No full-text available
To read the full-text of this research,
you can request a copy directly from the author.
Combat Trauma and Moral Fragmentation: A Theological Account of Moral Injury
Abstract
Moral injury, the experience of having acted (or consented to others acting) incommensurably with one’s most deeply held moral conceptions, is increasingly recognized by the mental health disciplines to be associated with postcombat traumatic stress. In this essay I argue that moral injury is an important and useful clinical construct but that the phenomenon of moral injury beckons beyond the structural constraints of contemporary psychology toward something like moral theology. This something, embodied in specific communal practices, can rescue moral injury from the medical model and the means–end logic of techne and can allow for truthful, contextualized narration of and healing from morally fragmenting combat experiences.
... Thus, MI can be viewed as multidimensional in nature, requiring an interdisciplinary, integrated approach to healing. Kinghorn (2012) has suggested that effectively, all forms of injury or offensepsychological, emotional, biological, social, behavioral, relational, and spiritual-have an element of moral trauma such that a person may question their own moral worth. Similarly, others (Bremault-Phillips et al., 2022;Currier et al., 2015;Hodgson and Carey, 2017;Litz et al., 2009;Pernicano et al., 2022;Usset et al., 2021) have implied that MI's unique psychospiritual phenomenology would be best served with a holistic approach. ...
... Given the increasing number of individuals in need of treatment services for MI, many of whom do not present at mental health treatment centers, it is critical to develop interventions that can be easily disseminated and implemented by a broad group of professionals. Emerging research on MI consistently shows its multidimensional nature, thus requiring an interdisciplinary, holistic approach for healing (Bremault-Phillips et al., 2022;Burkman et al., 2022;Hodgson and Carey, 2017;Kinghorn, 2012;Litz et al., 2009;Pernicano et al., 2022). It is vital that treatment options extend beyond traditional protocols for PTSD, as they have been shown to be ineffective for MI (Steenkamp et al., 2015), likely because of differences between the two conditions (e.g., the clash between a person's conscience and overwhelming existential experiences, spiritual distress such as acute loss of one's faith and erosion of meaning and purpose, appropriately resolving guilt/ blame/shame, and self-forgiveness). ...
... It is vital that treatment options extend beyond traditional protocols for PTSD, as they have been shown to be ineffective for MI (Steenkamp et al., 2015), likely because of differences between the two conditions (e.g., the clash between a person's conscience and overwhelming existential experiences, spiritual distress such as acute loss of one's faith and erosion of meaning and purpose, appropriately resolving guilt/ blame/shame, and self-forgiveness). The 6-FPSF fills this vital need by addressing the psychological, emotional, behavioral, social/ relational, somatic, and spiritual elements of moral trauma (Kinghorn, 2012) and the intra-and interpersonal aspects necessary to foster moral repair (Cornish and Wade, 2015) and moral resilience (Rushton, 2016). The 6-FPSF protocol was designed to facilitate self-forgiveness among those with MI and may be a valuable tool for reestablishing essential bonds of selfworth, trust, and life-sustaining relationships. ...
Conscience is the indestructible core of one’s personal identity and their sense of agency in the world. When it passes judgment against them, it generates inner conflict (i.e., moral injury). At its core, moral injury is about trust and sacred relationships, particularly the loss of safe connection with self, society, God/Divine/a Higher Power, and the world. The clash between a person’s conscience and overwhelming existential or psychospiritual experiences, which uniquely defines moral injury, alienates them from life-sustaining relationships. Healing requires more than reordering fractured belief systems. Reestablishing bonds of self-worth, trust, and life-sustaining relationships are essential. This paper presents the 6-Fold Path to Self-Forgiveness (6-FPSF), an interdisciplinary, narrative-based healing writing process for the treatment of moral injury, particularly self-induced moral injury. Self-forgiveness has been associated with psychospiritual and relational well-being. The protocol draws upon theoretical literature, evidence-based psychological interventions, spiritual-oriented practices, creative arts, and somatic exercises for mental health counseling and spiritual/religious ministration. In addition to describing the 6-component therapeutic model, the author offers intervention strategies for clinicians.
... The concept of moral injury has been praised for pushing the understanding of trauma toward the inclusion of ethical and sociological perspectives (Carey & Hodgson, 2018;Molendijk, 2021). For instance, while trauma-related guilt and anger often tend to be either overlooked or understood as the result of "distorted" cognitions in current PTSD models (American Psychiatric Association, 2013, p. 272), the concept of moral injury incorporates psychodynamic, philosophical and theological perspectives on guilt and anger as possibly reasonable and appropriate, and accordingly as requiring a focus on (self-)forgiveness rather than deresponsibilization (Kinghorn, 2012;Shay, 2014). In relation to this, while the focus of PTSD models often lies on internal psychological processes of the suffering soldier, and on interpersonal processes at most, studies on moral injury inspired by anthropology and other social sciences point out that soldiers' problems are also inextricably linked to wider contextual factors such as military culture, political mandate and societal attitudes (Farnsworth, 2014;Hautzinger & Scandlyn, 2013;Shay, 2014). ...
... However, most current studies on moral injury -while simultaneously asserting that moral injury is not an official diagnosis -are currently working on developing workable clinical models for moral injury, seeking to facilitate the clinical assessment and diagnosis of moral injury and its relation to PTSD, and developing therapies for moral injury (see e.g., the reviews of Frankfurt & Frazier, 2016;Griffin et al., 2019;Koenig et al., 2019;Williamson et al., 2018). Consequently, and probably unintentionally as many of these studies explicitly define moral injury as distinct from PTSD, the concept of moral injury risks turning into an individual-focused and pathologizing construct which explains trauma only in terms of intra-psychic and inter-personal processes, and gives sufferers the status of patients with mental disorders (Kinghorn, 2012;Scandlyn & Hautzinger, 2014). Yet, to reiterate, the very reason for moral injury's introduction was that current trauma literature and treatment was found to pay too little attention to ethical and social dimensions of military suffering (Griffin et al., 2019;Koenig et al., 2019;Litz et al., 2009;Shay, 1994). ...
... Therefore, scholars have voiced concern that the concept of moral injury actually risks to distort what it aims to capture. Despite the concept's de-pathologizing approach, they argue, current research on the concept remains onedimensionally focused on diagnosis and treatment, unintentionally reducing normative and political questions to individuals' troubled psyches (Kinghorn, 2012;K. T. MacLeish, 2018). ...
The concept of moral injury, referring to the psychological impact of having one’s moral expectations and beliefs violated, is gaining a firm place in research on military trauma. Yet, although moral injury has the recognized potential to extend the understanding of trauma beyond the individualizing and pathologizing focus of the clinical realm, most studies nevertheless focus on clinical assessment, diagnosis and treatment. This review aims to contribute to a better understanding of contextual dimensions of moral injury. To this end, it complements current theory on moral injury with a systematic review of literature relevant to contextual factors in moral injury. It draws together insights from psychology, philosophy, theology and social sciences into spiritual/existential, organizational, political and societal dimensions of moral injury. Thus an interdisciplinary theoretical foundation is created for context-sensitive research and interventions.
