If there is a current gold standard book that summarizes the best of research and practice dealing with military trauma, loss and moral injury it is this: Adaptive Disclosure by Litz, Lebowitz, Gray and Nash (Guilford, 2016). The most stunning revelation is its simplicity; the authors name the obvious, namely, that there are different aspects and dimensions of trauma. The implication is equally simple – these different aspects and dimensions require different approaches. One size does not fit all.
The three large domains of trauma are terror (from immanent death and destruction, that which directly affects our neurology and biology), loss (of those close to us and comrades in arms), and moral injury (resulting from the violation of personal or collective ethics, either as perpetrator, witness or victim).
As the authors examined the present approach of VA-validated treatment modalities, they observed that the models are expected to be used for each of these three aspects (or their variants). The truth is that cognitive therapies or prolonged exposure therapies have a very spotty success rate, depending on the condition and experience of the service person.
“Although there is ample evidence that CBT strategies such as PE and CPT are effective PTSD treatments among civilian motor vehicle accident and sexual assault survivors, these approaches have been shown to be substantially less efficacious with complex military trauma.”(6-7)
As other researchers have discovered, prolonged exposure methods alone often re-traumatize when they are not joined to other somatic or cognitive reframing approaches. That is one of the reasons that a huge percentage of combat vets who begin this treatment model do not complete it.
Probably the most hard-hitting observation of the book is about moral injury. This dimension of emotional/spiritual wounding does not respond to conventional therapeutic approaches. In fact, such methods often exacerbate the state of heart and mind. Anything that resembles rationalization of the behavior that caused the guilt or shame only makes it worse. They recommend, instead, a way to have “conversations” in imaginary space with those wronged or those who have wronged in the imaginary presence of a recognized moral authority – like a saint, angel, parent, religious leader. The moral response to moral injury is seeking pardon, forgiveness and when possible making reparations. When that is not physically possible those actions may take place with a surrogate of some kind.
“It is unclear how CPT and PE address what we consider to be the crux of moral injury among service members, namely, guilt and shame from acts of commission or omission that entail culpability from the service member’s point of view.”(17)
Speaking of the obvious … my immediate response to these observations about moral injury and redressing it is this: We used to call this confession, forgiveness and penance. You share with a religious representative the nature of your violation, forgiveness is pronounced and then something concrete is assigned to do as a response, including reparations. We may not need the priest and confessional booth now (but we may), but we need something parallel to it. That’s the model that is most direct and probably in the last analysis the most healing.