Relative to most civilian traumas, war zone exposure has been associated with considerably more enduring psychiatric, social, spiritual, and behavioral problems, as well as with poorer responses to treatment [1–7]. In order to improve the health and welfare of deployed service members and war veterans, it is critical to investigate why this is the case [8]. In doing so, there has been a focus on disaggregating war zone harms and their consequences into what appear to be three broad yet distinct principal types: life-threat (danger), traumatic loss, and moral injury [9].

Existing evidence-based treatments for posttraumatic stress disorder (PTSD) have overemphasized danger-based war zone harms; however, unlike civilian traumatic event contexts, there is good reason to assume that many fear- or danger-based stress reactions are mitigated by military preselection, training in resilience and recovery, and aspects of military culture, such as, leadership, cohesive units, rituals, which can serve as protective factors. By contrast, there are far fewer resources to alleviate and heal the lasting impact of traumatic loss and moral injury , a syndrome of self-handicapping and demoralization that occurs following a perpetration, failure to prevent, or bearing witness to war zone acts that violate deeply held beliefs and expectations about moral and ethical conduct; the crux of moral injury is significant guilt and shame in response to acts of commission or omission that entail culpability from the service member’s point of view [9]. It has been argued that because loss and moral injury are inherently not fear-based, they each require different ecologically sensitive and valid treatment strategies that are not part of existing treatments for PTSD [9].

Prolonged exposure (PE) [10] and cognitive processing therapy (CPT) [11], generally considered front-line treatments for PTSD, have started to include some content about ways in which guilt from loss and perpetration should be “contextualized” or “processed,” but there are no explicit exercises or developed dialogues to illustrate how that might be done. Without the latter, it is unlikely that therapists will know consistently and with confidence what to do when confronted with traumatic loss or moral injury, or whether their approach is replicable based on an operationalized standard. Indeed, these existing treatments for PTSD are well suited to help service members who are haunted by “should haves” (hindsight bias) and who shoulder an excessive amount of perceived responsibility due to a known, unequivocal, noncontingent outcome. However, it is unclear how these therapies specifically address the core elements of loss and moral injury among service members, as outlined above.

In many ways, these existing therapies for PTSD do not sufficiently consider the distinct cultural elements of military trauma or the phenomenology of exposure to combat and operational stressors, that is, loss and moral injury. In order to begin to address the gap in the treatment of service members and veterans, a new psychotherapy for PTSD has been developed that is specifically and strategically informed by an understanding of the unique phenomenology of service members’ experience, the warrior culture and ethos, and the diverse stressors and conflicts that arise in battle, especially in the context of guerilla wars of insurgency such as those in Iraq and Afghanistan. This therapy is called adaptive disclosure [12].

Adaptive disclosure is a relatively brief individual therapy that occurs over eight 90-min weekly sessions and employs different strategies to specifically target the unique phenomenology of danger-, loss-, and moral injury-based principal war zone harms [13, 14]. It is designed to help service members and veterans with PTSD experientially and emotionally process these divergent types of war zone harms, allowing them to gain exposure to corrective and more productive ways of construing the implications of their combat experiences, particularly in terms of their military identity, how they feel about themselves, how they relate to other people, and how they construct a narrative about their future.

Adaptive disclosure was predicated on a number of core assumptions and preconditions. First, adaptive disclosure is specifically designed to train providers in understanding, honoring, and accommodating military culture as well as the unique phenomenology of war trauma. This is particularly relevant when delivered within the context of active-duty military life where service members may be struggling with symptoms yet having to prepare for their next deployment or other military roles. Experienced providers in the military and Veterans Affairs (VA) clinics should be well versed in these matters; however, this may not be the case with trainees or civilian providers outside these contexts.

The assumption is that if all clinicians possess adequate knowledge about military culture, and are prepared to hear about every dimension of war experience without judgment, then service members would be more willing to build trust and have confidence that the intensely emotional and evocative engagement that is required when going through adaptive disclosure would be worthwhile. It is also important to bring military roles and expectations into the therapy room and for clinicians to understand the nature of a service member’s job, the degree of leadership responsibility inherent in that role, as well as how all of this may align with their former and current goals and aspirations. This knowledge provides context for clinicians to understand why the service member may be interpreting the events in a particular way as well as allow the clinician to help service members better conceptualize the implications of construing traumatic events with so much condemnation and self-destruction; it may also help inform a more realistic perception of expectations of behavior and responsibility so that service members may reconcile within themselves and move forward in their lives.

Second, the approach is based on the premise that the goal of the therapy should be to create a foundation for healing, repair, and recovery; in other words, treatment serves as an introduction to a different way of dealing with the psychological, behavioral, and spiritual legacy of combat and operational events, rather than an end point. Although it is possible for meaningful change to occur over the course of treatment, the brevity of adaptive disclosure and the chronicity of complex PTSD secondary to combat trauma make it unrealistic to assume that all symptoms will be eradicated and maladaptive cognitions and schemas supplanted with more realistic ones upon completion of the therapy. For many service members and veterans, a complete and total cure may not be possible and they should prepare themselves for life-long challenges. Instead, the idea behind adaptive disclosure is to “plant seeds” of healing through a deeper understanding of the context of events, moving toward acceptance of imperfections within oneself and others.

The third assumption is that active-duty service members and veterans who are treatment naïve may not be well versed in sharing and disclosing their experiences. As such, their narratives of shame- or guilt-based experiences may initially be somewhat disorganized and unduly limited; it typically requires time, along with the development of a trusting therapeutic relationship, for narratives to be properly revealed and processed. However, the reality of life for an active-duty service member is such that there is not a lot of time to do preparatory relationship and trust building. Therefore, by honoring and understanding the military ethos, utilizing a “no-nonsense, let’s get right to it” experiential approach, and targeting issues that resonate deeply with deployed service members, clinicians can create a trust that would otherwise take much longer to cultivate.