... Some have argued that moral distress and deployment-related suffering more generally should be understood not only as psychological damage but also as painful knowledge about the self and the world , Wiinikka-Lydon 2017, or more concisely, as a 'soul disorder' or 'lost innocence' (Ramsay 2019). More generally, some have pointed out that the concept focuses only on moral injury as a dysfunction that must be treated while failing to actually venture into the ethics of war (Kinghorn 2012, Wilson 2014, Beard 2015. Others, in addition, have signaled that it decontextualizes deployment-related trauma from the political leaders who send soldiers into war and the civilians who 'welcome' them back (MacLeish 2010, Scandlyn andHautzinger 2014). ...
... An important insight drawn from these disciplines is that an individual embodies multiple and potentially competing moral beliefs and assumptions (e.g. , Kinghorn 2012, Hitlin and Vaisey 2013, McConnell 2014. In this section, I will discuss this issue and its implications in more detail. ...
... Several scholars before me have noted that present-day societies lack adequate language for the moral complexities of military practice. Verkamp (1993), for instance, contends that soldiers' feelings of guilt are often reduced to an issue that needs psychological treatment, while Kinghorn (2012) argues that the moral aspects of war acts tend to be judged in legal terms only, namely by the standards of the Geneva Conventions and military Rules of Engagement. Verkamp (1993) and , moreover, point out that societies used to have spiritual and symbolic practices to guide warriors through warfare, but these no longer exist. ...
... Some have argued that moral distress and deployment-related suffering more generally should be understood not only as psychological damage but also as painful knowledge about the self and the world , Wiinikka-Lydon 2017, or more concisely, as a 'soul disorder' or 'lost innocence' (Ramsay 2019). More generally, some have pointed out that the concept focuses only on moral injury as a dysfunction that must be treated while failing to actually venture into the ethics of war (Kinghorn 2012, Wilson 2014, Beard 2015. Others, in addition, have signaled that it decontextualizes deployment-related trauma from the political leaders who send soldiers into war and the civilians who 'welcome' them back (MacLeish 2010, Scandlyn andHautzinger 2014). ...
... An important insight drawn from these disciplines is that an individual embodies multiple and potentially competing moral beliefs and assumptions (e.g. , Kinghorn 2012, Hitlin and Vaisey 2013, McConnell 2014. In this section, I will discuss this issue and its implications in more detail. ...
... Several scholars before me have noted that present-day societies lack adequate language for the moral complexities of military practice. Verkamp (1993), for instance, contends that soldiers' feelings of guilt are often reduced to an issue that needs psychological treatment, while Kinghorn (2012) argues that the moral aspects of war acts tend to be judged in legal terms only, namely by the standards of the Geneva Conventions and military Rules of Engagement. Verkamp (1993) and , moreover, point out that societies used to have spiritual and symbolic practices to guide warriors through warfare, but these no longer exist. ...
... Serious psychological problems such as posttraumatic stress disorder (PTSD) and moral injury (MI) can arise (11,15), leaving military members contending with intrusive thoughts, impulsivity, suicidal ideation, sleep disturbances, or substance use; avoiding experiential triggers; and engaging in maladaptive coping, aggressive, self-harming, self-handicapping, or demoralizing behaviors, all of which can be debilitating (11,13,16). More fundamentally, individuals can be impacted at the deepest level of their being (17) and spirit (18). As a result, consideration of the spiritual dimension is needed when trying to understand the impact of exposure to MIEs and prevention and treatment of MI. ...
... The literature reflects a close association between MI and spirituality (11,18,46,(53)(54)(55)(56)(57)(58)(59)(60)(61)(62)(63)(64)(65), with spirituality being described as underlying MI and MI having an equally salient impact on spirituality (55,58,(61)(62)(63)(64)(65)(66)(67)(68). A person's spiritual worldview contributes to the development of MI, with rigid religious principles and expectations potentially enhancing guilt and (18,54). ...
... The literature reflects a close association between MI and spirituality (11,18,46,(53)(54)(55)(56)(57)(58)(59)(60)(61)(62)(63)(64)(65), with spirituality being described as underlying MI and MI having an equally salient impact on spirituality (55,58,(61)(62)(63)(64)(65)(66)(67)(68). A person's spiritual worldview contributes to the development of MI, with rigid religious principles and expectations potentially enhancing guilt and (18,54). Spirituality is also identified both as a protective factor against MI (55,58,70,71) and as a means of coping with MIEs. ...
Introduction: Moral injury (MI) results when military personnel are exposed to morally injurious events that conflict with their values and beliefs. Given the complexity of MI and its physical, emotional, social, and spiritual impact, a holistic approach is needed. While the biopsychosocial aspects of MI are more commonly addressed, less is known of the spiritual dimension and how to incorporate it into treatment that facilitates restoration of one’s core self and mending of relationships with self, others, and the sacred/Transcendent. The purpose of this study was to gain a greater understanding of the relationship between spirituality/religion (S/R) and MI as experienced by military members and veterans and to consider how S/R might be better integrated into prevention and treatment strategies.
Methods: A mini-review of peer-reviewed articles published between January 2000 and April 2018 regarding the relationship between spirituality and MI among military personnel and veterans was conducted.
Results: Twenty-five articles were included in the final review. Five themes were identified and explored, including i) Spirituality: A potential cause of and protective factor against MI, ii) Self and identity: Lost and found, iii) Meaning-making: What once was and now is, iv) Spirituality as a facilitator of treatment for MI, and v) Faith communities: Possible sources of fragmentation or healing.
Discussion: Findings identified a cyclical relationship between S/R and MI, whereby S/R can both mitigate and exacerbate MI, as well as be affected by it. Seen as a type of S/R struggle, the use of S/R-specific strategies [e.g., forgiveness, review of S/R beliefs, engagement in S/R practices, and (re)connection with S/R communities], integration of S/R perspectives into general interventions, and help from chaplains may support healing, self-regulation, and mending of relationships, moral emotions, and social connection. Further research is yet needed, however, regarding i) S/R orienting systems, interventions, practices, and rituals/ceremonies that might protect against and treat MI; ii) features of individuals who do/do not experience MI; iii) S/R assessment tools and interventions; and iv) ways to maximize the positive contributions of faith communities.
... After all, there is a recognition that these veterans were often confronted with impossible situations, and self-aware individuals consider how they might have responded under duress. Paradoxically, those in the decades well after the Vietnam era have come home to a country and community more willing to commend them for their time and sacrifice, but for some, the public valorization of service can bring more pain than joy (Kinghorn, 2012;Purcell et al., 2016). Thus, while the public cheers and thanks them for their service, some veterans are painfully trying to come to terms with actions and behaviors that they cannot, at the moment, reconcile with their personal values and code of conduct. ...
