Correcting Misperceptions About Cognitive Processing Therapy to Treat Moral Injury: A Response to Gray and Colleagues (this issue)

We respond to the commentary by Gray, Nash, and Litz (this issue) regarding the use of cognitive processing therapy (CPT) to address moral injury as described in our previous publication (Wachen et al., 2016). In their commentary, Gray et al. posit that CPT is inappropriate when applied to the treatment of war-related traumas involving “real moral and ethical transgressions” (i.e., moral injuries). However, Gray and colleagues’ assertions are centered on a premise that is incorrect, namely that CPT is based on the idea that “self-blame and guilt are inherently illogical or inaccurate,” and that CPT assumes that all beliefs associated with moral injury are erroneous. On the contrary, we acknowledge that self-blame and guilt may be accurate responses to warzone trauma, yet disagree that CPT is not suitable in these situations. This response serves to clarify some of the inaccurate interpretations of the treatment as stated by Gray and colleagues, and reiterates the position of CPT on many of the issues that were raised. Specifically, we discuss the use of Socratic questioning within CPT to address the issue of moral injury. Furthermore, we highlight the strong evidence base for the use of CPT in treating veterans and active military. Until it has been determined through empirical study, it is premature to assert that CPT is insufficient in addressing moral injury in combat personnel.     

Using Prolonged Exposure and Cognitive Processing Therapy to Treat Veterans With Moral Injury-Based PTSD: Two Case Examples

Moral injury refers to acts of commission or omission that violate individuals’ moral or ethical standards. Morally injurious events are often synonymous with psychological trauma, especially in combat situations—thus, morally injurious events are often implicated in the development of posttraumatic stress disorder (PTSD) for military service members and veterans. Although prolonged exposure (PE) and cognitive processing therapy (CPT) have been well established as effective treatments for veterans who are struggling with PTSD, it has been suggested that these two evidence-based therapies may not be sufficient for treating veterans whose PTSD resulted from morally injurious events. The purpose of this paper is to detail how the underlying theories of PE and CPT can account for moral injury-based PTSD and to describe two case examples of veterans with PTSD stemming from morally injurious events who were successfully treated with PE and CPT. The paper concludes with a summary of challenges that clinicians may face when treating veterans with PTSD resulting from moral injury using either PE or CPT.     

Moral uncertainty and permissibility: Evaluating Option Sets

In this essay, we explore an issue of moral uncertainty: what we are permitted to do when we are unsure about which moral principles are correct. We develop a novel approach to this issue that incorporates important insights from previous work on moral uncertainty, while avoiding some of the difficulties that beset existing alternative approaches. Our approach is based on evaluating and choosing between option sets rather than particular conduct options. We show how our approach is particularly well-suited to address this issue of moral uncertainty with respect to agents that have credence in moral theories that are not fully consequentialist.     

The importance of meta-ethics in engineering education

Our shared moral framework is negotiated as part of the social contract. Some elements of that framework are established (tell the truth under oath), but other elements lack an overlapping consensus (just when can an individual lie to protect his or her privacy?). The tidy bits of our accepted moral framework have been codified, becoming the subject of legal rather than ethical consideration. Those elements remaining in the realm of ethics seem fragmented and inconsistent.Yet, our engineering students will need to navigate the broken ground of this complex moral landscape. A minimalist approach would leave our students with formulated dogma—principles of right and wrong such as the National Society for Professional Engineers (NSPE) Code of Ethics for Engineers—but without any insight into the genesis of these principles. A slightly deeper, micro-ethics approach would teach our students to solve ethical problems by applying heuristics—giving our students a rational process to manipulate ethical dilemmas using the same principles simply referenced a priori by dogma. A macro-ethics approach—helping students to inductively construct a posteriori principles from case studies—goes beyond the simple statement or manipulation of principles, but falls short of linking personal moral principles to the larger, social context. Ultimately, it is this social context that requires both the application of ethical principles, and the negotiation of moral values—from an understanding of meta-ethics.The approaches to engineering ethics instruction (dogma, heuristics, case studies, and meta-ethics) can be associated with stages of moral development. If we leave our students with only a dogmatic reaction to ethical dilemmas, they will be dependent on the ethical decisions of others (a denial of their fundamental potential for moral autonomy). Heuristics offers a tool to deal independently with moral questions, but a tool that too frequently reduces to casuistry when rigidly applied to “simplified” dilemmas. Case studies, while providing a context for engineering ethics, can encourage the premature analysis of specific moral conduct rather than the development of broad moral principles—stifling our students’ facility with meta-ethics. Clearly, if a moral sense is developmental, ethics instruction should lead our students from lower to higher stages of moral development.     

