The morally-injured veteran: Some ethical considerations.

Currier, Drescher and Harris (2014) provide good empirical evidence for a linkage between diminished spiritual functioning and PTSD in their samples of combatants from the Vietnam and Iraq/Afghanistan Wars. The authors’ report lower spiritual functioning—measured broadly in terms of both personal and public spiritual/ religious experience and engagement—in veterans who seek treatment for combat-related PTSD versus those who do not seek treatment. Problems experiencing forgiveness (e.g., selfforgiveness, forgiveness of others, a sense of divine forgiveness) were particularly predictive of PTSD symptom severity. Currier and colleagues make the reasonable supposition that negative religious coping and forgiveness problems might have a prominent role in the severity and chronicity of PTSD. They recommend that clinicians appraise traumatic stress disorders in spiritual terms, exploring the spiritual significance of symptoms and perhaps working to strengthen spiritual/religious cognitions, emotions, and behaviors in the course of psychotherapy. This excellent study raises a number of intriguing clinical questions related to the role of spirituality in the assessment and treatment of combat veterans. For instance, it remains unclear what role depression might play in diminished spiritual functioning. PTSD is often accompanied by depression in some form. Do the hopelessness, social disengagement, and dysphoric mood that define clinical depression simply color spiritual experience blue? Exploring the mediating role of depression between spirituality and PTSD should be a high priority in subsequent research. This study further raises the interesting possibility of reducing rates of PTSD among veteran populations through a robust precombat program of spiritual inoculation. For instance, might the Building Spiritual Fitness program described by Pargament and Sweeney (2011) offer a strategy for boosting spiritual health prior to combat exposure? Although Currier and colleagues (2014) raise a number of rich clinical possibilities, I am most concerned about two of the ethical implications. First, the authors wisely discuss the potential linkage between moral injury and PTSD. Moral injury may occur when a combatant transgresses deeply held moral beliefs (Litz et al., 2009); often, these beliefs are reinforced by religious conviction. For instance, when a service member is unable to morally or spiritually justify his or her actions (e.g., killing another person), including actions required to stay alive, significant anxiety and guilt may ensue. Currier and colleagues (2014) wisely suggest that clinicians working with veterans should have the therapeutic skills to address the spiritual dimensions of PTSD, perhaps including spiritual/ religious solutions for moral injury. But clinicians in this context should be cautious about mere symptom relief when moral anguish is in play. For instance cognitive techniques aimed at softening client beliefs about right and wrong or disputing the validity of the client’s guilt might paradoxically deprive a religiously committed client of rituals such as the confession of sin as an avenue to grace. Writing about Christian clients, McMinn, Ruiz, Marx, Wright, and Gilbert (2006) warn that, “therapists who strip away the language of sin from Christian clients may unwittingly take away a source of peace and hope by foreclosing the possibility of grace and forgiveness” (p. 296). Religion and spirituality-integrative clinical work requires some special sophistication. The ethical point here is that practitioners must consider the boundaries Correspondence concerning this Commentary should be addressed to W. Brad Johnson, United States Naval Academy Leadership, Ethics & Law, 112 Cooper Road, Luce Hall, Stop 7B, Annapolis, MD 21402. E-mail: johnsonb@ usna.edu T hi s do cu m en t is co py ri gh te d by th e A m er ic an Ps yc ho lo gi ca l A ss oc ia tio n or on e of its al lie d pu bl is he rs .