Healing Moral Injury

I read the story about moral injury, otherwise known as guilt and shame, as a condition distinct from Posttraumatic Stress Disorder (PTSD) comparing it with Dr. George Dawson’s blog post about regret.

(the AP version )

(the ABC news version)

(Dr. Dawson’s post on regret)

I agree with George’s opinion; “… regret is part of life and not an error in thought or emotion.” There is nothing right or wrong about feelings. As George points out, there is some evidence for the effectiveness of psychiatric treatment, including mindfulness, which may work, in part, by helping veterans tolerate the memories of their moment to moment horror [1,2]. And I tend to agree with one veteran’s opinion about psychiatry’s role in diagnosing and treating what might be called one of life’s sorrows.

“A psychiatrist may say they understand, but they don’t really..” He goes on to say that the mutual suffering among veterans who cope with moral injury creates an impenetrable bond between soldiers who have physically survived the horror of war but who may suffer moment to moment from their own personal horror at what they were compelled to do in that context.

The personal suffering itself may be impenetrable and can lead to depression, addiction, and suicide. Although some may object to giving this suffering a psychiatric label, thereby pathologizing and possibly stigmatizing a sorrow unimaginable by psychiatrists, families, friends, employers, and more–it undeniably calls attention to the torment, to which we then may bear witness and foster healing.

References:

  1. Polusny, M. A., et al. (2015). “Mindfulness-based stress reduction for posttraumatic stress disorder among veterans: A randomized clinical trial.” JAMA 314(5): 456-465.

Importance  Mindfulness-based interventions may be acceptable to veterans who have poor adherence to existing evidence-based treatments for posttraumatic stress disorder (PTSD).Objective  To compare mindfulness-based stress reduction with present-centered group therapy for treatment of PTSD.Design, Setting, and Participants  Randomized clinical trial of 116 veterans with PTSD recruited at the Minneapolis Veterans Affairs Medical Center from March 2012 to December 2013. Outcomes were assessed before, during, and after treatment and at 2-month follow-up. Data collection was completed on April 22, 2014.Interventions  Participants were randomly assigned to receive mindfulness-based stress reduction therapy (n = 58), consisting of 9 sessions (8 weekly 2.5-hour group sessions and a daylong retreat) focused on teaching patients to attend to the present moment in a nonjudgmental, accepting manner; or present-centered group therapy (n = 58), an active-control condition consisting of 9 weekly 1.5-hour group sessions focused on current life problems.Main Outcomes and Measures  The primary outcome, change in PTSD symptom severity over time, was assessed using the PTSD Checklist (range, 17-85; higher scores indicate greater severity; reduction of 10 or more considered a minimal clinically important difference) at baseline and weeks 3, 6, 9, and 17. Secondary outcomes included PTSD diagnosis and symptom severity assessed by independent evaluators using the Clinician-Administered PTSD Scale along with improvements in depressive symptoms, quality of life, and mindfulness.Results  Participants in the mindfulness-based stress reduction group demonstrated greater improvement in self-reported PTSD symptom severity during treatment (change in mean PTSD Checklist scores from 63.6 to 55.7 vs 58.8 to 55.8 with present-centered group therapy; between-group difference, 4.95; 95% CI, 1.92-7.99; P=.002) and at 2-month follow-up (change in mean scores from 63.6 to 54.4 vs 58.8 to 56.0, respectively; difference, 6.44; 95% CI, 3.34-9.53, P < .001). Although participants in the mindfulness-based stress reduction group were more likely to show clinically significant improvement in self-reported PTSD symptom severity (48.9% vs 28.1% with present-centered group therapy; difference, 20.9%; 95% CI, 2.2%-39.5%; P = .03) at 2-month follow-up, they were no more likely to have loss of PTSD diagnosis (53.3% vs 47.3%, respectively; difference, 6.0%; 95% CI, −14.1% to 26.2%; P = .55).Conclusions and Relevance  Among veterans with PTSD, mindfulness-based stress reduction therapy, compared with present-centered group therapy, resulted in a greater decrease in PTSD symptom severity. However, the magnitude of the average improvement suggests a modest effect.Trial Registration  clinicaltrials.gov Identifier: NCT01548742

2. Tang, Y.-Y., et al. (2015). “Circuitry of self-control and its role in reducing addiction.” Trends in Cognitive Sciences 19(8): 439-444.

We discuss the idea that addictions can be treated by changing the mechanisms involved in self-control with or without regard to intention. The core clinical symptoms of addiction include an enhanced incentive for drug taking (craving), impaired self-control (impulsivity and compulsivity), negative mood, and increased stress reactivity. Symptoms related to impaired self-control involve reduced activity in control networks including anterior cingulate (ACC), adjacent prefrontal cortex (mPFC), and striatum. Behavioral training such as mindfulness meditation can increase the function of control networks and may be a promising approach for the treatment of addiction, even among those without intention to quit.

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Comments

  1. The ability to self-soothe is paramount or so I found when dealing with trauma while directing a mental health crisis unit before, during, and after 9/11. The difficulty with most meditation teaching efforts is that the hyper-alertness accompanying trauma makes sitting quietly for an extended period of time difficult. Why I developed a One Minute Meditation Exercise. The most important trick is to start practicing when already somewhat relaxed or calm and to strengthen it before using it to calm when flash backs occur. Directions can be found on WikiHow. http://www.wikihow.com/Meditate-in-One-Minute. Hope this is helpful.

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