Moral injury

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Moral injury refers to an injury to an individual's moral conscience and values resulting from an act of perceived moral transgression,[1] which produces profound emotional guilt and shame[2], and in some cases also a sense of betrayal,[1] anger and profound "moral disorientation"[3]. The concept of moral injury emphasizes the psychological, social, cultural, and spiritual aspects of trauma.[1] Distinct from psychopathology, moral injury is a normal human response to an abnormal traumatic event.[1][4] The concept is currently used in literature with regard to the mental health of military veterans who have witnessed or perpetrated an act in combat that transgressed their deeply held moral beliefs and expectations.[5] Moral injury can also be experienced by warriors who have been transgressed against, and thus also in circumstances other than combat. The injury may in those cases include a sense of betrayal and anger.[6] For example, when one goes to war believing that the purpose of the war is to eradicate weapons of mass destruction, but finds that not to be the case, the soldier can experience moral injury. Those who have seen and experienced death, mayhem, destruction, and violence and have had their worldviews shattered – the sanctity of life, safety, love, health, peace, et cetera – can also suffer moral injury. This injury can also occur in the medical space – among physicians and other emergency or first responder care providers who engage in traumatic high impact work environments which can affect their mental health and well-being.[7]

Development of moral injury[edit]

The term moral injury was first coined by psychiatrist professor Jonathan Shay and colleagues based upon numerous narratives presented by military/veteran patients given their perception of injustice as a result of leadership malpractice. Shay's definition of moral injury had three components: 'Moral injury is present when (i) there has been a betrayal of what is morally right, (ii) by someone who holds legitimate authority and (iii) in a high-stakes situation.[8][9][10] Since this original definition, other definitions have subsequently developed.[11]

To understand the development of the construct of moral injury, it is necessary to examine the history of violence and the psychological consequences. Throughout history, humans have been killing each other, and have shown great reluctance in doing so.[12] Literature on warfare emphasizes the moral anguish soldiers feel in combat, from modern military service members to ancient warriors.[13] Ethical and moral challenges are expected from warfare.[14] Soldiers in the line of duty may witness catastrophic suffering and severe cruelty, causing their fundamental beliefs about humanity and their worldview to be shaken.[2]

Research has begun to look at the concept of moral injury to understand the impact that combat may have on soldiers, and their mental health afterwards. Currently, no systematic reviews or meta-analyses exist on the construct of moral injury – although a literature review of the various definitions since the inception of moral injury has been undertaken.[11] Some of the literature reflects that moral injury was developed as a response to the inadequacy of mental health diagnoses (e.g., Post-traumatic stress disorder), to encapsulate the moral anguish service members were experiencing after returning home from war.[2] Service members who are deployed into war zones are usually exposed to death, injury, and violence. Military service members represent the population with the highest risk of developing Post-traumatic stress disorder (PTSD).[15] PTSD was first included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders, the manual classifying mental health disorders published by the American Psychiatric Association, to begin to address the symptoms that Vietnam veterans exhibited after their wartime experiences.[2] As PTSD has developed as a diagnosis, it requires that individuals are either directly exposed to death, threatened death, serious injury, or sexual violence, witness it in person, learn about it occurring indirectly to a close relative or friend, or are repeatedly exposed to aversive details of traumatic events.[15] PTSD includes four symptom clusters, including intrusion, avoidance, and negative mood and thoughts, and changes in arousal and reactivity.[15] Individuals with PTSD may experience intrusive thoughts as they re-experience the traumatic events, as well as avoiding stimuli that reminds them of the traumatic event, and have increasingly negative thoughts and moods. Additionally, individuals with PTSD may exhibit irritable or aggressive, self-destructive behavior, and hypervigilance, amongst other arousal-related symptoms.[15]

While PTSD symptoms can have devastating effects, in the first review of moral injury, Litz and co-authors argued that service members may experience long-term pain and suffering stemming from their time in combat that is not encapsulated or represented by a diagnosis of PTSD. Unlike PTSD's focus on fear-related symptoms, moral injury focuses on symptoms related to guilt, shame, anger, and disgust.[16] A diagnosis of PTSD in the DSM-III listed an individual experiencing guilt for behaviors that required for their survival as a symptom. However, conceptualizations of PTSD in each subsequent DSM has dropped guilt as a symptom.

