-combatants (innocents), observing the death of fellow service members, and surviving when others have died, have been known to cause internal ethical conflict, guilt, self-condemnation, feelings of betrayal, difficulty forgiving, loss of trust, meaning and purpose, and spiritual struggles. Only within the past 5-10 years, however, has the concept of moral injury received serious attention or been connected with PTSD. Those with moral injury view themselves as immoral, irredeemable, and un-repairable, or struggle with their faith and believe they live in an immoral world, which may interfere with PTSD treatment unless addressed. Veterans who have been raised in a religious environment may be particularly vulnerable to moral conflicts from participating in the horrors of war and combat. The term “moral injury,” however, is not always appreciated by Veterans, since it suggests that their actions in combat were somehow immoral. The term “inner conflict” has been proposed as more neutral term.
CPT and prolonged exposure therapy (PE) are the primary evidence-based treatments for PTSD. More than 2,300 VA clinicians have been trained in CPT and 1500 in PE. In fact, the VA has mandated that Veterans with PTSD receive either CPT or PE. Unfortunately, these treatments seldom address the issues of moral injury and loss of faith, and despite the VA mandate, less than 10% of Veterans with PTSD have completed a course in either CPT or PE.
While there are many reasons why Veterans with PTSD are failing to complete CPT, one reason may be that those who are spiritual or from strong cultural/religious backgrounds perceive these therapies as conflicting with their beliefs. Religious professionals are often reluctant to refer members of their congregation to mental health professionals, especially for psychotherapy that seeks to alter beliefs and attitudes. Since clergy represent a major first line treatment for mental health problems in the community, the failure of clergy to refer may prevent many Veterans from receiving treatment. If military personnel or their family are members of a faith community, and that community does not support (or counteracts) the gains made in therapy, those gains may not last or treatment may be discontinued prematurely. Therefore, an evidence-based psychotherapy for PTSD that utilizes Veterans’ spiritual and cultural beliefs as part of the therapy may open the door to treatment for many Veterans with PTSD, especially if delivered by chaplains or trained clergy.
Spiritual factors have been shown to impact depressive symptoms over time in those with physical health problems, including Veterans (increasing speed of remission by 50-70%). Spiritual involvement has been shown to distinguish resilient from non-resilient Veterans by increasing emotional stability, serving as a protective psychosocial factor, and increasing social connectedness. Nevertheless, spiritual struggles are common in Veterans with PTSD, and PTSD symptoms have been significantly and positively associated with alienation from God, religious rifts, religious fear, and religious guilt. In contrast, post-traumatic growth (PTG) in Veterans is significantly and positively associated with spiritual practices. Studies reported this year (2015) reinforce these earlier findings. One survey of 3,157 Veterans found that S/R was the second strongest predictor of overall PTG, stronger than any other psychological or social measure. A second prospective study of 532 Veterans with severe PTSD found that those with spiritual resources had better outcomes during an inpatient treatment program. In contrast, spiritual struggles in that study were associated with worse PTSD outcomes, as others have likewise reported.
Treatments now in development for moral injury include (1) Adaptive Disclosure Therapy, (2) Impact of Killing in War, (3) Prolonged Exposure for Moral Injury, and (4) standard Prolonged Exposure or Cognitive Processing Therapy. Adaptive Disclosure Therapy (ADT) is a 6-session manualized treatment designed for active duty military (“combat-specific treatment”). The focus is on very brief therapy to minimize stigma, reduce shame, increase disclosure, and increase use of natural supports on reintegration in civilian roles. Impact of Killing in War is a 6-session treatment that focuses on education about the complex interplay of bio-psychosocial aspects of killing in war that may cause inner conflict and moral injury. Other treatment methods include Prolonged Exposure (PE) for Moral Injury and standard PE for the treatment of guilt and shame. The latest version of standard CPT also addresses shame and guilt. The only treatment today that specifically addresses spiritual issues involved in PTSD or takes a spiritual approach to treatment is the Building Spiritual Strength (BSS) intervention. This is an 8-session manualized group intervention designed to address spiritual distress associated with trauma exposure. The objective is to minimize stigma by using faith communities as possible treatment settings. Each session is 2 hours long, designed to create a community support group environment.
Finally, a spiritually oriented form of cognitive processing therapy (SOCPT) has been developed to address moral injury in the context of PTSD. Nevertheless, this treatment needs further development and refinement before going into the field, and funding sources need to be identified to support a preliminary randomized clinical trial comparing SOCPT with standard CPT to identify a “signal of effect.”
During the proposed panel, expert clinicians in psychiatry, medicine, and pastoral care will discuss the topic of moral injury in the setting of PTSD and will speculate about the best treatments that might be designed to address this problem. Also discussed will be the clinicians most qualified to address inner conflict and moral injury in Veterans. We expect that there will be Veterans in the audience who will be able to contribute their personal experiences with inner conflict resulting from combat experiences during war, which will enrich the discussion and provide direction for researchers as they develop spiritually-based treatments.
Harold Koenig, M.D., Professor, Duke University Medical Center
Panelists -
John R. Peteet, M.D., Associate Professor of Psychiatry, Harvard Medical School
Warren Kinghorn, M.D., ThD., Associate Research Professor of Psychiatry and Pastoral and Moral Theology, Duke University Medical Center and Duke Divinity School
Kerry Haynes, MDiv, BCC, Mental Health Chaplain, San Antonio VAMC
PTSD is the most common mental disorder among Iraq and Afghanistan Veterans and is a major risk factor for suicide. Inner conflict (also called “moral injury”) is common in PTSD, and if not addressed, may help to explain why only 20-30% of persons with PTSD achieve anything close to remission with existing treatments. Psychological therapies, such as Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), are evidence-based treatments widely used in PTSD. These therapies, however, do not typically focus on inner conflict related to moral injury, spiritual struggles, or attempt to utilize spiritual resources as part of the treatment. A spiritually-oriented therapy is needed for inner conflict/moral injury (ICMI) in Veterans with PTSD and subthreshold PTSD. We believe that ICMI lies directly on the etiologic pathway from distressing combat-related events to PTSD symptoms and co-morbid psychological and social disorders.