Good and Bad: Love and Intimacy From Plato to Melanie Klein

Melanie Klein’s theories on love outline a complex system of relations—an oscillating dynamic of psychical and emotional tendencies following from both actual experience and fantasies produced by the mind. Her insights are often discussed and applied in psychoanalytical contexts, but the philosophical implications of her theory—especially in relation to Platonic thought—have rarely been discussed. In this article, I will attempt to address this gap by setting out some preliminary yet core considerations shared by both Plato and Klein. First, I will describe some structural parallels between Kleinian and Platonic thought, especially in dialectical terms. Second, I will outline Plato’s covert influence on Freud as passing through the teachings of philosopher Franz Brentano. And last, I will discuss intimacy as a struggle between the forces of good and bad, creativity and destruction, and love and hate—suggesting that Klein’s conception of love emerges as a moral exigency.     

Flexible moral theories: Complexity,domination, and indeterminacy

In this article we identify three previously unnoticed problems with flexible moral theories, i.e., theories according to which different moral rules apply when there is full compliance and when there is partial compliance. The first problem is that flexible theories are necessarily very complex, which undermines their ability to motivate and guide action. The second problem is that flexible theories allow for a troubling kind of (moral) domination: the duties an agent has depend on other agents' willingness to comply. Finally, flexible theories introduce indeterminacy: it is sometimes impossible to determine which moral rules apply. When agents stand at the threshold—i.e., when a different rule would apply if a single additional act of noncompliance took place—it is impossible to determine which rule should apply.     

Gender Bias in Medical Implant Design and Use: A Type of Moral Aggregation Problem?

In this article, I describe how gender bias can affect the design, testing, clinical trials, regulatory approval, and clinical use of implantable devices. I argue that bad outcomes experienced by women patients are a cumulative consequence of small biases and inattention at various points of the design, testing, and regulatory process. However, specific instances of inattention and bias can be difficult to identify, and risks are difficult to predict. This means that even if systematic gender bias in implant design is an ethical issue, it is one with no clearly blameworthy player. From a practical perspective, there is no single obvious point at which to intervene. Philosophers working in other areas have explored structurally similar moral problems—sometimes referred to as “moral aggregation problems”—such as the type of environmental harm caused by small actions of many players. I describe key features of these type of problems and strategies to address them. I then draw on these to suggest an approach to gender bias in medical implant design and use.     

Being good to look good: Self-reported moral character predicts moral double standards among reputation-seeking individuals

Moral character is widely expected to lead to moral judgements and practices. However, such expectations are often breached, especially when moral character is measured by self-report. We propose that because self-reported moral character partly reflects a desire to appear good, people who self-report a strong moral character will show moral harshness towards others and downplay their own transgressions—that is, they will show greater moral hypocrisy. This self-other discrepancy in moral judgements should be pronounced among individuals who are particularly motivated by reputation. Employing diverse methods including large-scale multination panel data (N = 34,323), and vignette and behavioural experiments (N = 700), four studies supported our proposition, showing that various indicators of moral character (Benevolence and Universalism values, justice sensitivity, and moral identity) predicted harsher judgements of others' more than own transgressions. Moreover, these double standards emerged particularly among individuals possessing strong reputation management motives. The findings highlight how reputational concerns moderate the link between moral character and moral judgement.     

Discouraging unethicality versus encouraging ethicality: Unraveling the differential effects of prevention‐ and promotion‐focused ethical leadership

Theory on the impact of ethical leadership has traditionally been based on a deontological approach to morality. Underlying this perspective is the assumption that all leader behaviors that encourage “normatively appropriate conduct” will influence followers in a similar fashion. Put differently, the current consensus seems to suggest that actions that focus on preventing unethical behavior—attending to “the wrong”—will have the same impact as actions that focus on promoting ethical behavior—attending to “the right.” Taking a within‐person approach, we draw upon social exchange theory to challenge this consensus and build theory that suggests a follower's felt trust from their leader will be differentially impacted by prevention‐ versus promotion‐focused ethical leadership. We also explore how these different types of ethical leadership may indirectly, through felt trust, impact citizenship behavior and counterproductive work behavior. Finally, we consider how the role of the “moral manager” may interact with the “moral person” by identifying leader moral hypocrisy as an important between‐person moderator of these effects. Given the importance of ethical decision‐making in organizations and the calls for increased ethical leadership, our findings have important implications for both theory and practice.     

