Restitution for Moral Injury
Those of you who know me are aware that I’m currently studying for a Masters in Health Law at Sydney Law School. I also happen to be penning this post on the evening before I interview for a position on the NSW Mental Health Review Tribunal.
Psychiatry occupies a large space at the interface between Medicine and Law. I’ve been increasingly interested in Therapeutic Jurisprudence since the first time I presented a patient to a tribunal. I didn’t see or experience adversary in the room as in a Law & Order episode.
What I saw was the opportunity for therapeutic benefit when it worked well. I saw an unbiased place where everyone’s perspectives could be laid on the table to discuss and come to an agreement that was in the patient’s best interests.
An adversarial approach was invariably taken when it didn’t work well. This was often re-traumatising as transference and countertransference danced across the table.
As my own experience with trauma has grown and I’ve helped people recover, I’ve become more attuned to the nuances in this space. And Moral Injury is of the biggest challenges emerging in the trauma literature.
What is Moral Injury?
Moral injury is a relatively new and complex concept that continues to evolve. It was initially introduced and developed it as a character wound arising from a betrayal of justice. In this early conception, Moral Injury was a cluster of symptoms such as shame, grief, guilt, self-condemnation, self-sabotage, hopelessness, and loss of meaning.
However a definition of moral injury has been elusive despite the growth in moral injury research. Dr Nikki Jamieson and colleagues have developed consensus definition that highlights that moral trauma can arise from a sense of internal conflict, or perceived betrayal or violation.
So Moral Injury can be divided into: 1) betrayal-based moral injury in which the individual is perceived as a victim; and 2) perpetration-based moral injury in which the individual perceive that they have committed a moral violation.
Whilst the characteristics of moral injury are distinct from the symptoms of Posttraumatic Stress Disorder (PTSD), there is overlap between PTSD and moral injury and they can co-occur. Common shared symptoms include intrusions, anger, guilt, and self-blame.
The underlying difference between Moral Injury and PTSD is that Moral Injury is a moral-based concept while PTSD is a fear-based disorder, and this is reflected in the differing neurobiology.
Recovery from Moral Injury
Effective treatment of Moral Injury is still an ongoing area of research.
Motivated by the co-occurrence of symptoms between PTSD and Moral Injury, research has largely focused on modifying trauma-focused therapies. Prolonged Exposure and Cognitive Processing Therapy have demonstrated reductions in trauma-related guilt. However these approaches have limited pathophysiological basis for patients presenting with Moral Injury without PTSD.
Other forms of therapy attempt to tackle the underlying feelings of shame (Acceptance and Commitment Therapy), guilt (Adaptive Disclosure), and loss of meaning (Building Spiritual Strength group).
Psychotherapy alone cannot repair moral injuries, and so a holistic approach must also include social and spiritual interventions. Research has been turning towards interdisciplinary approaches and adjunctive therapies.
However, Dr Haleigh Barnes and colleagues note that the common thread among the psychological treatment strategies may essentially reduce the “injustice gap”. This returns the question of therapy to earlier conceptions of Moral Injury as a betrayal of justice.
Restitution of Justice
Restitution of a harm through the recognition of legal liability of a wrong with the award of damages is the basis of tort law. Torts protect the fundamental rights of an individual and therefore engages in the questions of how people may treat one another and what to do when the social and moral norms are transgressed.
I would argue that the limited benefit of psychotherapy in treating Moral Injury therefore raises the question of the potential role of jurisprudence in the restitution of Moral Injury.
This is a question that has been discussed in the jurisprudence literature. Restorative justice approaches can provide a workable solution to war criminals. Preventative law has been proposed to address the sense of betrayal of justice inherent in Moral Injury. Indeed, Moral Injury is a key concept that is considered within Veteran Treatment Courts. The idea of “healing justice” has been framed within the context of transformative justice to address systemic factors that lead to moral injury.
The clinical literature remains mute.
Discovery at the Interface
These jurisprudence discussions signal the potential therapeutic role of the law, which is the fundamental question in the Therapeutic Jurisprudence literature.
Together with my own interests, they have inspired me to work on a little interdisciplinary paper with a couple of colleagues to explore this concept. Hopefully it will spark some serious consideration of whether psychological approaches to Moral Injury can be augmented with non-adversarial justice approaches.
And maybe, if I’m successful in the interview tomorrow, I may be able to scatter a few glimmers of the idea in practice.