With the inability of current diagnoses to account for moral anguish, research has begun to encapsulate moral conflict in warriors.[17] The phrase 'moral injury' (originally defined by Jonathan Shay[10]) was modified by Brett Litz and colleagues (2009) as "perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long term, emotionally, psychologically, behaviorally, spiritually, and socially" (p. 695). Treating moral injury is often thought of as "soul repair" due to the nature of moral anguish.[13] As someone wrestles with the impact of what they did, failed to do, or witnessed, it can seem like their entire guiding principles for life have been altered or removed. The consequences of moral injury can be disastrous. An individual with a moral injury can experience severe distress, including major depression, and suicidality.[2] While moral injury can be experienced by people other than military service members, current research has paid special attention to moral injury in military populations.[2]

Military culture[edit]

Although moral injury does not only exist among military populations, the exposure to violence that occurs during war times make military and veteran population at a higher risk of developing moral injury. It has been reported that 32% of service members deployed to Iraq and Afghanistan were responsible for the death of an enemy and 60% stated that they had witnessed both women and children who were either ill or wounded that they were unable to provide aid to.[2] Additionally, 20% reported being responsible for the death of a non-combatant.[2] These statistics were taken in 2003 and an updated survey of the number of service members who have been directly responsible for the death of an enemy, a non-combatant, or having to leave sick and wounded women and children behind can shed light onto the magnitude of the issue of moral injury among service members.

During times of war a service member's personal ethical code may clash with what is expected of them during war. Approximately 27% of deployed soldiers have reported having an ethical dilemma to which they did not know how to respond.[18] Research has shown that longer and more frequent deployments can result in an increase in unethical behaviors on the battlefield.[19] This is problematic considering deployment lengths have increased for the war in Iraq and Afghanistan.[2][19] During times of war the military promotes an ethical pardon on the killing of an enemy, going against the typical moral code for many service members.[2] While a service member is deployed, killing of the enemy is expected and often rewarded. Despite this, when a service member returns home the sociocultural expectations are largely different from when they were deployed.[2] The ethical code back home has not changed, making the transition from deployment to home difficult for some service members.[18] This clash in a personal ethical code and the ethical code and expectations of the military can further increase a service member's deep-seated feelings of shame and guilt for their actions abroad.

Psychological perspective[edit]

Brett Litz and colleagues can be credited for major developments in the psychological perspective on moral injury. They define moral injury as "perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations."[2] Litz and colleagues focus on the cognitive, behavioral, and emotional aspects of moral injury in a preliminary conceptual model. This model posits that cognitive dissonance occurs after a perceived moral transgression resulting in stable internal global attributions of blame, followed by the experience of shame, guilt, or anxiety, causing the individual to withdraw from others.[2] The result is increased risk of suicide due to demoralization, self-harming, and self-handicapping behaviors.[2]

Psychological risk factors that make an individual more prone to moral injury includes neuroticism and shame-proneness. Protective factors includes self-esteem, forgiving supports, and belief in the just-world hypothesis.[2]

Social and cultural perspective[edit]

