Using Prolonged Exposure and Cognitive Processing Therapy to Treat Veterans With Moral Injury-Based PTSD: Two Case Examples

Abstract

Moral injury refers to acts of commission or omission that violate individuals' moral or ethical standards. Morally injurious events are often synonymous with psychological trauma, especially in combat situations; thus, morally injurious events are often implicated in the development of PTSD for military service members and veterans. Although Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) have been well-established as effective treatments for veterans who are struggling with posttraumatic stress disorder (PTSD), it has been suggested that these two evidence-based therapies may not be sufficient for treating veterans whose PTSD resulted from morally injurious events. The purpose of this manuscript is to detail how the underlying theories of PE and CPT can account for moral-injury based PTSD and to describe two case examples of veterans with PTSD stemming from morally injurious events who were successfully treated with PE and CPT. The manuscript concludes with a summary of challenges that clinicians may face when treating veterans with PTSD resulting from moral injury using either PE or CPT.

Negative Posttrauma Cognitions Mediate the Association Between Morally Injurious Events and Trauma‐Related Psychopathology in Treatment‐Seeking Veterans

“…These findings align with existing cognitive models of trauma, which attribute the genesis and maintenance of PTSD and depression symptoms, at least in part, to the development of negative posttrauma cognitions following traumatic experiences (Ehlers & Clark, ). In line with a recent case report (Held, Klassen, Brennan, & Zalta, ), the present findings suggest that individuals who perceive themselves to have engaged in moral transgressions are likely to blame themselves for what they have done and may view themselves more negatively. Similarly, individuals who perceive betrayal may develop more negative views of others and the world, as well as negatively evaluate themselves and their own actions.…”

“…In summary, the present study suggests that potentially morally injurious experiences and PTSD and depression severity appear to be only indirectly related through negative posttrauma cognitions in treatment-seeking veterans with PTSD. Our findings may explain why a variety of treatment approaches, such as cognitive processing therapy (Resick, Monson, & Chard, 2014), prolonged exposure (Foa, Hembree, & Rothbaum, 2007), and adaptive disclosure (Gray et al, 2012;Litz, Lebowitz, Gray, & Nash, 2016), that target posttrauma cognitions have been found to be effective at reducing PTSD and depression symptoms in veterans affected by moral injury (Gray et al, 2012;Held et al, 2017;Litz et al, 2016). Future studies with veterans who have been exposed to potentially morally injurious events should examine both a more comprehensive model and the impact of reducing negative posttrauma cognitions over the course of treatment on PTSD and depression symptoms.…”

Moral Injury

“…Introducing new information that is incompatible with service members' and veterans' erroneous cognitions about a potentially morally injurious event makes way for modifying thoughts and feelings about the moral wrongdoing. This then allows the individual to redefine their feelings, associations, and thoughts about the event (Farnsworth, 2019;Griffin et al, 2019;Held et al, 2018;Paul et al, 2014;Smith et al, 2013). Further, there is empirical evidence that PE leads to reductions in trauma-related guilt over the course of treatment (Griffin et al, 2019;Held et al, 2018;Paul et al, 2014;Smith et al, 2013).…”

“…CPT uses cognitive restructuring techniques to modify maladaptive cognitions related to a trauma (Held et al, 2018). In cases of moral injury, cognitive restructuring interrogates individuals' maladaptive and erroneous beliefs about a morally injurious event and addresses feelings of guilt, shame, or betrayal (Farnsworth, 2019;Griffin et al, 2019).…”

“…Researchers have also developed Spiritually Oriented CPT (SOCPT) to target existential and religious/spiritual problems associated with moral injury (Held et al, 2018;Koenig et al, 2017;Pearce et al, 2018;Resick et al, 2014;Resick et al, 2017;Wade, 2016). In SOCPT, the spiritual concepts of mercy, repentance, forgiveness, spiritual surrender, prayer/contemplation, divine justice, hope, and divine affirmations are discussed as means to engage with service members' and veterans' shame, guilt, anger, humiliation, spiritual struggles, and loss of faith.…”