A Critical Outlook on Combat-Related PTSD: Review and Case Reports of Guilt and Shame as Drivers for Moral Injury

ABSTRACT

The model of posttraumatic stress disorder (PTSD) that has been dominant for many years has focused on fear conditioning and anxiety-related symptoms as main drivers of the pathology. Yet, the fear based conceptualization fails to consider the rules of modern combat, the culture of combatants, operational stressors and the moral dimension. Recently there is renewed interest in moral distress and moral injury with a focus on guilt, shame, and anger. Accumulating evidence suggests a link between transgression of moral values and symptoms of guilt and shame, anger, suicidal ideation, and PTSD in military servicemen and veterans. Although proper assessment is still in its infancy, there is a need to better understand how moral decisions can affect the mental health of military personnel at any point during their careers, including postrelease. The authors illustrate this with three clinical case reports. They conclude with a call for attention to the relation between the incurrence of moral injurious distress, and the role of guilt and shame as drivers for chronicity of PTSD. Identifying and addressing these issues can contribute to therapy adherence, facilitate successful progression, and contribute to healing and moral repair and reduce overall symptoms of PTSD.

KEYWORDS:

• Moral injury
• shame
• guilt
• PTSD
• fear
• repair
• disclosure

Introduction

Trauma-focused psychotherapies such as prolonged exposure and cognitive processing therapy (the current predominant evidence-based interventions in civilian and military posttraumatic stress disorder [PTSD]) do not always translate well to military and veteran populations. As has recently been addressed, between one third and half of veterans receiving these interventions do not demonstrate clinically meaningful symptom improvement addressed (Haagen et al., 2015; Steenkamp, Litz, Hoge, & Marmar, 2015). This could be due to a variety of factors including context specificity (e.g., rape trauma and military trauma are very different things which PTSD treatments do not consider). Moreover, even when patients do improve, symptoms often remain high: Mean PTSD scores in trials of military-related PTSD have tended to remain at or above diagnostic thresholds following evidence-based interventions and approximately two-thirds of patients retain their PTSD diagnosis. Veterans that do not respond to one or two evidence-based interventions soon receive labels such as “difficult to treat,” “treatment refractory,” “or nonresponders.” This calls for inquiry into the causes of symptom perseverance. The decisions service members were forced to make in conflict may be drivers of chronic psychopathology that needs to be understood beyond the fear and anxiety as typically expected in PTSD (Dennis et al., 2016). Moreover, it also calls for recognition of the contribution of different types of combat experiences to the pathology of PTSD (Shea, Presseau, Finley, Reddy, & Spofford, 2016).

Some authors have noted the prevailing model of PTSD limits its focus to fear conditioning and learning and has centered predominantly on anxiety-related symptoms (Gray et al., 2012; Litz et al., 2009). They suggest that elements such as guilt, shame, and anger are missing in the current care models designed to treat combat-related PTSD. They emphasize these as drivers of chronic PTSD. Guilt has been well studied and is known for years to be a common symptom amongst many Vietnam veterans with PTSD (see Kubany, 1994). It is questionable if this is adequately addressed in the current exposure based therapies, such as prolonged exposure (PE) in such way that results in healing and reduction of PTSD (Paul et al., 2014; Yehuda & Hoge, 2016).

The moral injury construct was proposed to describe the suffering some veterans experience when they engage in acts during combat that violate their beliefs about their own goodness or the goodness of the world. Moral dilemmas and decisions are underlying, as personal or societal values, and help to determine what is considered right and wrong or good and bad. They typically involve issues that are related to the interest or well-being of others. As above, moral injury is typically found in literature describing the mental health of military veterans who have witnessed or perpetrated an act in combat that transgressed their deeply held moral beliefs. They may involve acts of commission (e.g., firing at a child soldier) or acts of omission (e.g., being unable to act while a woman is being raped). There are rules of war and rules of engagement that may help guide difficult moral decisions. However, these rules are overarching in nature reflecting law and mission objectives and may not provide a clear, unambiguous moral direction for specific situations. Distress may result from the conflict between an individual's personal values and these rules and may later cause internal conflict and mental health problems. Recent work has identified symptoms of guilt and shame related to moral injury as contributing significantly to combat-related mental health issues (Henning & Frueh, 1997; Pugh, Taylor, & Berry, 2015; Shay, 2014). Even though not fully understood, there is accumulating evidence that suggests a link between the perceived transgression of moral values and moral standards (e.g., using disproportional force in combat for other reasons than just fulfilling the mission; following orders that were illegal; failing to provide medical aid; failing to report violent actions; a change in belief about the justification of war) and symptoms of guilt and shame, anger and suicidal ideation and PTSD within military samples and veterans (Bryan, Bryan, Morrow, Etienne, & Ray-Sannerud, 2014; Dennis et al., 2016; Kienzler, 2008).