... 703) Singer (2004) posits that if the individual is going to move past trauma and moral wounds, in the end, forgiveness must come from within the person, with additional help, where needed, coming from professionals and other members of their support system. Kinghorn (2012) notes that due to a medicalized view of PTSD, too often trauma therapies become tools that serve the narrow goal of reducing the symptoms of suffering. However, when moral injury is at hand, symptom relief is not the ultimate goal. ...
... In some cases, restoration of spiritual beliefs and participation in what may be considered sacred rituals and practices may be key to healing. As Kinghorn (2012) suggests, such activities "place the healing of combat trauma within a richly contextual context that clinical psychology cannot" (p. 67). ...
As our understanding of trauma is expanding, greater consideration is being given to factors such as moral injury and spirituality. Moral injury appears to be especially pertinent in the case of war-related trauma, as one may not only be the victim of, or witness to, troubling events but also be the perpetrator of acts that run counter to personal values. For some, moral beliefs and values and key elements of the assumptive world are intertwined with spiritual and religious matters. This article discusses moral injury and repair in the context of spiritually and culturally sensitive practice. Strategies for addressing issues such as moral anguish, loss of meaning, identity disturbance, guilt and shame, forgiveness, and spiritual struggle are discussed.
... It is reflected in the destruction of moral identity and loss of meaning. Its symptoms include shame, survivor guilt, depression, despair, addiction, distrust, anger, a need to make amends and the loss of a desire to live' (p. 1) Kinghorn (2012) '. . .the experience of having acted (or consented to others acting) incommensurably with one's most deeply held moral conceptions' (p. ...
... These tensions can heighten intrapersonal trauma, manifesting as symptoms and emotions described as moral injury (Kruger 2017;Moon 2019). Moral injury, therefore, is founded in moral judgement and subsequently requires a working conscience for one to be vulnerable to it (Kinghorn 2012). ...
Moral injury is the current term describing the breaching or violation of one's moral code and has gained international research attention due to suicide linkages in military populations (Jamieson et al., Invisible wounds and suicide: Moral injury and veteran mental health. International Journal of Mental Health Nursing, 29, 105-109, 2020). Moral injury's core features are spiritual/existential conflict, shame, guilt and self-condemnation. To date, research focuses on the core features of moral injury and or the nature of events that exposed individuals to moral injury. Walker and Avant (Strategies for Theory Construction in Nursing, Prentice Hall New York, 2011) concept analysis model was used to examine the literature. The aim of this study is to enhance understanding of the defining attributes, antecedents, consequences and empirical referents of moral injury and systematically analyse the concept of moral injury in the context of military members. A literature search was undertaken using specific websites and journals, electronic databases, library catalogues and hand-searches. Concept analysis was used to explicate moral injury, focusing exclusively on use of the concept in the included literature, comparing the terms used over time and across disciplines, and measurement tools for the concept. This concept analysis provides a renewed definition of moral injury in relation to the experience of veterans-'moral trauma' and defined as: 'the existential, psychological, emotional and or spiritual trauma arising from a conflict, violation or betrayal, either by omission or commission, of or within one's moral beliefs or code(s)'. The analysis will facilitate understanding and operationalization of the concept applied to teaching, learning, practice and research.
... While the concept of moral injury has been developed in psychological circles as a psychological condition, scholars in the fields of humanities and social sciences have argued that the phenomenon can never be understood in isolation from its context (Boudreau, 2011;Kinghorn, 2012;MacLeish, 2018;Shay, 1994Shay, , 2014. As they argue, when understanding moral injury merely in terms of guilt and shame, a disproportionate part of the issue is located in the minds of individuals. ...
... Rather than reducing moral injury to an internally contained condition solely situated in people's minds, it should be appreciated as embedded in external factors, agents, and structures (cf. Boudreau, 2011;Kinghorn, 2012;MacLeish, 2018;Shay, 1994Shay, , 2014. ...
There is widespread agreement that lower level organizational members face moral challenges because their personal values conflict with organizational directions. Yet we argue that intentional strategic ambiguity, too, may lead to moral challenges, particularly among organizational members operating in high-stake situations. Drawing on interviews with border guards deployed during the European migration crisis, we use vignettes to present two coping strategies. First, members may disengage from moral challenges and redefine their work as a clear-cut duty. Second, they may embrace moral disorientation and conflicts, and follow felt moral obligations. Both may lead to “moral injury.” Moral injury refers to psychological suffering that is engendered by performing, failing to prevent, or falling victim to actions that conflict with one’s moral belief system. We make three theoretical contributions by (a) identifying the roots of moral challenges in strategic decision-making, (b) signaling different coping mechanisms, and (c) challenging pragmatic perspectives on strategic ambiguity.
... As an extension of the intra-and interpersonal repair that can occur in such groups, many have argued for community integration as a necessary component of healing from moral wounds [13,14]. We are especially intrigued by the possibilities contained within religious and cultural rituals, so much so that incorporating ritual is considered a core component of moral injury care for some from our perspective [15]. ...
Purpose of Review
Integrative Mental Health (IMH), a program office in the Department of Veterans Affairs (VA) devoted to advancing integrated mental health and spiritual care, was coincidentally launched the same year that moral injury was introduced into the scientific literature. Given the psychological, social, and spiritual dynamics operative within moral injury, IMH has devoted substantial attention to how mental health professionals and chaplains can collaborate in the care of moral injury, especially as part of co-led groups. This review provides a rationale, history, and overview of ways that IMH has approached moral injury work in VA.
Recent Findings
This review covers how IMH is “piecing together” moral injury efforts in three ways: 1) facilitating mental health professionals and chaplains collaboratively working together; 2) encouraging veterans with moral injury coming together in the context of groups to care for themselves and one another; and 3) piecing together research, clinical quality improvement projects, and community engagement efforts within IMH to mutually inform and enhance each other.
Summary
By engaging multiple disciplines, perspectives, care paradigms, and investigative lenses on moral injury, IMH has sought to cultivate richly layered understandings of moral injury and attending approaches to care.
... As previously mentioned, the BPPS framework advocated in this study aims to supplement the currently used biopsychosocial framework with spiritual elements in order to cover the prevention of the whole spectrum of work, induced psychological distress caused by trauma exposure and moral suffering. The extant research makes it clear, and so does the quantitative findings from the current study, that R/S matters are intimately linked to moral Page 48 of 96 suffering (Carey & Hodgson, 2018;Kinghorn, 2012;Litz et al., 2009;Molendijk, 2018;Nieuwsma, 2015;Phoenix Australia & Canadian Centre of Excellence -PTSD, 2020;Wortmann et al., 2017;Yeterian et al., 2019). ...
The NSW Centre for Work Health and Safety partnered with a Charles Sturt University to develop a framework to prevent psychological harms in first responder organisations.
The research involved:
Quantitative studies: Gathering data directly from first responders through surveys and analysis.
Deep diving into lived experiences: Exploring 21 Australian first responder autobiographies and interviewing their authors.
Critical reflection through practical theology: Illuminating the data, questioning existing approaches, and proposing alternative solutions.