Direct and indirect freedom in addiction: Folk free will and blame judgments are sensitive to the choice history of drug users

People view addiction as a source of diminished free will and moral responsibility. Yet, people are also sensitive to the personal histories of moral actors, including, perhaps, the way by which people became addicted. Across two studies (N = 806), we compare people’s moral intuitions about cases in which the actor becomes addicted by force or by choice. We find that perceptions of reduced free will partially mediate an association between choice (vs. no choice) in addiction and moral blame for a bad act (Study 1). We replicate this pattern and show that blame judgments are stronger when the bad act is related (vs. unrelated) to obtaining the addictive substance (Study 2). Our work is novel in demonstrating that lay people evince relatively nuanced intuitions about the role of free will in addiction and morality—they track direct and indirect paths to choices when making free will and blame judgments.     

The Caveman's Conscience: Evolution and Moral Realism

An increasingly popular moral argument has it that the story of human evolution shows that we can explain the human disposition to make moral judgments without relying on a realm of moral facts. Such facts can thus be dispensed with. But this argument is a threat to moral realism only if there is no realist position that can explain, in the context of human evolution, the relationship between our particular moral sense and a realm of moral facts. I sketch a plausible evolutionary story that illuminates this relationship. First, the sorts of adaptive pressures facing early humans would have produced more than just potent prosocial emotions, as evolutionary antirealists like to claim; it would have produced judgments—often situated within emotions—to the effect that others could reasonably disapprove of some bit of conduct, for an early human who cared deeply about how others might respond to her action enjoyed the benefits of more cooperative exchanges than those early humans who did not. Second, according to objectivist versions of moral constructivism, moral facts just are facts about how others, ideally situated, would respond to one's conduct. Thus if any objectivist moral constructivism story is true, then we can intelligibly assert that a) our capacity for moral judgment is the product of adaptive pressures acting on early humans and b) some moral judgments are objectively true.     

When Love Hurts: Treating Abusive Relationships

This paper describes an integrative approach for treating couples in abusive relationships. Because of the power inequities that often obtain in such cases, the therapist faces special challenges. Both partners must be defined as clients, yet the two are not on equal footing. Sustaining moral clarity in a context of such psychological ambiguity is crucial, and it requires skills beyond those we typically associate with the art and craft of the interview. A mutative factor in any therapy requires bearing witness to injustices large and small—leading the author to raise questions about the place of the moral work of psychotherapy in our therapy-saturated society. She poses an urgent social question: Is it possible to intervene therapeutically in abusive relationships to make love safer for women and less threatening to men?     

An Actor's Knowledge and Intent Are More Important in Evaluating Moral Transgressions Than Conventional Transgressions

An actor's mental states—whether she acted knowingly and with bad intentions—typically play an important role in evaluating the extent to which an action is wrong and in determining appropriate levels of punishment. In four experiments, we find that this role for knowledge and intent is significantly weaker when evaluating transgressions of conventional rules as opposed to moral rules. We also find that this attenuated role for knowledge and intent is partly due to the fact that conventional rules are judged to be more arbitrary than moral rules; whereas moral transgressions are associated with actions that are intrinsically wrong (e.g., hitting another person), conventional transgressions are associated with actions that are only contingently wrong (e.g., wearing pajamas to school, which is only wrong if it violates a dress code that could have been otherwise). Finally, we find that it is the perpetrator's belief about the arbitrary or non‐arbitrary basis of the rule—not the reality—that drives this differential effect of knowledge and intent across types of transgressions.     

Moral Injury,Spiritual Care and the Role of Chaplains: An Exploratory Scoping Review of Literature and Resources

This scoping review considered the role of chaplains with regard to ‘moral injury’. Moral injury is gaining increasing notoriety. This is due to greater recognition that trauma (in its various forms) can cause much deeper inflictions and afflictions than just physiological or psychological harm, for there may also be wounds affecting the ‘soul’ that are far more difficult to heal—if at all. As part of a larger research program exploring moral injury, a scoping review of literature and other resources was implemented utilising Arksey and O’Malley’s scoping method (Int J Soc Res Methodol 8(1):19–32, 2005) to focus upon moral injury, spirituality (including religion) and chaplaincy. Of the total number of articles and/or resources noting the term ‘moral injury’ in relation to spiritual/religious issues (n = 482), the results revealed 60 resources that specifically noted moral injury and chaplains (or other similar bestowed title). The majority of these resources were clearly positive about the role (or the potential role) of chaplains with regard to mental health issues and/or moral injury. The World Health Organization International Classification of Diseases: Australian Modification of Health Interventions to the International Statistical Classification of Diseases and related Health problems (10th revision, vol 3—WHO ICD-10-AM, Geneva, 2002), was utilised as a coding framework to classify and identify distinct chaplaincy roles and interventions with regard to assisting people with moral injury. Several recommendations are made concerning moral injury and chaplaincy, most particularly the need for greater research to be conducted.     