Guilt is a frequently reported posttraumatic emotion that may also be critical to the development and/or maintenance of the disorder. Commission of abusive violence is one type of wartime experience that may be particularly associated with guilt. Both guilt and shame are complex cognitive and emotional experiences that arise when one's behavior is perceived to transgress an internal moral standard. Also, guilt may impede the emotional processing of fear or that it can be exacerbated by exposure to trauma-related cues that may maintain trauma-related pathology (Ehlers & Steil, 1995). Unlike fear, which is current or future orientated, guilt is considered a retrospective emotion and is considered less amenable to change through habitual exposure in therapy (Dalgleish, 2004). Moreover, guilt may also prevent successful integration of the traumatic events with prior beliefs, maintaining to the use of avoidant coping strategies that sustain PTSD symptomology (Street, Gibson, & Holohan, 2005). Guilt can be quite complex and among combat-deployed veterans it may be a mechanism through which abusive violence is related to PTSD and MDD (Marx et al., 2010). It has also been well established since the Vietnam war that guilt also emerges as a risk for suicide (Hendin & Haas, 1991). This article explores this clinical domain by describing three case reports of servicemen diagnosed with PTSD, dealing with issues related to morality and symptoms of guilt and shame after deployment.

Moral decision-making in military operations

Military operations often involve difficult decisions that can directly or indirectly impact the well-being of the decision-makers, their subordinates, peers, adversaries, and civilians. Although they have been primarily associated with war, these decisions exist throughout the full-spectrum of military operations (e.g. peacekeeping, peacemaking, humanitarian, as well as combat) (NATO report, 2016). One of the inherent difficulties stems from the fact that during operations a service member must make timely and difficult decisions often involving competing goals or values, such as choosing between mission success, civilian safety, force protection, and unit loyalty. These decisions require ongoing moral justification and can contribute to psychological and moral distress (Farnsworth, Drescher, Nieuwsma, Walser, & Currier, 2014), while often increasing the likelihood of being exposed to life threat and death (loss). First, soldiers must be aware that the consequences of a single bad decision can erode local, national, international, and host nation support thereby potentially derailing the strategic mission and putting troops at risk. Second, attention to the interplay between moral decision-making and mental health is a crucial component of leaders' responsibility for their soldiers. This demands strong leadership initiatives (e.g., education and ethics training, after action reviews, counseling, reintegration programs, and facilitating disclosure) that mitigate the threat to the mission and soldier well-being (Warner et al., 2011).

Military service members have a professional and moral responsibility to behave in accordance with laws, values, and ethics. However, these may be at times be in conflict and contribute to emotional distress (de Graaff, Schut, Verweij, Vermetten, & Giebels, 2016). Service members are increasingly more likely to confront morally injurious experiences during deployment rather than life-threatening combat (Hoge et al., 2004). As such, there is a return of interest in understanding the concept of moral distress and injury and to explore if this can contribute to an enhanced understanding of how military operations can impact the psychological health of military personnel and veterans.

