Case Conceptualizing in Acceptance and Commitment Therapy for Moral Injury: An Active and Ongoing Approach to Understanding and Intervening on Moral Injury

Abstract

Acceptance and Commitment Therapy for Moral Injury (ACT-MI; 10–11), is an application of Acceptance and Commitment Therapy principles designed to help individuals live their values, even in the presence of moral pain. ACT-MI differs from other emerging treatments for moral injury in that ACT-MI is not based on a traditional syndromal approach to conceptualizing moral injury, which treats moral injury as a collection of signs and symptoms to be reduced. Rather than assuming moral injury causes suffering through a constellation of symptoms that a person has, in ACT-MI, moral injury is defined by what a person does in response to moral pain. Consistent with this framework, we present a unique approach to moral injury case conceptualization that emphasizes function over form, providing clients the opportunity to break free from the patterns of behavior that cause moral injury-related suffering to persist. Rooted in approaches to conceptualizing that have demonstrated utility in extant interventions (e.g., ACT), ACT-MI clinicians conduct ongoing functional analyses to inform case conceptualization and intervention. Functional analysis is used to disrupt the processes maintaining moral injury, as the client and therapist work to identify and intervene on the behaviors reinforcing avoidance and control of painful internal experiences causing moral injury. In the current article, we guide the reader through a framework for applying functional analysis to the conceptualization of moral injury where the reinforcers driving moral injury are explored. We also provide examples of questions that can be used to help uncover the functions of moral injury consistent behavior. Case examples based on our experiences treating moral injury are presented to demonstrate how various types of morally injurious events can evoke different features of moral pain which in turn motivate different repertoires of avoidance and control. These inflexible patterns of avoidance and control create suffering by engaging in behavior designed to escape moral pain, such as social isolation, spiritual disconnection, reduced self-care, suicidal ideation, and substance use. We discuss how to target this suffering using functional analysis to guide treatment decisions, matching interventional processes within ACT-MI to the specific functions that moral injury-related behavior is serving for an individual. We suggest that the use of functional analytic case formulation procedures described herein can assist clients in disrupting behavioral patterns maintaining moral injury and thereby free them to pursue lives of greater meaning and purpose.

Perceptions of Military Experience Among Veterans Reporting Lifetime Warzone Moral Injury

“…These themes and subthemes provide important information in conceptualizing moral injury and also point to potential treatment implications. To begin to explore these treatment implications across different theoretical models explaining the development and maintenance of moral injury (e.g., Borges et al, 2022a;Litz et al, 2022), we have situated our discussion in a process-based psychotherapy framework that cuts across treatment paradigms (Hayes and Hofmann, 2018).…”

“…Learning to identify that MIEs are a part of an individual's experience that occurred in a particular context (e.g., the warzone) rather than all of their identity can be an important element in developing freedom from stories about moral injury and the opportunity to live meaningfully in the present. Moral injury interventions work with identity in different ways, such as stepping back from self-stories and experiencing a conscious self that is bigger than any one experience via self-as-context work in Acceptance and Commitment Therapy for Moral Injury (ACT-MI), through challenging beliefs about one's identity within adaptive disclosure (AD), or through writing a letter to a prewar version of oneself asking for forgiveness in impact of killing (IOK) (Borges et al, 2022a;Burkman et al, 2022;Litz et al, 2016).…”

Policy Changes as a Context for Moral Injury Development in the Wake of Dobbs v Jackson Women's Health Organization

“…Living consistently with one's values while learning skills to cultivate an acceptance of self-and other-directed moral pain (guilt, shame, contempt, anger, and disgust) is at the core of treatment. Conceptual frameworks applying components of ACT-MI to health care workers have been published, 5,6 an intervention targeting features of moral injury has been piloted among health care workers, 29 and an online, self-guided application of ACT targeting moral injury is currently being developed for health care workers in the U.S. Department of Veterans Affairs. AD (Adaptive Disclosure)…”

“…Moral injury results when efforts to manage moral distress cause an individual's life to narrow and lead to social, psychological, and spiritual suffering. 5–8 This suffering can manifest through a number of psychological symptoms (eg, suicidal ideation and behavior, symptoms of posttraumatic stress disorder and depression, substance use) and psychosocial functional impairment (eg, difficulties engaging in relationships, work, spirituality, self-care). 9–12…”

“…Moral injury results when efforts to manage moral distress cause an individual's life to narrow and lead to social, psychological, and spiritual suffering. [5][6][7][8] This suffering can manifest through a number of psychological symptoms (eg, suicidal ideation and behavior, symptoms of posttraumatic stress disorder and depression, substance use) and psychosocial functional impairment (eg, difficulties engaging in relationships, work, spirituality, self-care). [9][10][11][12] Exposure to potentially morally injurious events and negative psychosocial outcomes associated with moral injury have been demonstrated in health care professionals across contexts, including the COVID-19 pandemic, deployments to combat zones, and cases involving child protective services.…”