Barr Nicholas, Atuel Hazel, Saba Shaddy, Castro Carl A
School of Social Work, University of Nevada, Las Vegas, Las Vegas, NV, United States.
Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, United States.
Front Psychiatry. 2022 Aug 24;13:883338. doi: 10.3389/fpsyt.2022.883338. eCollection 2022.
Moral injury has emerged as a topic of significant research and clinical interest over the last decade. However, much work remains to be done to comprehensively define the moral injury construct, with implications for understanding the etiology and maintenance of moral injury, its symptoms, associations with and distinctions from traumatic illness, and treatment approaches. We provide a brief overview of the existing moral injury literature and introduce a novel dual process model (DPM) of moral injury and traumatic illness. The DPM posits an event exposure which may satisfy DSM-5 posttraumatic stress disorder (PTSD) criterion A, potential morally injurious event (PMIE) criteria, or both, followed by individual role appraisal as a perpetrator through action or inaction, a witness, a victim, or a combination of the these. Role appraisal influences symptoms and processes across biological, psychological, behavioral, social, spiritual/religious, as well as values, character, and identity domains to support a label of traumatic illness, moral injury, or both. The DPM provides a flexible analytical framework for evaluating symptoms associated with moral injury and traumatic stress and has important implications for treatment. The most thoroughly reviewed evidence-based interventions for traumatic stress hinge on exposure and habituation mechanisms to manage dysregulation of fear and memory systems, but these mechanisms often do not address core domains of moral injury identified in the DPM, including spiritual, religious, values, character, and identity domains as these exist largely outside of the putative fear network. We provide brief vignettes to illustrate the practical application of the DPM and argue that adjunct and stand-alone approaches which address values and character domains, leveraging principles of Stoicism, non-judgment of experience, acceptance, and values-oriented action, are more likely than traditional trauma treatment approaches to positively affect moral injury symptoms.
在过去十年中，道德伤害已成为一个重要的研究和临床关注话题。然而，要全面定义道德伤害的概念，仍有许多工作要做，这对于理解道德伤害的病因、持续存在、症状、与创伤性疾病的关联和区别以及治疗方法都具有重要意义。我们简要概述了现有的道德伤害文献，并介绍了一种新的道德伤害和创伤性疾病双重过程模型（DPM）。DPM假设一个事件暴露可能满足《精神疾病诊断与统计手册》第5版（DSM-5）创伤后应激障碍（PTSD）A标准、潜在道德伤害事件（PMIE）标准或两者兼具，随后个体通过作为实施者采取行动或不作为、作为目击者、作为受害者或这些角色的组合进行角色评估。角色评估会影响生物、心理、行为、社会、精神/宗教以及价值观、性格和身份领域的症状和过程，以支持创伤性疾病、道德伤害或两者兼具的诊断。DPM为评估与道德伤害和创伤性应激相关的症状提供了一个灵活的分析框架，并对治疗具有重要意义。针对创伤性应激的最全面审查的循证干预措施依赖于暴露和习惯化机制来管理恐惧和记忆系统的失调，但这些机制往往无法解决DPM中确定的道德伤害的核心领域，包括精神、宗教、价值观、性格和身份领域，因为这些领域在很大程度上存在于假定的恐惧网络之外。我们提供简短的案例来说明DPM的实际应用，并认为采用斯多葛主义原则、对经验不评判、接纳和以价值观为导向的行动来处理价值观和性格领域的辅助和独立方法，比传统的创伤治疗方法更有可能对道德伤害症状产生积极影响。