Recently a NATO panel produced its Technical Report on the issue of moral dilemmas (NATO report, 2016). The panel defined moral dilemmas stipulating that these are a special class of moral decisions, in which (a) there is a conflict between at least two core values/obligations (i.e. loyalty, obedience, respect for life); (b) acting in a way that is consistent with one underlying value means failing to fulfill the other(s); (c) harm will occur regardless of the option chosen; (d) decision is inescapable and inevitable; some action must be taken (Vermetten et al., 2016). Moral dilemmas require the reconciliation of conflicting values and obligations. These decisions may create psychological distress associated with what some call moral injuries (Maguen et al., 2009) such as grief, shame, or guilt. Although some authors are not clear about this, we feel that for moral injury there needs to have been an “A” event. In some cases, moral dilemmas may contribute to mental health problems such as PTSD, depression, and anxiety. In addition, the underlying presence of psychological distress may also negatively influence soldiers' attitudes toward following the laws of armed conflict and rules of engagement. This negative impact on “battlefield ethics” can contribute to decision-making that can be resulting in misconduct or other unethical behaviors (Castro & McGurk, 2007).

Reverse engineering of moral injury?

A large body of research has demonstrated that veterans who suffer psychological pain because of their actions toward others may be at risk of PTSD, depression, aggression, substance abuse, and other forms of psychopathology (Hoge et al., 2004). It is well known that combat veterans may experience chronic guilt and shame related to various acts of omission or commission during deployment (Kubany, 1994). As recent research showed these may be important contributors to suicide risk among military personnel with combat exposure, whether or not they meet criteria for a diagnosis of PTSD (Bryan, Morrow, Etienne, & Ray‐Sannerud, 2013). The recent reintroduction of moral injury has been proposed to emphasize the psychological sequelae of morally charged events in combat that result in guilt, shame, or inner conflict. It is described as witnessing, failing to prevent, or perpetrating acts that transgress deeply held moral beliefs and expectations (Litz et al., 2009). In this description, betrayal on either a personal or an organizational level can also act as a precipitant. Litz et al. argue that these events may lead to survivor guilt (guilt over acts of omission and acts of commission, guilt about thoughts/feelings). Such experiences may be intrusively re-experienced and lead to shame and social disengagement, as well as self-handicapping, self-harm, and demoralization, serving as drivers to chronic PTSD, and in some cases to suicidal ideation or attempts.

Moral distress is also increasingly used by professionals to name experiences of frustration and failure in fulfilling moral obligations inherent to their relationship with others. Although some literature reports limit this to health care professionals (Austin, 2012), it can be extended to the military as well. Moral distress can be used to describe the anger, frustration, guilt, and powerlessness that military professionals experience when they are unable or when they feel that they have failed to practice per their ethical standards or rules of conduct. It is not completely clear how this is different than moral injury, that has emphasizes the transgression of deeply held moral beliefs and expectations (Nash & Litz, 2013).

In a therapeutic process exposure to trauma-related cues can exacerbate guilt. Cognitive factors such as perceived wrongdoing, acceptance of responsibility, perceived lack of justification, and false beliefs about pre-outcome knowledge caused by hindsight bias are some factors that need to be addressed in treatment when they arise. A preemptive escape can maintain the guilt reaction and prevent exposure to the fear-related cues. Cognitive-behavioral trauma-focused therapies that emphasize cognitive restructuring or resolution of cognitive “stuck points” as well as extinction of trauma-related affective responses may be well-suited to PTSD patients for whom guilt regarding acts of omission or commission is a prominent feature. Guilt may also prevent successful integration of the traumatic events with prior beliefs, maintaining to the use of avoidant coping strategies that sustain PTSD symptomology (Street et al., 2005). Studies have shown that higher anger and guilt were associated with worse treatment outcome, and it remains to be seen whether the experience of guilt is associated with the relatively high dropout from treatment in combat-related PTSD cases (Clifton, Feeny, & Zoellner, 2017). For many, it is difficult to acknowledge guilt and shame as causal factors because they have alienated themselves from it. Adaptive exposure can be important for unassisted posttraumatic recovery and is fundamental to extinction-based therapy techniques. As has been illustrated in the case reports, it is less amenable to change through habitual exposure in therapy (Dalgleish, 2004) and it may require time and specific treatment approaches (see Kudany & Manke 1995). For some, in addition to PTSD, there can be a search for meaning and wish for the restoration of their religious faith and their call for a more central place of spirituality in addition to PTSD (Decker, 2007; Fontana & Rosenheck, 2004; Harris et al., 2011).