The concept of moral injury was introduced by clinical psychiatrist Jonathan Shay, and the cultural perspective on moral injury has been developed in his work. He defines moral injury as stemming from the "betrayal of 'what's right' in a high-stakes situation by someone who holds power."[20] The process of recovery, according to Shay, should consist of "purification" through the "communalization of trauma." Shay places special importance on communication through artistic means of expression. Moral injury can only be absolved when "the trauma survivor… [is] permitted and empowered to voice their experience…."[20] For this to occur, there needs to be openness on the part of civilians to hear the veterans' experiences without prejudice. The culture in the military emphasizes a moral and ethical code that normalizes both killing and violence in times of war.[2] Despite this, decisions made by service members who engage in killing or violence through this cultural lens may still experience psychological and spiritual impact.[2] Fully coming "home" means integration into a culture where one is accepted, valued and respected, has a sense of place, purpose, and social support.[20]

Research on the political and societal aspects of moral injury by anthropologist Tine Molendijk has shown that as unresolved conflicts at the political level create potentially morally injurious situations for soldiers on the ground, "experiences of institutional betrayal" and "a resultant search for reparations" by veterans can also be part of moral injury.[6] Also, it is indicated that both public condemnation and public heroification of veterans may contribute to moral injury, given that both are generally experienced by veterans as alienating distortions of their war experience, meaning that both may entail an "injustice" being done to the experience.[21]

Spiritual perspective[edit]

Major developments in the spiritual perspective on moral injury can be credited to Rita Nakashima Brock and Gabriella Lettini. They emphasize moral injury as "…souls in anguish, not a psychological disorder."[4] This occurs when veterans struggle with a lost sense of humanity after transgressing deeply held moral beliefs.[4] The Soul Repair Center at Brite Divinity School is dedicated to addressing moral injury from this spiritual perspective.[22] Research by Dr. Lindsay Carey at La Trobe University (Melbourne, Australia) and Tim Hodgson at the University of Queensland (Brisbane, Australia) confirm the importance of spirituality with regard to moral injury, and that community clergy, or chaplains in particular, have a key role with regard to providing spiritual care for those suffering a moral injury.[23] US Army chaplains, particularly at the US Army Medical Department Center & School, are also addressing the spiritual aspects of moral injury and the chaplains' role in assisting the healing process, by teaching and engaging in further research about moral injury.[24]

As noted however by Carey and Hodgson,[11] when it comes to conducting research there have emerged approximately seventeen (n = 17) different definitional variations of 'moral injury' since Jonathan Shay's original term,[25] causing confusion and making both research and treatment interventions by chaplains a serious challenge. While some have argued that moral injury is predominantly a 'psychological issue' or purely a 'spiritual' or 'religious' issue, Carey and Hodgson argue for a 'bio-psycho-social-spiritual' paradigm to be utilsed when defining, screening, assessing, or treating moral injury, so as to ensure that biological, psychological, social and spiritual aspects are equally considered in correlation; that is, moral injury should be considered as a bio-psycho-social-spiritual syndrome. It is with this perspective that Lindsay Carey (Australia), John Swinton (UK) and Daniel Grossoehme (USA),[26] provide a comprehensive holistic definition of moral injury based on the systematic reviews of Jinkerson[27] plus Hodgson and Carey.[11]

“Moral injury is a trauma related syndrome caused by the physical, psychological, social and spiritual impact of grievous moral transgressions, or violations, of an individual's deeply-held moral beliefs and/or ethical standards due to: (i) an individual perpetrating, failing to prevent, bearing witness to, or learning about inhumane acts which result in the pain, suffering or death of others, and which fundamentally challenges the moral integrity of an individual, organization or community, and/or (ii) the subsequent experience and feelings of utter betrayal of what is right caused by trusted individuals who hold legitimate authority.