Since the 1980’s, war-time experiences such as violence, direct or indirect killing of enemy combatants and non-combatants (innocents), observing the death of fellow service members, and surviving when others have died, have been known to cause internal ethical conflict, guilt, self-condemnation, feelings of betrayal, difficulty forgiving, loss of trust, meaning and purpose, and spiritual struggles. Only within the past 5-10 years, however, has the concept of moral injury received serious attention or been connected with PTSD. Those with moral injury view themselves as immoral, irredeemable, and un-repairable, or struggle with their faith and believe they live in an immoral world, which may interfere with PTSD treatment unless addressed. Veterans who have been raised in a religious environment may be particularly vulnerable to moral conflicts from participating in the horrors of war and combat. The term “moral injury,” however, is not always appreciated by Veterans, since it suggests that their actions in combat were somehow immoral. The term “inner conflict” has been proposed as more neutral term.
CPT and prolonged exposure therapy (PE) are the primary evidence-based treatments for PTSD. More than 2,300 VA clinicians have been trained in CPT and 1500 in PE. In fact, the VA has mandated that Veterans with PTSD receive either CPT or PE. Unfortunately, these treatments seldom address the issues of moral injury and loss of faith, and despite the VA mandate, less than 10% of Veterans with PTSD have completed a course in either CPT or PE.
While there are many reasons why Veterans with PTSD are failing to complete CPT, one reason may be that those who are spiritual or from strong cultural/religious backgrounds perceive these therapies as conflicting with their beliefs. Religious professionals are often reluctant to refer members of their congregation to mental health professionals, especially for psychotherapy that seeks to alter beliefs and attitudes. Since clergy represent a major first line treatment for mental health problems in the community, the failure of clergy to refer may prevent many Veterans from receiving treatment. If military personnel or their family are members of a faith community, and that community does not support (or counteracts) the gains made in therapy, those gains may not last or treatment may be discontinued prematurely. Therefore, an evidence-based psychotherapy for PTSD that utilizes Veterans’ spiritual and cultural beliefs as part of the therapy may open the door to treatment for many Veterans with PTSD, especially if delivered by chaplains or trained clergy.
Spiritual factors have been shown to impact depressive symptoms over time in those with physical health problems, including Veterans (increasing speed of remission by 50-70%). Spiritual involvement has been shown to distinguish resilient from non-resilient Veterans by increasing emotional stability, serving as a protective psychosocial factor, and increasing social connectedness. Nevertheless, spiritual struggles are common in Veterans with PTSD, and PTSD symptoms have been significantly and positively associated with alienation from God, religious rifts, religious fear, and religious guilt. In contrast, post-traumatic growth (PTG) in Veterans is significantly and positively associated with spiritual practices. Studies reported this year (2015) reinforce these earlier findings. One survey of 3,157 Veterans found that S/R was the second strongest predictor of overall PTG, stronger than any other psychological or social measure. A second prospective study of 532 Veterans with severe PTSD found that those with spiritual resources had better outcomes during an inpatient treatment program. In contrast, spiritual struggles in that study were associated with worse PTSD outcomes, as others have likewise reported.
Treatments now in development for moral injury include (1) Adaptive Disclosure Therapy, (2) Impact of Killing in War, (3) Prolonged Exposure for Moral Injury, and (4) standard Prolonged Exposure or Cognitive Processing Therapy. Adaptive Disclosure Therapy (ADT) is a 6-session manualized treatment designed for active duty military (“combat-specific treatment”). The focus is on very brief therapy to minimize stigma, reduce shame, increase disclosure, and increase use of natural supports on reintegration in civilian roles. Impact of Killing in War is a 6-session treatment that focuses on education about the complex interplay of bio-psychosocial aspects of killing in war that may cause inner conflict and moral injury. Other treatment methods include Prolonged Exposure (PE) for Moral Injury and standard PE for the treatment of guilt and shame. The latest version of standard CPT also addresses shame and guilt. The only treatment today that specifically addresses spiritual issues involved in PTSD or takes a spiritual approach to treatment is the Building Spiritual Strength (BSS) intervention. This is an 8-session manualized group intervention designed to address spiritual distress associated with trauma exposure. The objective is to minimize stigma by using faith communities as possible treatment settings. Each session is 2 hours long, designed to create a community support group environment.
Finally, a spiritually oriented form of cognitive processing therapy (SOCPT) has been developed to address moral injury in the context of PTSD. Nevertheless, this treatment needs further development and refinement before going into the field, and funding sources need to be identified to support a preliminary randomized clinical trial comparing SOCPT with standard CPT to identify a “signal of effect.”
During the proposed panel, expert clinicians in psychiatry, medicine, and pastoral care will discuss the topic of moral injury in the setting of PTSD and will speculate about the best treatments that might be designed to address this problem. Also discussed will be the clinicians most qualified to address inner conflict and moral injury in Veterans. We expect that there will be Veterans in the audience who will be able to contribute their personal experiences with inner conflict resulting from combat experiences during war, which will enrich the discussion and provide direction for researchers as they develop spiritually-based treatments.