The study has resulted in the development of a biopsychosocial-spiritual (BPSS) framework. By integrating spiritual aspects into the traditional biopsychosocial model, the BPSS framework goes beyond managing trauma. It directly addresses moral injury, a deep psychological wound inflicted by betrayal from authorities in high-stakes situations.
... J. Griffin et al., 2019;Williamson et al., 2018). At the same time, a growing body of literature points out that the specific potential of the concept lies in drawing attention to the often complicated ethical and social dimensions of military suffering, aspects which have received marginal attention in trauma literature (Kinghorn, 2012;Scandlyn & Hautzinger, 2014;Shay, 2014). Indeed, when veterans speak about feeling guilty, ashamed and angry about what they have done, failed to do, or had to witness, they speak about an experience of moral conflict engendered by, for instance, confrontations with tragic dilemmas in which they had to choose between two evils Rietveld, 2009;Sherman, 2015). ...
‘There will be no development without security and no security without development’ (Annan, 2005). This mantra became the foundation for many missions—a combination of security forces and development strategies—and has been given various names, such as ‘comprehensive approach’, ‘whole of government approach’ and ‘3D -approach’. To date the future of this approach is far from certain. This chapter evaluates the application of the comprehensive approach of the last decades by connecting it to three perspectives on the human security concept, leading to the conclusion that the future of the comprehensive approach as a feasible option for military interventions depends on which version of human security becomes dominant in policy making.
... In contrast with this trajectory, the care of those who come home from war remains largely depoliticized. The wounds of war are personal and political, and care requires attending to the political dimension (Kinghorn, 2012;Wiinikka-Lydon, 2017). ...
Pastoral theological scholarship on moral injury has not yet fully metabolized the liberative trajectory of pastoral theological discourse. To date, the care of those who come home from war remains largely depoliticized. This article argues that the wounds of war are personal and political and that care requires attending to the political dimension. The first section of the article sets the current pastoral theology conversation around moral injury within the historical context of the field around the care of veterans and the depoliticized nature of the clinical literature. The second section of the article argues the liberative trajectory of the field provides not only a basis for a robustly political response but also sets of relevant conceptual categories and care resources for veterans. The third section takes up Ryan LaMothe’s concept of “unconventional warriorism” as a basis for reimagining the political agency of soldiers and veterans. The article concludes by sketching out a broad proposal for the integration of politics and care for veterans.
... Indeed, there appears to be something of a mismatch between emerging empirical research on moral injury-which has consistently identified experiences of feeling betrayed by individuals or institutions as major drivers of moral injury (Bryan et al., 2016;Ferrajão & Aragão Oliveira, 2016;Nash & Litz, 2013;Schorr et al., 2018)-and attempts to categorise moral injury as a disorder centred on guilt. This has led to critiques from cross-disciplinary researchers (Antal et al., 2019;Kinghorn, 2012;Molendijk, 2018Molendijk, , 2019Molendijk et al., 2018;Wiinikka-Lydon, 2017) who caution against the pathologisation of moral distress and the privileging of an individualistic and depoliticised focus on guilt and perpetration over Shay's (1994Shay's ( , 2003 original emphasis on betrayal which places emphasis on wider social and organisational contexts. ...
Objective:
Research on 'moral injury'-the psychological wound experienced by military personnel and other 'functionaries' whose moral values are violated-has proliferated in recent years. Many psychological researchers, including those in the UK, have subscribed to an increasingly individualised operationalisation of moral injury, with medicalised criteria that closely mirrors PTSD. This trend carries assumptions that have not been comprehensively verified by empirical research. This study aims to explore UK military veterans' experiences of, and challenges to, their moral values in relation to their deployment experiences, without prematurely foreclosing exploration of wider systemic influences.
Method:
Twelve UK military veterans who served in Afghanistan and/or Iraq were interviewed, and the data were analysed thematically and reflexively.
Results:
Three inter-related themes were generated: (1) 'you've been undermined', (2) 'how am I involved in this?' and (3) 'civilianised'.
Conclusions:
The analysis suggests that several assumptions privileged in moral injury research may be empirically contradicted, at least in relation to the experiences of UK military veterans. These assumptions include that moral injury is exclusively driven by individual, episodic acts of commission and omission, invariably leads to guilt and necessarily bifurcates into variants of either perpetration or betrayal. Instead, participants understood the moral violations they experienced as socially contingent. Rather than 'treating' moral injury as a disorder of thinking and feeling located within an individual, the socially contextualised understanding of moral injury indicated by this study's findings may prompt the development of psychological and social interventions that understand moral injury as the fallout of what occurs between people and within systems.
... Warren Kinghorn argues that the concept of moral injury is important in the study of war trauma because it demands a "critical analysis of the relationship between combat trauma and the moral agency of the acting soldier," 66 FMJ focuses on the dangers of perverting religious faith to convince young recruits that killing is not merely acceptable, but is an act worthy of praise. BFJ highlights how weaponizing religion to prosecute war for ideological ends can traumatize individuals, while de Palma's CW addresses how the American national self was morally compromised because of the Vietnam War. ...
This essay focuses on the representation of religion in Stanley Kubrick's Full Metal Jacket (1987), Oliver Stone's Born on the Fourth of July (1989), and Brian de Palma's Casualties of War (1989). It explores how religion intersects with the experience of moral trauma at an individual level, and how the films portray moral injury to be as damaging an aspect of war trauma for Vietnam veterans as grievous physical harm. Further, the essay considers how moral injury is a fundamental component of the collective trauma the nation experienced and, in turn, the culture wars that erupted during and after the war in Vietnam.
... At the heart of PMIEs and the moral injury that may result are questions of right and wrong or beliefs about good and evil. As a result, PMIEs may negatively impact one's spiritual beliefs, practices, and identity [6][7][8][9]. These concerns have traditionally been considered within the purview and practice of religion, rather than mental and behavioral health. ...
Purpose
Moral injury describes the psycho-socio-spiritual suffering that can follow potentially morally injurious events (PMIEs). PMIEs involve actions taken or not taken, or witnessing or being directly impacted by someone else’s actions or inactions, that violate deeply held notions of right and wrong. Moral injury is hypothesized to be a syndrome that is marked by symptoms of reexperiencing and avoidance, accompanied by moral emotions, demoralization, and social isolation or withdrawal. Further, moral injury is posited to involve questions of meaning and purpose and changes in religiosity and spirituality (R/S). This review examined current assessment tools for moral injury and described religiously and spiritually oriented treatments for moral injury and efforts to measure their impact.
Recent Findings
A few measures of exposure to PMIEs and moral injury as an outcome have been developed, primarily for active-duty service member and veteran populations. R/S therapies include an individual therapy, Spiritually-Based Cognitive Processing Therapy, and a group therapy, Building Spiritual Strength. Non-R/S therapies include adaptations to trauma-focused therapies (i.e., Cognitive Processing Therapy, Prolonged Exposure, Acceptance and Commitment Therapy) and new PMIE-focused therapies (Adaptive Disclosure, Impact of Killing). In general, there has been little psychometric research on moral injury assessment tools and few clinical trials of R/S-oriented psychotherapies.