From the Galleries to the Clinic: Applying Art Museum Lessons to Patient Care

Increasingly, medical educators integrate art-viewing into curricular interventions that teach clinical observation—often with local art museum educators. How can cross-disciplinary collaborators explicitly connect the skills learned in the art museum with those used at the bedside? One approach is for educators to align their pedagogical approach using similar teaching methods in the separate contexts of the galleries and the clinic. We describe two linked pedagogical exercises—Visual Thinking Strategies (VTS) in the museum galleries and observation at the bedside—from “Training the Eye: Improving the Art of Physical Diagnosis,” an elective museum-based course at Harvard Medical School. It is our opinion that while strategic interactions with the visual arts can improve skills, it is essential for students to apply them in a clinical context with faculty support—requiring educators across disciplines to learn from one another.     

ALTRUISM: TOWARD A PSYCHOBIOSPIRITUAL CONCEPTUALIZATION

Altruism, defined here as a regard for or devotion to the interest of others with whom we are interrelated, is pitted against two other dispositions in human beings: nepotism and egoism. We propose that to become fully human is to become more altruistic. We describe how altruism is mediated by our physiology, is expressed in our psychological development, is evolving in our social institutions, and becomes the moral communities that enforce our sense of right and wrong. A change in any one of these influences changes our disposition—changes who we are and what we do—potentially making altruism more possible in the world.     

Self-blame among parents of infants with perinatal complications: the role of self-protective motives

According to the literature on defensive attribution, behavioral self-blame can bolster a sense of personal efficacy and is more likely to occur when victims perceive their misfortune as severe. In this study, mothers of infants with severe perinatal complications rated the severity of their child's condition, were asked about its causes, and completed a measure of emotional adaptation. As predicted according to the defensive attribution hypothesis, behavioral self-blame was associated with greater perceived severity and preventability of recurrence. The pattern of correlations suggests that greater perceived severity may produce greater self-blame, which in turn may play an indirect role in adaptation through its association with the belief that a recurrence could be prevented. Results of a post hoc path analysis were consistent with this hypothesis. These findings are discussed in terms of the adaptive features of behavioral self-blame, its relation to perceived control, methodological issues in the study of coping with victimization, and implications for helping professionals.     

Other People’s Errors

The question of when other people’s bad acts belong on our moral ledger arises in a number of different scenarios. Each scenario has received some philosophical attention, but no one has noted the structural similarities of these various scenarios or the implications of a proposed approach to one for how the others should be approached. That is the ambition of this article. In it, seemingly disparate moral phenomena—blunt rules, preemptive restrictions, moral blackmail, complicity, retreat and proportional response, and the duty to rescue from a peril one has caused—are shown to have similar structures and thus to require similar moral approaches.     

Do emotions play an essential role in moral judgments?

The past few decades of moral psychology research have yielded empirical anomalies for rationalist theories of moral judgments. An increasing number of psychologists and philosophers argue that these anomalies are explained well by sentimentalism, the thesis that the presence of an emotion is necessary for the formation of a sincere moral judgment. The present review reveals that while emotions and moral judgments indeed often co-occur, there is scant evidence that emotions directly cause or constitute moral judgments. Research on disgust, anger, sympathy, and guilt indicates that people only reliably experience emotions when judging conduct that is relevant to the welfare of the self and valued others. Moreover, many recent studies have either failed to replicate or exposed crucial confounds in the most cited evidence in support of sentimentalism. Moral psychologists should jettison sentimentalism, and focus instead on how considerations of harm and welfare—the core concepts of rationalist theories— interact with empirical beliefs to shape moral judgments.     

On Some Recent Attempts to Resolve the Debate between Internalists and Externalists

An important debate in moral philosophy concerns the thesis of internalism, of which the characteristic idea is that there is a conceptual link between moral judgment and motivation. According to the internalist, to judge that something is right is to be motivated to do it (at least under certain conditions). Externalists are those who deny the truth of internalism. There are two ways that either party to this debate may argue for their preferred position. The indirect approach requires defending an account of moral judgment and showing (for internalists) that it entails there is a conceptual link between moral judgment and motivation or (for externalists) that it entails there is no such link. In contrast, the direct approach requires arguing in favor of one position without assuming any particular account of moral judgment. In this paper, I examine two attempts—one by Michael Smith and one by Sigrún Svavarsdóttir—to resolve this debate between internalists and externalists by using the direct approach. Smith attempts to do so in favor of internalism while Svavarsdóttir makes the attempt in favor of externalism. I conclude that both attempts fail.