Several issues need to be addressed. We briefly highlight here the legitimacy of moral injury as a disorder or separate diagnostic category. And second, if a Type A criterion event is necessary to label the symptoms as moral injury. We favor the recent reconceptualization of moral injury not as a diagnosis, but rather as cluster of dimensional symptom drivers within PTSD. We also favor the same A criteria as is required for the diagnosis of PTSD. This is a sort of “reverse engineering” of moral injury as we feel that we search for an explanation of the nonresponse to evidence-based therapy in military members and veterans diagnosed with PTSD. Some authors talk about “potentially morally injurious events” (Wisco et al., 2017), in line with other authors that introduced the term potentially traumatic events (Bolton, Litz, Britt, Adler, & Roemer, 2001; Norris, 1992) when it comes to PTSD. There is a need for assessment instruments of moral injury. We also feel that a debate around PTSD and moral injury needs to highlight the importance of thinking in a multi- or interdisciplinary fashion about helping repair of heal the moral wounds of war. Disclosure is a critical element in starting to reconnect with loved ones and with society. This may call for new skills and competencies and introduce a concept like forgiveness, which can be seen as an effective problem-solving strategy in releasing one's anger and joining in a community with others. Who is authorized to forgive? How do you learn to do this? We realize that this is not a binary check-box element, but as a gradual process-related event toward healing or, as some label, moral repair. We agree with Litz et al. (2009) that existing PTSD treatment frameworks can augment therapy by acknowledging, addressing, and specifically targeting symptoms of moral injury and providing ingredients of moral repair.

Case reports

The following cases illustrate the impact of incidents that were driven by moral decisions and behavior. All cases presented in military mental health settings as atypical and complex cases of PTSD. Criteria of PTSD were clearly met, but the presentation was different compared to the majority of cases of PTSD, either in absence of flashbacks or in severity of symptoms.

Case #1

Corporal S presented with symptoms of anhedonia, fatigue, and vague prepsychotic symptoms in conjunction to classic symptoms of PTSD. He was diagnosed with an atypical presentation of PTSD since symptoms of fatigue, in conjunction with persistent distorted negative cognitions to his health, were his driver symptoms. He had been exposed to serious injuries of fellow soldiers (and therefore endorsed the A1 criterion for PTSD). In the years after his return from Bosnia (deployed in 1995), he had become preoccupied with his health after hearing that he may have been exposed to toxic substances on the compound. He had visited a series of medical specialists and finally was diagnosed with medical unexplained medical illness. He presented delusion-like ideas that Bosnians would come to his house and seek revenge for the failed mission. He self-attributed his symptoms to a series of traumatic incidents he faced when he was deployed to former Yugoslavia. It had been his first deployment and his role was assisting to protect the enclave (a United Nations safe zone) in Srebrenica. Eye movement desensitization and reprocessing (EMDR) did not provide him relief. It was not until several years later he disclosed how intense guilt had driven him to “pay back” the Bosnian survivors with his frequent visits. Several years into treatment, he opened up and began speaking about his experiences. He had been in some incidents where gunfire was involved in which he feared for his life. He strongly felt that many of his symptoms were driven by a single incident. In his role to protecting the enclave he was told not to make any contact with the locals at the gate. Yet, like many others, engaged in frequent daily conversations that eventually lead to a deal: He accepted a large sum of money and agreed to deliver it to relatives in other parts of Europe. He promised that this would be done, yet he wasted the money. He never spoke about this with anybody. It haunted him and he started to become paranoid. This explained his delusional belief that Bosnians would come and take revenge on him. He felt guilty and ashamed over what he had done with the money. He felt an urge to return to the former Yugoslavia, reconnect with locals, and set up a social media campaign that was aimed at reuniting lost family members. His symbolic payback has not yet been openly discussed with the locals. It became clear in his therapy how he found a way to pay back what he owed the locals. He visits them regularly and still dedicates efforts to reconnect family members by social media.

