In talking with colleagues working within the Veterans Administration in the US, I’ve noticed that the topic of moral injury is receiving a lot of attention as of late. For those of us interested in helping people with deep-seated shame, the literature around moral injury is important because it deals with a context in which chronic and extreme shame often arise. A moral injury happens when a person perceives themselves as having violated closely held beliefs or moral codes. Shame, humiliation, and other social emotions are central to this experience of moral injury and need to be targeted in any intervention. One of the best researched treatments for moral injury is something called Adaptive Disclosure, and a new book by Litz and colleagues called “Adaptive Disclosure: A New Treatment for Military Trauma, Loss, and Moral Injury” provides an excellent overview on the treatment.
For those who are already familiar with exposure-based treatments for trauma, this book will give you some ideas for how to expand your use of exposure-based approaches to address types of trauma beyond the more typical “threat to life” that is typically the focus of prolonged exposure for PTSD. The treatment outlines several variations for how exposure-based methods can be modified to target three types of traumatic war-zone related experiences: life threat, traumatic loss, and moral injury.
In Adaptive Disclosure, the treatment of life threat related trauma essentially follows a typical prolonged exposure approach with little added. What’s unique is how the treatment addresses the two other types of traumatic experiences: traumatic loss and moral injury.
How adaptive disclosure works with moral injury
When working with trauma emerging from moral injury, prolonged exposure is supplemented with various perspective taking interventions involving imaginal dialogues with a “moral authority” who judges, but also has the authority to forgive the person for their breach of morality or ethics. Perspective taking strategies are key in our work targeting shame, guilt, and other social emotions that arise from experiences of having violated one’s own moral code (for example, someone who feels shame about being a perpetrator of abuse). This book provides great practical guidelines, examples, and questions to ask to guide the dialogue in those perspective taking interventions.
The treatment of traumatic losses also involves traditional prolonged exposure, but adds a unique component involving imagined dialogues with the friend who was lost. The addition of this form of perspective taking intervention is to assist the person in reestablishing healthy attachments to others, finding ways to honor the lost person, and facilitating self-forgiveness. Often guilt, self-blame, and shame are an important part of what keeps the person stuck in rumination around the loss and unable to move on with their lives.
In addition to teaching how to do the intervention, the book also outlines the basics of military culture so that these factors can be taken into account during treatment. While this book is written specifically to help service members and veterans, these interventions also could be applied to people who have experienced traumatic loss or moral injuries outside of a military context. I highly recommend the book for those who are interested in how trauma relates to moral emotions such as shame and guilt and how perspective taking interventions can help clients develop a more forgiving and healthy way of relating to oneself and others.
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