Summary
Because moral injury is an emerging clinical construct, there are few gold standard assessment tools or evidence-based treatments. Potential limitations of existing approaches and future directions for developing R/S-oriented moral injury treatments are discussed.
... It seems reasonable, then, to reconsider definitions of MI from a much more comprehensive and inclusive perspective of human nature and experience since "failing to pay sufficient attention to the impact of events with moral and ethical implications; events that evoke shame and guilt may not be assessed or targeted sufficiently" (Litz et al., 2009, p. 696). It now appears more likely that there is a component of moral trauma in virtually all forms of injury or offense-physical, psychological, emotional, relational, and spiritual-by virtue of the fact that all of these injuries may lead a person to question their own moral value as persons (Kinghorn, 2012). ...
During psychotherapy assessments clinicians may recognize that some of their injured and traumatized clients may be wrestling with issues related to a lack of forgiveness linked to Moral Injury (MI). This paper presents the Forgiveness Interview Protocol (FIP), a narrative therapy writing-process model for the treatment of Moral Injury, drawing upon the philosophical work of Margaret Holmgren: “Forgiveness and the Intrinsic Value of Persons” (1993) now linked to a variety of evidence-based psychological sources. The FIP utilizes three distinct theoretical and clinical disciplines to arrive at a semi-structured interview intended for mental health counseling, and religious and spiritual care.
... While this article will be of interest to theologians and religious professionals working with trauma survivors, its purview is limited to the aforementioned purpose. The present article explores neither "experiences of religious and spiritual growth following trauma" [3], advice for spiritual advisors [4], nor offers a theology of trauma [5] or the moral injury accompanying trauma [6]. Neither does this article provide a psychological analysis of trauma or faith development [7]. ...
Written from a standpoint of religious ethics, this article interprets the work of trauma response and recovery in transcendent and moral terms not always apparent to the practitioner or institution. This article provides a broad understanding of spirituality, transcendence, and faith as these concepts relate to Judith Herman’s stages of trauma healing and the characteristics of trauma-informed response articulated by the Substance Abuse and Mental Health Services Administration. These features are then mapped onto specific modes of transcendence and moral themes identifiable in a wide range of religious traditions. The connective framework for this mapping is provided by utilizing the concept “bearing witness,” as synthesized from a wide range of disciplinary perspectives, to describe the work of trauma-informed response. This article concludes by recognizing bearing witness as a form of social action, a moral response with implied if not explicit religious dimensions and spiritual implications, for which an understanding of religious ethics is a helpful ally. Thus, this article concludes that religious ethics can be a valuable resource and partner in addressing the personal, systemic, and political aspects of trauma response and recovery, enabling attention to spiritual well-being of both the trauma survivor and the one responding to the survivor.
... Breaches of morality and ethical codes may have intrinsic religious or spiritual connotations, and the concept of moral injury and the amelioration of moral injury-related distress has also been discussed in theological contexts (Brock & Lettini, 2012;Kinghorn, 2012). Spiritual counseling or retreats for morally injured veterans have been advocated, such as Soul Repair (Brock & Lettini, 2012) or Soldier's Heart Retreats (Tick, 2014), where a sense of purpose is redeveloped through acts of service and veterans are encouraged to confess their morally injurious experience and receive forgiveness (Antal & Winings, 2015) akin to confessions and prayers of forgiveness practiced in most religions. ...
Within the past decade, the emerging field of moral injury has focused mostly on the clinical dimension of a traumatic event (Griffin et al., Journal of Traumatic Stress, 2019, 32, p. 350). This article will present a character dimension of moral injury and briefly introduce a dual pathway model of moral injury reflecting clinical and character dimensions. The investigation of the character domain borrows from the theoretical and empirical bases of moral philosophy, moral psychology, character psychology, and social psychology. Hence, this multidisciplinary understanding of moral injury encompasses: (a) moral failure, or the failure to adhere to a virtue as prescribed by a group or institution, (b) suffering or death as a direct result of moral failure, (c) unethical marking on a person’s character, and (d) experience of identity negotiation between the real self and the undesired self. This character framework attempts to advance a broader theoretical foundation for moral injury that has wider applicability to the varieties of human experience, and reflects a deeper understanding of the self-concept that is not defined by and does not necessarily reflect clinical impairments.
... It damages deeply held understandings of right and wrong and undermines one's own humanity and sense of self (Brock and Lettini 2012). This spiritual damage is why this phenomenon has caught the attention of philosophers (Sherman 2011;Bernstein 2015), as well as religious studies scholars (Kinghorn 2012;Worthington and Langberg 2012;McClymond and Lemieux 2014). Increasing public visibility and acknowledgment of moral injury as a distinct form of harm has led to social distress over the lack of treatment for this condition, as in the title of the 2016 book on moral injury, What Have We Done (Wood 2016;also Junger 2016). ...
The war in Iraq unleashed disastrous global instability—from the strengthening of Al-Qaeda, to the creation of ISIS, and civil war in Syria accompanied by a massive exodus of refugees. The war in Afghanistan is continuing in perpetuity, with no clear goals or objectives other than the United States’ commitment to its sunk cost. The so-called war on terror is a vague catch-all phrase for a military campaign against moving targets and goalposts, with no end date and no conceivable way to declare victory. The toll of these wars on civilians in Iraq and Afghanistan and elsewhere in the Middle East, on US troops, and on the US economy is staggering. But these ambiguous campaigns are also fundamentally changing US state identity—its view of itself, its role in the world, and its commitment to a liberal international order. They are producing profound anxiety in the US body politic and anxiety in US relationships with other international actors. To understand the sources and consequences of this anxiety, we adopt an ontological security perspective on state identity. We enrich ontological security scholarship by introducing the concept of moral injury and its three main consequences: loss of control, ethical anxiety, and relational harm. We demonstrate how the concept of moral injury illuminates some of the most central anxieties at the core of US identity, offering a new understanding of our global moment of crisis.
... Elsewhere, I call for chaplains to serve within the military as Christian "signs of contradiction" (Tietje 2018a). If chaplains provide only a priestly/pastoral witness within the military, the priestly/pastoral work is always in danger of being subsumed as religious technologies that become subservient to military ends (Kinghorn 2012). I suggest that the prophetic witness of chaplains is necessary to disrupt the straightforward appropriation of the work of the chaplain as directed merely to the ends of military readiness. ...
This paper makes the case that to the extent that churches and military chaplains leave the command-obedience relationship of soldiers and the state unchallenged they are complicit in structures that put their care to potentially abusive ends. The paper provides an analysis of the civil-military distinction, in light of which soldiers are subject to patriarchal dynamics by the state. Thomas Aquinas’s moral psychology is used to argue that the command-obedience relationship of soldiers and the state is deeply problematic. Moral injury phenomena are perhaps best understood in this context. Churches and chaplains are unwittingly caught up in the command-obedience dynamic and potentially reinforce its abuses. This paper presses pastoral caregivers to acknowledge their fraught position and provide a prophetic witness that prioritizes obedience to God.
