Treating War-Related Moral Injury and Loss with Adaptive Disclosure: A Case Study

  • Alexandra L. LaiferEmail author
  • Amy D. Amidon
  • Ariel J. Lang
  • Brett T. Litz


Existing evidence-based treatments for posttraumatic stress disorder (PTSD), while effective for many fear-based traumas, do not sufficiently target the unique phenomenology of psychological wounds stemming from combat, specifically, moral injury and traumatic loss. The experience of moral injury and loss cause deeply complex challenges across multiple domains—behavioral, biological, cognitive, social, and spiritual—in ways that are significantly different from danger-based harms. Adaptive disclosure, a new psychotherapy, was specifically designed to address this gap in treatment and help service members and veterans begin the process of healing from combat stress and trauma. This chapter presents the conceptual foundation and change agents for adaptive disclosure along with the case of a new veteran whose principal harm was moral injury complicated by loss. The patient in this case made modest gains in PTSD symptom severity alongside authentic cognitive and behavioral signs of increased agency, proactivity, hopefulness, and vitality that were clear departures from moral injury, suggesting the utility of this treatment approach in addressing the psychological wounds of war.


Adaptive disclosure and PTSD moral injury traumatic loss combat trauma combat stress 


  1. 1.
    Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048–60.CrossRefPubMedGoogle Scholar
  2. 2.
    Kulka RA, Schlenger WE, Fairbank JA, et al. Trauma and the Vietnam war generation: report of findings from the National Vietnam Veterans Readjustment Study. Philadelphia: Brunner/Mazel; 1990.Google Scholar
  3. 3.
    Santiago PN, Ursano RJ, Gray CL, et al. A systematic review of PTSD prevalence and trajectories in DSM-5 defined trauma exposed populations: intentional and non-intentional traumatic events. PloS ONE. 2013;8(4):e59236. doi:10.1371/journal.pone.0059236.PubMedCentralCrossRefPubMedGoogle Scholar
  4. 4.
    Steenkamp MM, Litz BT. Early interventions with military personnel. In Moore BA, Barnett JE, editors. Military psychologists’ desk reference. New York: Oxford University Press; 2013. p. 256–60.Google Scholar
  5. 5.
    Forbes D, Lloyd D, Nixon RD, et al. A multisite randomized controlled effectiveness trial of cognitive processing therapy for military-related posttraumatic stress disorder. J Anxiety Disord. 2012;26(3):442–52.CrossRefPubMedGoogle Scholar
  6. 6.
    Schnurr PP, Friedman MJ, Engel CC, et al. Cognitive behavioral therapy for posttraumatic stress disorder in women: a randomized controlled trial. JAMA. 2007;297(8):820–30.CrossRefPubMedGoogle Scholar
  7. 7.
    Bradley R, Greene J, Russ E, Dutra L, Westen D. A multidimensional meta-analysis of psychotherapy for PTSD. Am J Psychiatry. 2005;162(2):214–27.CrossRefPubMedGoogle Scholar
  8. 8.
    Litz BT, Schorr Y, Delaney E, et al. A randomized controlled trial of an internet-based therapist-assisted indicated preventive intervention for prolonged grief disorder. Behav Res Ther. 2014;61:23–34.PubMedCentralCrossRefPubMedGoogle Scholar
  9. 9.
    Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695–706.CrossRefPubMedGoogle Scholar
  10. 10.
    Foa EB, Hembree EA, Rothbaum BO. Prolonged exposure therapy for PTSD: emotional processing of traumatic experiences. New York: Oxford University Press; 2007.CrossRefGoogle Scholar
  11. 11.
    Resick PA, Schnicke MK. Cognitive processing therapy for rape victims: a treatment manual. Thousand Oaks: Sage; 1993.Google Scholar
  12. 12.
    Litz BT, Lebowitz L, Gray MJ, Nash W. Adaptive disclosure: An experiential approach to military trauma, loss, and moral injury. New York: Guilford; in press.Google Scholar
  13. 13.
    Gray MJ, Schorr Y, Nash W, et al. Adaptive disclosure: an open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behav Ther. 2012;43(2):407–15.CrossRefPubMedGoogle Scholar
  14. 14.
    Steenkamp MM, Litz BT, Gray MJ, et al. A brief exposure-based intervention for service members with PTSD. Cogn Behav Pract. 2011;18(1):98–107.CrossRefGoogle Scholar
  15. 15.
    Foa EB, Keane TM, Friedman MJ, Cohen JA, eds. Effective treatments for PTSD: practice guidelines from the International Society for Traumatic Stress Studies. New York: Guilford; 2008.Google Scholar
  16. 16.
    Gortner E-M, Rude SS, Pennbaker JW. Benefits of expressive writing in lowering rumination and depressive symptoms. Behav Ther. 2006;37(3):292–303.Google Scholar
  17. 17.
    Weathers FW, Litz BT, Huska JA, Keane TM. The PTSD checklist—Civilian version (PCLC). Boston: National Center for PTSD; 1994.Google Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  • Alexandra L. Laifer
    • 1
    Email author
  • Amy D. Amidon
    • 2
  • Ariel J. Lang
    • 3
  • Brett T. Litz
    • 4
  1. 1.Veterans Medical Research Foundation, VA San Diego Healthcare SystemSan DiegoUSA
  2. 2.Department of PsychologyNaval Medical Center San DiegoSan DiegoUSA
  3. 3.VA San Diego Healthcare SystemUniversity of California San DiegoSan DiegoUSA
  4. 4.Department of Psychiatry, VA Boston Healthcare SystemBoston UniversityBostonUSA

Personalised recommendations