The violation of deeply-held moral beliefs and ethical standards—irrespective of the actual context of trauma—can lead to considerable moral dissonance, which if unresolved, leads to the development of core and secondary symptoms that often occur concurrently. The core symptoms commonly identifiable are: (a) shame, (b) guilt, (c) a loss of trust in self, others, and/or transcendental/ultimate beings, and (d) spiritual/existential conflict including an ontological loss of meaning in life. These core symptomatic features, influence the development of secondary indicators such as (a) depression, (b) anxiety, (c) anger, (d) re-experiencing the moral conflict, (e) social problems (e.g., social alienation) and (f) relationship issues (e.g., collegial, spousal, family), and ultimately (g) self-harm (i.e., self-sabotage, substance abuse, suicidal ideation and death)” (Carey & Hodgson, 2018).[28]

Carey and Hodgson,[23] using the World Health Organization ICD-10-AM 'Spiritual Intervention Codings' (WHO-SPICs) as a paradigm, argue that clergy/chaplains have four key roles with regard to moral injury: (i) Spiritual Assessments (including screening), (ii) Spiritual Education and Counselling, (iii) Spiritual Support and (iv) Spiritual Ritual and Worship activities. The WHO-SPICs provide a framework for not only ensuring and evaluating the breadth and provision of quality spiritual care, but in addition (given contemporary moral injury is a relativey recent phenomena), the WHO-SPICs also provide a framework for considering the appropriate resourcing and implemention of such interventions for the benefit of those suffering the effects of a moral injury. Timothy Hodgson, an experienced veteran chaplain, proposed a new technique, "Pastoral Narrative Disclosure" (PND), for chaplains engaging in the 'spiritual counselling and education' of military veterans suffering moral injury. PND comprises eight stages: Rapport, Reflection, Review, Reconstruction, Restoration, Ritual, Renewal and Reconnection. [29] PND is currently undergoing the process of validation, however many clergy/chaplains will be familiar with components of PND, which as a holistic spiritual care model looks to be systematically comprehensive.[30]

Treating moral injury[edit]

There is little that is known about the treatment of moral injury. Gaudet and colleagues (2015) suggest that current interventions are lacking and new treatment interventions specific to moral injury are necessary. It is not enough to treat moral injury in the same way that depression or PTSD are commonly treated.[2] In spite of the lack of research on the treatment of moral injury, factors such as humility, gratitude, respect and compassion have shown to either be protective or provide for hope for service members.

Although there is a delineation between PTSD and moral injury, the shame that many individuals face as a result of moral injury may predict symptoms of posttraumatic stress disorder.[18] When considering the impact of shame in PTSD, shame is known to be highly correlated with each cluster of symptoms of PTSD.[18] Although no definitive treatment for moral injury has been found, it is hypothesized that treating the underlying shame that is often associated with service member's symptoms of PTSD is necessary.[18] Additionally, it has been shown that allowing feelings of shame to go untreated can have deleterious effects.[18] This can often make the identification of moral injury in a service member difficult because shame tends to increase slowly over time.[2] Shame has been linked to complications such as interpersonal violence, depression, and suicide.[18] Although there are no systematic reviews or meta-analyses on the treatment of moral injury, Litz and colleagues (2009) have hypothesized a modified version of CBT that addresses three key areas of moral injury: "life-threat trauma, traumatic loss, and moral injury Marines from the Iraq and Afghanistan wars." Although a significant amount of research on moral injury and specifically the treatment of it is still lacking, these proposed treatments and protective factors provide researchers with a starting foundation.

Moral injury of physicians[edit]

Moral injury in the context of healthcare was directly named in the Stat News article by Drs. Wendy Dean and Simon Talbot, entitled "Physicians aren't 'burning out.' They're suffering from moral injury."[7] While technically not a 'moral injury' according to any of the multiple definitions relating to moral injury (refer Hodgson and Carey, 2017 [31]), nevertheless the article and concept goes on to explain that physicians (in the United States) are caught in double and triple and quadruple binds between their obligations of electronic health records, their own student loans, the requirements for patient load through the hospital and number of procedures performed – all while working towards the goal of trying to provide the best care and healing to patients possible. However, the systemic issues facing physicians often cause deep distress because the patients are suffering, despite a physician's best efforts. This concept of moral injury in healthcare[32] is the expansion of the discussion around compassion fatigue and 'burnout.'


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