... This has undeniably influenced the frame through which moral injury has been introduced to the field of psychology, despite explicit caution against confining the discourse on moral injury to killing and atrocities in war (Litz et al., 2009). Other conceptualizations of moral injury have also been advanced in the literature, including emphasis on the function of moral emotions and related suffering (Farnsworth, Drescher, Evans, & Walser, 2017), and existential suffering that beckons beyond the bounds of modern psychology and medicine and into the realm of theology and religious/spiritual faith practices (Kinghorn, 2012;Meador & Nieuwsma, 2018). These conceptualizations highlight aspects of the experience of moral injury that differ from the danger-based events and fear-based responses that characterize PTSD diagnosis and treatment using both DSM-IV and DSM-5 definitions (Griffin et al., 2019). ...
Moral injury merits further study to clarify its identification, prevalence, assessment, and intersection with psychosocial and psychiatric problems. The present study investigated the screening potential of the Brief Moral Injury Screen (BMIS) in a sample of post‐9/11 veterans (N = 315) and comparatively evaluated how this tool, the Moral Injury Events Scale (MIES), and the Moral Injury Questionnaire‐Military Version (MIQ‐M) relate to psychiatric diagnoses and mental illness symptom severity. Those who endorsed failing to prevent or doing something morally wrong had the highest symptomatology scores on measures of posttraumatic stress disorder (PTSD), depression, suicidality, and alcohol and drug abuse, followed by those who reported solely witnessing a moral injury event. PTSD and depressive symptoms correlated most strongly with scores on the MIQ‐M; suicidality, alcohol abuse, and drug abuse scores correlated most strongly with scores on the BMIS and MIQ‐M. Moral injury, as measured by three scales, was robustly correlated with worse outcomes on various symptom measures. The three scales appear to differentially predict mental illness symptomatology and diagnoses, with the BMIS predicting suicidality and alcohol and drug abuse as well as or better than other measures.
... In combination with a growing S/R toolbox, current research on combat veterans struggling with combat wounds suggests that spiritual and religious dimensions may prove to be a neglected yet promising route to healing and recovery (Brémault-Phillips et al., 2017;Edwards, 2018;Koenig et al., 2017;Wortmann, et al., 2017). This implicates that religious leaders and pastoral and spiritual caregivers have an important role in assisting veterans in need of care and guidance (Graham, 2017;Kinghorn, 2012;Nieuwsma et al., 2013;Sippola et al., 2009). It has been suggested that it may be beneficial for clinical workers or teams and S/R caregivers to cooperate or collaborate in various ways, mainly because clinical teams, such as psychologists, psychiatrists, social workers, nurses, and/or physicians are trained in secular traditions and therefore often lack sensitivity, knowledge, and experience rooted within S/R traditions (Bobrow, Cook, Knowles, & Vieten, 2013;Smith-MacDonald et al., 2018). ...
This spiritual-psychological exegesis continues to expand the gallery of biblical combat veteran types by shedding light on a new biblical combat character. Gideon from the Book of Judges was an experienced combat veteran and military commander. The findings include the proposal of a new categorical type of a combat veteran who illustrates both spiritual integrity and resilience. The article engages in conversations of what the findings may mean for pastoral care and their connections to theology.
... Accordingly, theologians, philosophers, psychologists, all types of therapists and psychotherapists, social commentators contributed substantially in deepening our understanding of its nature, implications and treatment (e.g. Antal & Winings, 2015;Bernstein, 2005;Dombo, Gray & Early, 2013;Drescher & Foy, 2008;Frankfurt & Frazier, 2016;Gilligan, 2014;Harris, Park, Currier, Usset & Voecks, 2015;Jinkerson, 2016;Kinghorn, 2012;Levinson, 2015;Miller, 2009;Nickerson, Schnyder, Bryant, Schick, Mueller & Morina, 2015;Sreenivasan, Smee & Weinberger, 2014;Worthington & Langberg, 2012). ...
... The damage done to the psyche was only compounded when these soldiers, often placed in untenable positions, lost faith in their leaders, country, and even God (Bunkers, 2008;Currier, McCormick, & Drescher, 2015;Fontana & Rosenheck, 2004;Hodgson & Carey, 2017;Jinkerson, 2016;McCormack & Ell, 2017). Where a welcoming nation could have served as a needed balm for the wounds suffered, instead, many faced hostility and condemnation (e.g., the use of the label "baby killers"; Kinghorn, 2012;Purcell et al., 2016). ...
Posttraumatic stress disorder (PTSD) may not fully explain why some who experience war feel as though their assumptive world and sense of meaning has been shattered. Two concepts mentioned in the literature that address this feature of trauma are moral injury and spiritual injury. This work reports on qualitative findings from postgroup interviews with 18 participants who completed a spiritually integrated eight-session group intervention known as Search for Meaning. The group is designed to deal directly with issues of moral and spiritual wounds. This article discusses three main themes related to (a) the group process, (b) spiritual struggles and repair, and (c) the role of the group leaders. The findings support the call for specialized interventions to supplement mainstream PTSD treatments.
... There is a growing interest and awareness among researchers and clinicians within the contemporary field of clinical treatment of veterans with PTSD and/or MI that spiritual/religious traditions and faith communities may be crucial to the recovery from combat trauma (Vargas, Hanson, Kraus, Drescher, & Foy, 2013;Wortmann et al., 2017). Such traditions often have a long history and a strong capacity to forward and offer divine forgiveness and/or appropriate ritual forgiveness for transgressions made in the line of duty (Kinghorn, 2012;Weaver, Flannelly, & Preston, 2003). This has been recognized in counseling and therapies, even to the point that this recognition has tailored ongoing research (Currier, Drescher, Holland, Lisman, & Foy, 2016;Harris, Park, Currier, Usset, & Voecks, 2015;Koenig et al., 2017;Vieten et al., 2016). ...
This article continues to build on the biblical combat veteran types (BCVTs) which were recently presented as a tool to describe and understand biblical combat veterans through the lenses of post-traumatic stress disorder and moral injury. The purpose of this article is to connect the BCVTs with real-life cases so as to show the potential usefulness of the biblical types. This article further develops a model for pastoral care which integrates this tool.