Case #2

T is a veteran who presented with idiopathic pseudo-epileptic seizures. He had been diagnosed with severe PTSD, yet the underlying trauma was not fully understood. His symptoms were dramatic. Differential diagnosis included conversion disorders along with a possible personality disorder. He had been hospitalized and treated with high doses of neuroleptics and sedatives. One of his therapists was suspicious about a military onset and referred him to a military treatment unit. Trauma-focused therapy resulted in increased symptoms, increased drinking, and intermittent aggressive outbursts. Because of the increase in symptoms, exposure was tapered. Pieces of the puzzle revealed that an incident had happened during the years he had served as a Marine. During a mission in 1980, that was meant to be primarily a training mission for a host nation, he and his colleagues were unintentionally involved in a firefight. He was involved in the killing of others and witnessed several unarmed children being killed as innocent victims. The incident was never publicly acknowledged but had not left him. When back home with his small unit he and his peers agreed that this was never to be spoken about. He avoided thinking about it and started avoiding it by working hard and drinking heavily. He did relatively well until approximately 10 years later when he started to developed seizures and was hospitalized for over a year. During hospitalization, he never spoke about the incident. Over the course of several years the story unfolded, and as he disclosed the story he needed to find a way to deal with the disloyalty he felt toward his peers and the betrayal to the host nation by talking about a mission that was never to be reported. Because of the covert operation, he was denied veteran status and accompanying benefits. He fought for years to get recognition, which eventually occurred due to pressure from his wife on the government. A medal was created of which there only exists only one, which was awarded in a family gathering. He shared his story with his now adult children and found support for his engraved memories. He continued to feel guilty and shame regarding his disloyalty to his fellow Marines, but he is relieved from the negative impact of the memories that dramatically impacted his life.

Case #3

J had been deployed to Lebanon in 1980. At the time of clinical presentation, he was a father of three, divorced three times, and had been unable to keep a job. He was a heavy drinker at times. His symptoms of PTSD were dramatic, and he had alienated himself from his children and his local community. His most recent relationship motivated him to seek treatment. He began therapy 20 years after his deployment. His psychiatrist worked with him on a series of traumatic experiences that he reported, including being kidnapped and severely tortured. He was left hanging by his arms, cigarettes were extinguished on his arms and he was ‘water boarded’. These events occurred when he was 21 years old. His deployed role in Lebanon had been to deliver supplies to the various observation posts. During the trips, he had been intimidated and shot at many times and had learned to cope with this. The kidnapping was different as he was tortured and released after a couple of days. He would never discuss the mission since he reported being fearful of his own emotions. After the retirement of his psychiatrist and referral to a new therapist, he started to discuss more details of the mission and now could disclose that he actively killed insurgents. No reports had been made of these events, he acted alone. Because there were sanctions on disclosure of these experiences with risk of imprisonment, he had pushed these details away—and there was also grief, guilt, and shame. He had received a purple heart for his PTSD, but he had not been able to talk about his active role in the killing of several insurgents on different occasions. These experiences had driven his symptoms for 25 years. He felt an urge to disclose his grief and wanted to explore how he could express grief toward the families of the victims. He gradually stopped abusing alcohol and took responsibility for his children, working on his relationships with them as well as others in his life. In retrospect, he had been afraid of his own emotions and is still working on dealing with the guilt for killing insurgents. He is working on forgiveness and on a way to make this work for him.

In all three cases, the veterans were faced with difficult decisions. The first case about breaking a promise in a context of failing to provide aid to civilians (act of omission), the second case involved the betrayal of peers (act of commission) killing insurgents, and the failing to report knowledge of a failed mission (act of omission), and the third case on the use of unsanctioned deadly force in combat that was never shared (act of commission). All made a moral decision that only much later became complicated by guilt and shame. Self-protection and fear had driven them to do things that had not been explicitly part of their mission mandate. Their actions were outside of the range of experiences that were expected and they chose to not talk about it fearing the consequences. Anxiety, hyperarousal, and avoidant coping with increased alcohol intake were the prevailing coping behaviors, whereas shame and guilt were ongoing pressure cookers. The memories of the events persisted for years and needed to be suppressed by avoidant cognitions and behavior. Loyalty was a strong factor in active avoidance as there are some things you experience as a soldier that “you just don't talk about.” In the first case, the veteran demonstrated an attempt at symbolic payback to assuage guilt. In the second case, the traumatic memories needed be released at the price of appearing disloyalty to his peers. In the last case (Case #3), the undisclosed story of killing insurgents never allowed this veteran to move beyond his operational tour and to understand, provide meaning, and ask forgiveness for his actions, in the context of having been kidnapped and tortured by the same insurgents.

