Our issue of articles about moral injury concludes today with an interview with Marek Kopacz, a senior researcher at Fors Marsh Group in Arlingon, VA, and Irene Harris, a research clinical psychologist at the Veterans Administration outpatient center in Lewiston, Maine.
Q. Can you tell me a little about your recent moral injury work?
Harris: We have five evidence-based treatments in use. Building spiritual strength is the most widely used, in 64 VA centers, and it’s the only one administered by chaplains. The self-forgiveness workbook could also be used in chaplain practice. (Note: see the table at the bottom of this article.)
Kopacz: Not long before the pandemic hit, I got a letter to the editor published in The Lancet touching on differences between burnout, which is a diagnosable condition, and moral injury, which isn’t yet. Then COVID hit, and, people started referencing this letter to the editor in journal articles being published about moral injury in healthcare providers. These articles described a sense of helplessness in some healthcare workers. Despite their best efforts, they sometimes hit a wall, and many different types of walls – running out of hospital rooms, or misinformation on the evening news. They were supposed to save lives, but they couldn’t, or they were impeded from doing so.
Q. So moral injury isn’t a formal diagnosis?
Harris: Moral injury is not a diagnosable condition in any manual. Insurance companies do not cover it as a diagnosis. I use a V code of spiritual or social or functional issues. It’s typically a comorbidity with PTSD or depression. A V code is provision in the diagnostic manual for another condition that may warrant attention, such as homelessness.
Kopacz: A few years ago, I conducted a study examining supportive services for “other psychological or physical stress, not elsewhere classified” to veterans who survived a suicide attempt and were seeking healthcare at VA centers. This was a catchall diagnosis that can cover, among others, religious or spiritual problems. Chaplains were the predominant provider for services connected with this diagnosis,
Q. Can you briefly describe the intervention technique that chaplains would use?
Harris: When I first talk to veterans about moral injury, and I hate that term, they feel like they have done something wrong, or been helpless to prevent other people from doing wrong, or betrayed, put in harm’s way on purpose. I’ve provided services to more than 300 veterans, and the common factor is a moral dilemma. And almost always, the veteran is not prepared for it. In our early moral development, everyone is taught that things are good or bad, right or wrong, with very clear boundaries. My focus is to help them to realize that a decision is not good-bad, it’s better-worse, on a continuum. Usually if they can do that, the distress disappears.
I also help veterans understand in which ways guilt is useful. Maybe the man next to a veteran was killed and he wasn’t, and they feel guilty because they believe they didn’t use their combat skills well enough. Before the guilt kicks in, they are terrified and can’t function. After the guilt begins, they can cope, because they’ve deluded themselves into believing they could control the situation. But when they leave combat, it begins to kill them. The risk of suicide is up to twice as high among veterans with moral injury.
Q. So how do you address that?
Harris: First, we identify that guilt is a coping strategy. Second, we develop substitute coping strategies. It might be a relationship with a higher power that provides ongoing support, or being able to reach out and support other people, or living their faith in the world in a way that helps other people.
Q. What about chaplains who are suffering from moral injury themselves?
Harris: Chaplains can understand the ambiguity, but they’re so worn out from crisis, their brain doesn’t go there right now. I would say: How much sleep have you had? When was the last time you had a shower? How much did you eat today? Have you had enough water to drink? Until those things are taken care of, you don’t have enough neurotransmitters in brain to deal with it.
Kopacz That ambiguity Irene is alluding to is spot on. Chaplains are used to operating in that ambiguous environment more than some clinically trained professionals, but that doesn’t mean you’re immune to the effects. If a chaplain experiences moral injury or burnout, which are two different conditions, first I encourage that person to acknowledge their own humanity, to seek help. No one expects them to be indestructible and immune. Providing help is one thing, seeking it out is another.
Q. You said earlier that you don’t like the term “moral injury.” Why?
Harris: A moral dilemma is not the same as actually doing something wrong. Usually, people haven’t actually violated the rules of engagement. But the term “moral injury” creates the idea that you have done something bad. Veterans tell me that they find the term stigmatizing and judgmental. So first of all, I always ask a veteran what language they would like to use. If they don’t have an idea themselves, I use “spiritual distress” if they identify as spiritual, or if not, “values-related distress.” In my practice that has been much more successful. I know some say it’s helpful to put label on something, but I’m hearing more and more from others that the term is stigmatized.
| Table 1: Existing Evidence-Based Treatments of for Moral Injury Syndrome | |||||
| Adaptive Disclosure | Impact of Killing in War | Self-Forgiveness Workbook | Building Spiritual Strength | Trauma- Informed Guilt Reduction | |
| Populations Researched | Those who served since 2001 | Veterans who feel responsible for deaths | Civilians | All military cohorts | OEF/OIF Combat Veterans |
| Modality | Individual | Individual | Self-administered | Group | Individual |
| Provider | Mental Health | Mental Health | Mental health providers may provide coaching | Chaplains or Mental Health | Mental Health |
| Level of Evidence | 1 published RCT, (N=122) a second trial almost finished | 1 published RCT,(N=33) one trial underway | 1 RCT (N=204) | 2 published RCTs, (N=56 and N=138), a third trial underway | 1 pilot trial (N=10) and 1 RCT, (N=145) |
| Number of Known VA Sites | 2 | 3 | 5 | 64 | 1 |
| Outcomes Studied | *PTSD
*Depression *Functioning |
*PTSD
*General mental health *Quality of Life |
*Self-forgiveness
*Self-condemnation |
*PTSD
*Spiritual Distress |
*PTSD
*Depression *Guilt |