Fourth, given that meaning-making is an essential change agent in all forms of psychotherapy, the developers of adaptive disclosure were especially keen to employ strategies to help service members uncover and clarify the meaning they ascribe to the experiences that haunt them, particularly in terms of their identity and behavior as service members and future veterans, as well as in various interpersonal roles they hold in their lives. Perhaps due to the characteristic stoicism reinforced by military identity and training, many service members and veterans have not sufficiently reflected on the meaning and implications of war zone harms, let alone articulated and shared these ideas prior to treatment. Consequently, it is important that service members engage in evocative experiential strategies to unearth constructions of the meaning and implications of war zone harms.

Finally, as a point of departure from conventional CBT approaches, adaptive disclosure does not assume that anguish, shame, and distress are inevitably caused by distorted thinking. In many instances, self-blame or blame of others is not entirely inaccurate, given the values embedded within military culture and particularly in the context of the codependencies of units in battle. Clinicians need to be aware that military training and culture teach service members that their most treasured moral construct—honor—is earned through actions that are identified as just, moral, and ethical, as well as through noble sacrifices. Consequently, perceived transgression is particularly anguishing and disruptive for a service member; it undermines their moral identity by damaging their ability to trust their sustaining moral values and guiding ideals, or to even abide by them. Therefore, in adaptive disclosure, the goal is not necessarily to have the patient challenge the veracity of these conclusions, but rather to respect and honor the foundation from which they come while promoting more adaptive and sensible future possibilities.

At its core, adaptive disclosure entails exposure-based, experiential, and emotion-focused processing of the principal combat or operational experience and a real-time rendering of constructions about the implications of the event in terms of self-view, professional role, expectations about others, and the future. For all trauma types, similar to other CBT-based approaches, adaptive disclosure provides an opportunity for service members and veterans to realize how they have changed as a result of combat and operational experiences, to reflect upon who they want to be, and to create a path of how to get there. Unlike other therapies for PTSD, adaptive disclosure employs strategies that are specific to each type of principal harm. If the service member endorses life-threat as his or her most currently distressing and haunting war zone experience, then the therapy is similar to PE, given that conceptually and empirically PE has been demonstrated to be the treatment of choice for conditioned fear-based PTSD [15]. If the principal event is related to loss or moral injury, separate break-out strategies are used to foster exposure to corrective experience and new learning specific to these dynamics.

The therapy follows a set structure. Each session includes an intense narrative of the traumatic event followed by raw emotional processing of the meaning and implication of the event and an experiential exercise related to the principal identified harm. The narrative is exposure-based in that it requires the patient to recount the event in real time with eyes closed and in great detail. Unlike traditional exposure therapy for life-threat/danger-based PTSD, where the goal is to extinguish conditioned fear and to modify fear-beliefs, adaptive disclosure uses exposure to bring about emotional activation or a “hot-cognitive” state of mind, in order to facilitate deeper meaning-making processing around loss or moral injury . As such, the trauma is told via exposure only once each session, followed by the other treatment elements. Many times the intensity of these experiences elicits a high level of distress and arousal that requires the inclusion of grounding exercises at the end of the session in order for the patient to be returned to a functional state. Each session also includes a written homework assignment that is either related to the content of the current session or preparation for the following session. Some assignments also include behavioral tasks as well.

In cases where loss is most prominent, the emotions and thoughts that are elicited following the trauma narrative usually involve self-blame and guilt. In order to further process these emotions and thoughts, the accompanying experiential exercise entails an imaginal dialogue with the person who was lost. The idea is for the patient to acknowledge, in real time, how the loss has impacted him, what it might mean to the person who was lost, and then for the patient to voice how that person might respond to the patient’s self-destructive ways. The goal is to promote an emotionally charged accommodation of a corrective “message” voiced by the deceased, who would likely only want the patient to live well. In addition to the dialogues in session, the patient is also encouraged to think about and engage in behavioral tasks outside the therapy room that may memorialize the person. This may include going to a specific place that held meaning to the person, visiting a cemetery, reaching out to family members and others who served alongside the person, volunteering for a related cause, or doing an activity that elicits positive associations with that person.

In cases where moral injury is the principal harm, the experiential exercise involves an imaginal “confession” and dialogue with a compassionate, forgiving moral authority or other salient figures (e.g., a subordinate service member or veteran, a “future self,” the harmed victim, etc.) in order to begin to challenge and address the shame and self-defeat that accompany such experiences. There are also homework assignments that include behavioral tasks to initiate the process of moral repair, such as giving back to the community or other ways to engage their innate goodness in a way that might be meaningful to them.

The assumption of adaptive disclosure is that the treatment can start, but cannot finish, the moral repair process. It is believed that self-forgiveness and the possibility of living a moral and virtuous life will ultimately require significant life-course changes for most veterans of war. Moreover, the goal is not to attempt to eradicate or fully replace the service member’s self-constructions of moral compromise, as this is unlikely to occur within the context of such a short intervention, but rather to foster a more balanced perspective of the event, a deeper understanding of the context of the injury, and forward movement. Adaptive disclosure aims to help the patient accept the part of him or herself that engaged in or was subjected to morally transgressive acts without overly attempting to modify constructions about culpability or the moral implications of the event(s). At the same time, the therapy is designed to help the patient reclaim goodness and humanity and to manifest those parts in his life as prominently as possible.

Here, a case study will be reported in which adaptive disclosure was used to target moral injury in a recently discharged Marine who suffered from combat-related PTSD. This case was treated in a VA outpatient specialty care context.