Although in the cases, shame was based upon the self-perception that the soldier/veteran had not lived up to standards and performed adequately, guilt typically tied them to their own aggressive acts and their own sadism. Long after the war, a soldier's shame may keep him in the shadows, whereas his guilt may turn his aggression toward himself; this time he may feel it is “he” who must suffer. Because these feelings are not fully conscious or easily articulated, a therapist must often infer their presence based upon the veteran's clinical presentation and history. Certain behavioral indicators usually point the way. So it can be that shame keeps clinical material hidden from sessions, whereas guilt pushes material into the session. If a patient alludes to ‘horrible things done” during the war, it can almost be certain he is alluding to a history of atrocities. He both wants to tell the therapist and doesn't want to. It is then as if his shame competes with his guilt (Singer, 2004). Although guilt is the troubling feeling that one survived when others did not, shame is the feeling of doubting the right to exist. Shame may lead to a global and painful affective reaction with a desire to hide or escape from others. All three cases saw both guilt and shame as drivers of their PTSD symptoms.

These cases also illustrate the soldier's personal theories of the causal linkage between the difficult events they experienced while deployed and the potential for long-term psychological distress. Evidence-based therapies such as cognitive behavioral therapy, PE, or EMDR do not always sufficiently address the underlying moral fear and can lead to drop out or disengagement from the therapeutic process. A revised therapeutic goal can promote new openings in the form of corrective feedback about the appraised implications and related messages about forgiveness and the possibility of repair. Some authors have labeled these approaches as acceptance and commitment therapy (ACT; Hayes, Luoma, Bond, Masuda, & Lillis, 2006), adaptive disclosure (Gray et al., 2012) or self-forgiveness (Worthington & Langberg, 2012). ACT is a “third wave” cognitive behavioral therapy that focuses on increasing psychological flexibility through value-directed behavioral change. ACT helps clients to focus on values and committed action while providing tools to decrease experiential avoidance (e.g., mindfulness skills). Adaptive disclosure takes into account unique aspects of the phenomenology of military service in war to address difficulties such as moral injury and traumatic loss. The approaches were designed to facilitate a perspective that shift beliefs and behaviors resulting from self-blame, even if objectively true, and to accommodate the potential for living a moral and virtuous life going forward. If the repair is successful, it creates a new life perspective or contribute to make major life changes (Walker, 2006).

Discussion

This review pointed toward a relation between the incurrence of moral distress, the development of guilt and shame, and the emergence of psychopathology (Yehuda, Vermetten, & McFarlane, 2012). Theories and therapies for PTSD have primarily evolved to understand and treat anxiety and phobic avoidance, fitting in to an amygdala-centered orientation of the disorder (Nazarov et al., 2015; Vermetten & Lanius, 2012). Mainstream treatment options for combat-related PTSD that rely, for example, on cognitive processing therapy may just not yet be sufficient to address the psychological distress, anger, alienation, and shame that is related to moral injuries. It is time that exposure-based treatments are modified to be able to address the implications of serial cuing of affect and avoidance as is performed in extinction-based therapy techniques. Some new approaches are emerging. Although PTSD treatments to date have centered predominantly on fear-based PTSD symptoms, novel exposure protocols focused on disclosure of moral injuries have appeared and are quite promising (Steenkamp et al., 2011; Gray et al., 2012). These are considered part of third line, cognitive-based therapies, such as ACT (Orsillo & Batten, 2005) and mindfulness-based cognitive therapy (King et al., 2013).

Three case reports served to illustrate that guilt and shame, when left unrecognized and untreated, may contribute to chronic pathology and be a barrier to therapeutic change. The denial or repression of guilt and shame may be the “pressure cooker” that can lead to other presentations including distressing dreams, feelings of anger, self-hatred, distorted cognitions, somatic symptoms, or chronic fatigue. The wounds and their stories have shaped the life of the individual, much in the same fashion as if they were burns or amputations. Although guilt is recognized in DSM-5 as an important feature of PTSD it has received far less recognition than other symptoms that are associated with fear and intense threat (Pugh et al., 2015). It is not well known how many veterans experience complex grief, loss, despair, or (existential) guilt due to events they have witnessed or participated in. Despite several contributions in literature, still little is known, however, about the role that combat guilt and shame play in the development and maintenance of PTSD. It is well known that guilt cognitions may maintain posttrauma sequela. Inadequate measurement of combat-related guilt may be one reason for this deficiency in the literature. Yet, despite some initial reports (Nash et al., 2013; Campbell, 2016; Currier, Holland, & Malott, 2015), well validated instruments measuring moral injury are lacking.

