Moral injury refers to an injury to an individual's moral conscience resulting from an act of perceived moral transgression which produces profound emotional shame. The concept of moral injury emphasizes the psychological, cultural, and spiritual aspects of trauma. Distinct from pathology, moral injury is a normal human response to an abnormal event. The concept is currently used in literature about the mental health of military veterans who have witnessed or perpetrated an act in combat that transgressed their deeply held moral beliefs. Moral injury can also be experienced by those who have been transgressed against. For example, when one goes to war thinking that the purpose of the war is to eradicate weapons of mass destruction, but finds that not to be case, the warrior can experience moral injury. Those who have seen and experienced death, mayhem, destruction, and violence have had their worldviews shattered - the sanctity of life, safety, love, health, peace, etc. - can suffer moral injury as well.
Development of Moral Injury
The development of moral injury has been inextricably tied to the psychological consequences of war. To understand the development of the construct of moral injury, it is necessary to examine the history of violence and it psychological consequences. Throughout history, humans have been killing each other, and have shown great reluctance in doing so. Literature on warfare emphasizes the moral anguish soldiers feel in combat, from modern military service members to ancient warriors. Ethical and moral challenges are expected from warfare. 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.
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. However, the literature reflects that moral injury was developed as a response to the inadequacy of mental health diagnoses to encapsulate the moral anguish service members were experiencing after returning home from war. Service members are routinely exposed to death, injury, and violence. Military service members represent the population with the highest risk of developing Posttraumatic Stress Disorder (PTSD). 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. 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. PTSD includes four symptom clusters, including intrusion, avoidance, and negative mood and thoughts, and changes in arousal and reactivity. 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.
While these 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. 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 current diagnoses’ inability to account for moral anguish, research has begun to search to encapsulate moral conflict in warriors. The phrase ‘moral injury’ was defined by Brett Liz 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. As someone wrestles with the impact of what they did or failed to do, 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. 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.
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. Additionally, 20% reported being responsible for the death of a non-combatant. 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. Research has shown that longer and more frequent deployments can result in an increase in unethical behaviors on the battlefield. This is problematic considering deployment lengths have increased for the war in Iraq and Afghanistan. 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. 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. The ethical code back home has not changed, making the transition from deployment to home difficult for some service members. 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.
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.” 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. The result is increased risk of suicide due to demoralization, self-harming, and self-handicapping behaviors.
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.
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.” 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 his or her experience….” 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. Despite this, decisions made by service members who engage in killing or violence through this cultural lens may still experience psychological and spiritual impact. Fully coming “home” means integration into a culture where one is accepted, valued and respected, has a sense of place, purpose, and social support.
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.” This occurs when veterans struggle with a lost sense of humanity after transgressing deeply held moral beliefs. The Soul Repair Center at Brite Divinity School is dedicated to addressing moral injury from this spiritual perspective. Research by Dr. Lindsay Carey at La Trobe University (Melbourne, Australia) and Tim Hodgson at the University of Queensland (Brisbane, Australia) clearly confirms that clergy, and chaplains in particular, have a key role with regard to moral injury and spiritual care. US Army chaplains, particularly at the US Army Medical Department Center & School, are 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.
Treating Moral Injury
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. 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 (PTSD). When considering the impact of shame in PTSD, shame is known to be highly correlated with each cluster of symptoms of PTSD. 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. Additionally, it has been shown that allowing feelings of shame to go untreated can have deleterious effects. This can often make the identification of moral injury in a service member difficult because shame tends to increase slowly over time. Shame has been linked to complications such as interpersonal violence, depression, and suicide. 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.
- Litz, BT; Stein, N; Delaney, E; Lebowitz, L; Nash, WP; Silva, C; Maguen, S (2014-11-12). "Moral injury and moral repair in war veterans: a preliminary model and intervention strategy". Clin Psychol Rev. 29: 695–706. doi:10.1016/j.cpr.2009.07.003. PMID 19683376.
- Rita Nakashima and Gabriella Lettini, Soul Repair: Recovering from Moral Injury After War (Boston: Beacon Press, 2012).
- Maguen, Shira; Litz, Brett. "Moral Injury in the Context of War". PTSD: National Center for PTSD. U.S. Department of Veterans Affairs. Retrieved December 13, 2015.
- Bica, Camillo Mac; Thomas, Claude AnShin (2016-01-01). Beyond PTSD: The Moral Casualties of War (1st ed.). Gnosis Press. ASIN 099682071X. ISBN 9780996820714.
- Grossman, Dave (2009). "On combat: the psychology and physiology of deadly conflict in war and in peace". Illinois: Warrior Science Pub.
- Brock, Rita (2013). "Soul repair: Recovering from moral injury after war". The Right to Heal: Holding the US Accountable for the Human Costs of War.
- Blinka, Dee (2016). "Moral injury in warriors and veterans: The challenge to social work". Social Work & Christianity. 43 (3): 7–27.
- Litz, Brett (2009). "Moral injury and moral repair in war veterans: A preliminary model and intervention strategy". Clinical Psychology Review. 2 (8): 695–706. doi:10.1016/j.cpr.2009.07.003.
- American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, D.C.: Author.
- Farnsworth, Jacob (2014). "The role of moral emotions in military trauma: Implications for the study and treatment of moral injury". Review of General Psychology. 18 (4): 249–262. doi:10.1037/gpr0000018.
- Drescher, Kent (2011). "An exploration of the viability and usefulness of the construct of moral injury in war veterans". Traumatology. 17 (1): 8013.
- Gaudet, Camille; Sowers (2016). "A review of PTSD and shame in military veterans". Journal of Human Behavior in the Social Environment. 26 (1): 56–68. doi:10.1080/10911359.2015.1059168.
- Mental Health Advisory Team (MHAT-IV). (2006, November 17). Operation Iraqi Freedom 05- 07. Retrieved December 18, 2008, from http://www.armymedicine.army.mil/reports/mhat/mhat_iv/mhat-iv.cfm
- Jonathan Shay, Odysseus in America: Combat Trauma and the Trials of Homecoming (Scribner, 2010).
- "Soul Repair : Brite Divinity School". Brite.edu. 2014-06-20. Retrieved 2015-03-04.
- Carey, Lindsay & Hodgson, Timothy et al (2016) 'Moral Injury, Spiritual Care and the Role of Chaplains'. https://rd.springer.com/article/10.1007/s10943-016-0231-x
- "U.S. Army Medical Department Center & School Portal". www.cs.amedd.army.mil. Retrieved 2016-10-20.
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