This paper describes the development and initial chaplaincy user evaluation of ‘Pastoral Narrative Disclosure’ (PND) as a rehabilitation strategy developed for chaplains to address moral injury among veterans. PND is an empirically informed and integrated intervention comprising eight stages of pastoral counselling, guidance and education that was developed by combining two previously existing therapeutic techniques, namely Litz et al's (2017) 'Adaptive Disclosure' and ‘Confessional Practice’ (Joob & Kettunen, 2013). The development and results of PND can be categorized into five phases. Phase 1: PND Strategy Formation—based upon extensive international research demonstrating that MI is a complex bio-psycho-social-spiritual syndrome with symptoms sufficiently distinct from post-traumatic stress disorder. The review also provided evidence of the importance of chaplains being involved in moral injury rehabilitation. Phase II: Development and Implementation of ‘Moral Injury Skills Training’ (MIST)—which involved the majority of available Australian Defence Force (ADF) Chaplains (n = 242/255: 94.9%) completing a basic ‘Introduction to Moral Injury’ (MIST-1) as well as an ‘Introduction to PND’ (MIST-2). Phase III: MIST-3-PND-Pilot evaluation—involved a representative chaplaincy cohort (n = 13) undergoing the PND eight-stage strategy to ensure the integrity and quality of PND from a chaplaincy perspective prior to wider implementation. The pilot PND evaluation indicated a favourable satisfaction rating (n = 11/13: 84.6%; M = 4.73/5.0 satisfaction). Phase IV: MIST-3-PND Implementation—involved a larger cohort of ADF Chaplaincy participants (n = 210) completing a revised and finalized PND strategy which was regarded favourably by the majority of ADF Chaplains (n = 201/210: 95.7%; M = 4.73/5.0 satisfaction). Phase V: Summation. In conclusion the positive satisfaction ratings by a significant number of ADF chaplaincy personnel completing MIST-3-PND, provided evidence that chaplains evaluated PND as a suitable counselling, guidance and education strategy, which affirmed its utilisation and justifies further research for using PND to address MI among veterans, that may also prove valuable for other chaplains working in community health and first responder contexts.
LAY SUMMARY
This article highlights how the current literature conceptualizes and describes the link between military sexual trauma and moral injury. It describes some potential effects of sexual-assault-related moral injury on survivors and contributes to the broader, growing understanding of how sexual assault affects survivors, researchers, clinicians, and policy makers involved in the health and well-being of military members. Furthermore, this work can inform the development of future clinical interventions for individuals with more unique circumstances, such as those who may have experienced moral injury related to sexual trauma in the military.
When health professionals experience moral distress during routine clinical practice, they are challenged to maintain integrity through conscientious practice guided by ethical principles and virtues that promote the dignity of all human beings who need care. Their integrity also needs preservation during a crisis like the COVID-19 pandemic, especially when faced with triage protocols that allocate scarce resources. Although a crisis may change our ability to provide life-saving treatment to all who need it, a crisis should not change the ethical values that should always be guiding clinical care. Enduring ethical commitments should encourage clinicians to base treatment decisions on the medical needs of individual patients. This approach contrasts with utilitarian attempts to maximize selected aggregate outcomes by using scoring systems that use short-term and possibly long-term prognostic estimates to discriminate between patients and thereby treat them unequally in terms of their eligibility for life-sustaining treatment. During times of crisis and calm, moral communication allows clinicians to exercise moral agency and advocate for their individual patients, thereby demonstrating conscientious practice and resisting influences that may contribute to compartmentalization, moral injury, and burnout.
LAY SUMMARY
This article highlights how the current literature conceptualizes and describes the link between military sexual trauma and moral injury. It describes some potential effects of sexual- assault-related moral injury on survivors and contributes to the broader, growing understanding of how sexual assault affects survivors, researchers, clinicians, and policy makers involved in the health and well-being of military members. Furthermore, this work can inform the development of future clinical interventions for individuals with more unique circumstances, such as those who may have experienced moral injury related to sexual trauma in the military.
Generations ago, when American warriors stepped foot off the battlefield, they made a slow journey back home. It was nearly always by ship, taking weeks or months to complete. During that time, they decompressed from what they had experienced. Friends, who had seen what they had seen, surrounded them. They collectively mourned their losses. A few seasoned soldiers would tell the stories from previous wars. During this time, these service members underwent a significant transformation in returning to their homes and families. They had served their country, their tour of duty was complete, and now their primary task was to live a life of peace. They returned to their church congregations and took a job in a local economy next to their fellow veterans. They joined rotary clubs, bowling leagues, and had a beer at the VFW on Saturday nights. They re-integrated with their war buddies, their families, and their community. Veterans of the Post-9/11 conflicts have a very different experience. Through the use of aircraft, many accomplish the transition from combat to stateside in 24 hours or less. Particularly in the SOF enterprise, a modern warrior may know their anticipated rotation back to warzone before they complete their current tour. Too many have deployed countless times in their career, and there is no indication that the demand is waning. The force is strained. The suicide rate, divorce statistics, alcohol dependence, and high-profile criminal cases are leading indicators that this generation of veterans is experiencing problems in reintegration. There is a methodical process for turning men and women into warriors, but there is little being done to transition them from the battlefield back into their homes and communities. The mental health community has been at the forefront of diagnosing and assisting veterans with post-deployment issues. While this is a noble and necessary endeavor, many of the concerns of combat warriors are inherently spiritual in nature. Why is there evil in the world? What does it mean for one’s soul to participate in the taking of life, either directly or via proxy? Where do you find hope and peace? Chaplains, clergy members, and church organizations must heed a call to provide robust spiritual care to returning service members. They must create an environment where veterans can gather to reexamine their deployments with trusted friends. The group can assist these warriors in reframing their stories and considering their actions from different angles. Veterans need a safe place to engage in spiritual and social rituals that help them to explore deeper meanings and assist them in commemorating the sacrifices made by their colleagues. Most importantly, veterans must have an opportunity to meaningfully and purposefully reconnect with their communities. Spiritual communities can play a powerful role in purposefully engaging veterans. With their assistance, the men and women who have been willing to die for their country can transition into people who are willing to fully live for their country.
The United States military is engaged in the longest war of its history. Post-Traumatic Stress Disorder (PTSD) will torment a significant number of warriors who have taken up arms during the Global War on Terror. Combat stress, spiritual wounds of moral injury, strained relationships, and suicidal ideations will afflict others. While the medical and mental health communities address a portion of these issues, they remain inadequately equipped to answer the questions that impact the soul of the warrior. Military members need chaplains, clergy members, and local churches to address the spiritual aspects of combat and engage them on paths to healing and wholeness. The following project develops and implements a three-part curriculum to prepare warriors for the challenges they will face upon their return from combat. It presents contemporary examples of veterans facing reintegration issues and encourages participants to share their own war stories. Participants in the intervention exhibited a 49 percent reduction in trauma-related symptoms, measured by the PTSD Checklist (PCL- 5), and a 55 percent increase in positive coping beliefs as measured by the Posttraumatic Growth Inventory (PTGI). Chaplains and clergy members can use the included curriculum and facilitator’s guide as a tool for engaging military members in the process of healing from the invisible wounds of war.
Objectives:
Moral reasoning is an underexamined and potentially useful area of research relative to the care of moral injury in veterans. However, the most widely used measure of moral reasoning, the moral foundations questionnaire (MFQ), has not been validated in this population.
Methods:
Post-9/11 veterans (N = 311) completed questionnaires which included the MFQ. Veterans' scores were compared to the general US population. Confirmatory factor analysis was used to test existing models of the MFQ in the sample. Exploratory factor analysis (EFA) was also used to examine potentially improved model fits.