Although it is not possible to predict who will be exposed to difficult decisions during deployment, it may be possible to predict who is more likely to perceive certain events as morally distressing. By assessing predeployment styles of moral judgment using validated assessment tools, it may be possible to identify those military members most likely to experience moral distress, to have resulting symptoms of guilt and shame, and to possibly be at a greater risk of developing combat-related PTSD and/or MDD. Given that the emergence of guilt and shame (additional targets of systematic measurement) is dependent on one's perception of behavior as diverging from personal moral values and standards, assessing these moral standards prior to deployment may show how individuals may emotionally respond to morally ambiguous circumstances in the combat theater (Nazarov et al., 2015). Members identified as being at risk for moral injury may then be targeted by preventive and/or early intervention efforts. This may be achievable through education and training (see Robinson, 2007; Thompson & Jetly, 2014; van Baarda and Verweij, 2006). Preemptive screening and removal from service of individuals at risk of moral injury and associated symptoms of guilt and shame is not warranted, as it is those individuals with an appropriately high sense of personal responsibility and intolerance for moral transgressions who are actively sought among military ranks.

Conclusion

In conclusion, we feel it is important to further explore the concept of moral injury, as well as the relation between guilt and shame in military populations, and its implications for the onset, maintenance, and treatment of combat-related PTSD and other mental conditions (see also Currier et al., 2015; Yan, 2016). We reviewed and illustrated how guilt and shame can be drivers to chronicity in PTSD. Contributing to the reasons for failure of traditional therapies may be the lack of recognition of these psychological constructs. Using individual or group-based psychotherapy that specifically targets and addresses symptoms of guilt and shame may allow participants to discuss a wider range of experienced symptoms and to move past fear-based conceptualizations of combat-related PTSD (Nazarov et al., 2015).

Finally, we ask what disciplines will play a role in these novel approaches. In some cases, chaplains will contribute to a healing perspective as concepts of forgiveness, acceptance, spirituality, justice, and mercy are important in theology, philosophy, psychiatry, counseling, and even in human development. Sometimes a religious pilgrimage can unstuck a therapeutic process (Maddrell, 2013). As therapy for combat-related PTSD is becoming more manualized, there may be a need for a redefinition of this in which the focus is on healing. The psychiatric approach is the recognition of the need to explore a multiple discipline approach to the drivers of chronicity, which can consist of a wider set of experts than the traditional ones in psychotraumatology. Treatment interventions that concentrate on transforming symptoms of guilt and shame to acceptance and forgiveness can be an important asset as research and clinical efforts address the enduring impact of moral injuries on military personnel.

Highlights

•	Service members are increasingly more likely to confront morally injurious experiences during deployment than life-threatening combat.
•	Assessment of guilt and shame issues needs to be refined for better understanding of conceptualization of moral injury.
•	Theories and therapies for PTSD have primarily evolved to understand and treat anxiety and phobic avoidance, limiting PTSD to an amygdala-centered orientation.
•	Guilt and shame, when left unrecognized and untreated, may contribute to chronic pathology and be a barrier to therapeutic change.
•	Repression of guilt and shame may be a “pressure cooker” that can lead to presentations, including distressing dreams, feelings of anger, self-hatred, distorted cognitions, somatic symptoms, or chronic fatigue.
•	Although fear is current or future orientated, guilt is a retrospective emotion and less amenable to change through habitual exposure in therapy— it may prevent successful integration of the traumatic events with prior beliefs, maintaining to avoidant coping strategies that sustain PTSD.
•	Third line, cognitive-based therapies that focus on increasing psychological flexibility through value-directed behavioral change need to be further developed and tailored to the military.