Results:
The two leading, preexisting MFQ models were both poor fits for the data. EFA results produced a four-factor model for the veteran sample using 25 of the original 30 items of the MFQ.
Conclusions:
Measuring moral reasoning among veterans may be important in understanding the experience of moral injury. However, the most widely used scale (MFQ) performs poorly among a sample of post-9/11 veterans, indicating that veterans may respond differently to the measure than the general US population. Military culture may uniquely influence veterans' moral reasoning, suggesting the need for military specific measures for this construct.
Experiences of trauma not only shed light on a person’s mental injuries themselves, but also bring to the surface several broader tensions and vulnerabilities underlying these injuries, which normally remain hidden This is especially true for moral injury, which refers to the lasting psychological impact of tragic dilemmas and moral transgressions. This chapter considers moral injury in this sense. First, it explains moral conflict as inherently part of human nature. Next, it shows how veterans’ stories of moral injury offer important insights into violence, human nature and military ethics, at the level of the individual soldier’s psyche, the relationship between soldier and society, and society. Finally, it reflects on the implications of these insights for military ethics.
Moral injury was originally conceived as a socially‐inflicted wound of betrayal experienced by military veterans (Shay, 1994). However, moral injury has since been redefined by psychological researchers as an individualised, predominantly perpetration‐driven, and psychopathological phenomenon (e.g., Currier et al., 2015; Jinkerson, 2016). However, social scientific researchers (e.g., Hodgson & Carey, 2017; Molendijk, 2019; Wiinikka‐Lydon, 2017) have contested mainstream psychology's medicalisation and decontextualisation of moral injury. This theoretical review integrates insights from across these discourses, and brings them into dialogue with ideas from moral psychology, evolutionary science, and community psychology. The aim of this cross‐disciplinary review is to promote a more holistic understanding of moral injury that does justice to its individual and social dimensions. Drawing on these different theoretical strands, this paper proposes that moral injury can be best understood as a psychological wound to basic human needs for social belonging and cohesion. The implications of this integrative understanding of moral injury for applied psychologists and other societal actors are explored. While the relevance of moral injury to civilian populations such as health and social care professionals is clear (e.g., Dombo et al., 2013; French et al., 2021), this paper focuses on military veterans, whose experiences originally prompted the coinage of the term. Please refer to the Supplementary Material section to find this article's Community and Social Impact Statement.
Warrior Welcome Home retreats have hosted Australian soldiers, veterans and their families since 2007. This article is an appreciative inquiry into theological and spiritual resources that respond to the emerging understanding of military moral injury. It discusses how Scriptural hermeneutics and experience of moral injury inform one another, how leadership fosters a nurturing community, how liturgy can aid spiritual healing and other implications of the retreats. Participants’ experience of Warrior Welcome Home demonstrates the therapeutic character of the Christian scriptures, community and liturgy in ways that are relevant to understanding and responding to moral injury with efficacious spiritual care.
Moral injury results from the violation of deeply held moral commitments leading to emotional and existential distress. The phenomenon was initially described by psychologists and psychiatrists associated with the US Departments of Defense and Veterans Affairs but has since been applied more broadly. Although its application to healthcare preceded COVID-19, healthcare professionals have taken greater interest in moral injury since the pandemic’s advent. They have much to learn from combat veterans, who have substantial experience in identifying and addressing moral injury—particularly its social dimensions. Veterans recognise that complex social factors lead to moral injury, and therefore a community approach is necessary for healing. We argue that similar attention must be given in healthcare, where a team-oriented and multidimensional approach is essential both for ameliorating the suffering faced by health professionals and for addressing the underlying causes that give rise to moral injury.
A moral injury framework, adapted to the carceral context from veterans' affairs, challenges the concept of “crime” and why people commit them. Moral injury asserts that human begins are moral agents and that no one violates their own moral code lightly. Healing from moral injury requires individuals and communities to get curious about the matrix of social factors and individual choices involved in any given “crime,” challenging both individual responsibility and social theory narrations of criminality. This article names the ways that theological and political concepts like sin and crime have been laminated together in the narratives upholding mass incarceration. The moral injury framework challenges the language of this laminated theo-political narrative at all three of its major loci: the naming of moral violation as sin/crime, of people as sinner/ criminals, and of the process of restoration as redemption/rehabilitation thereby opening pathways toward new modes of both thought and practice.
Moral injury embodies the claim that war is so transgressive for soldiers that it can create situations that may undermine one’s trust in oneself, others, and the world. Central to leading conceptualizations of moral injury is the assumption that soldiers are perhaps uniquely prone to such moral harm in combat. Other individuals who help form the context of such an injury, and who may also suffer, are overshadowed by the singular light cast on the veteran. This article argues that the nature of one’s moral injury, as well as the ethical landscape of the battlefield, will be misunderstood if definitions of moral injury continue to elide the relationships in which such injury arises. Focusing on one soldier’s reflection, the article critiques such definitions and proposes understanding moral injury as a harm that arises between persons in a wartime’s moral ecology, viewing it as a form of intersubjectivity. It also explores the political and ethical dimensions of such a reformulation.
I argue that there are some situations in which it is praiseworthy to be motivated only by moral rightness de dicto, even if this results in wrongdoing. I consider a set of cases that are challenging for views that dispute this, prioritising concern for what is morally important (de re, and not de dicto) in moral evaluation (for example, Arpaly, 2003; Arpaly & Schroeder, 2013; Harman 2015; Weatherson, 2019). In these cases, the agent is not concerned about what is morally important (de re), does the wrong thing, but nevertheless seems praiseworthy rather than blameworthy. I argue that the views under discussion cannot accommodate this, and should be amended to recognise that it is often praiseworthy to be motivated to do what is right (de dicto).
In recent years the concept of moral injury has become a common term to describe the lasting impact of moral transgressions on frontline workers. This article aims to broaden the largely clinical debate by involving the views of a diverse group of mental health practitioners who support military and police personnel in the Netherlands. These practitioners are chaplains, confidential counsellors, social workers, psychologists and integrity officers. How do these practitioners describe the moral injuries of servicemen and police officers and how do they think these should be approached? Through interviews with thirty different practitioners this study shows that definitions of moral injuries diverge considerably. In addition, the article analyses six different approaches to moral injuries. These range from framing moral injury as an exceptional problem that requires specific expertise, to seeing it as a broad issue that places workers in a larger moral community. An analysis of this variety both serves as an indication of possible ways to deal with moral injuries, and as a basis for a critical reflection on the implications of various approaches.
Moral injury is a term coined both to reflect the moral dimension of wartime experience and to critique overly clinical approaches to psychological harms originating in wartime. Originally defined not only with the tools of the behavioral sciences but also literature and philosophy, clinical approaches have come to dominate moral injury discourse over the past decade. This article argues for a return to interdisciplinarity by engaging metaphysics and ethics, and in particular Iris Murdoch’s post‐Christian notions of the Good and void, to help better account for the experiences of veterans who claim that they hurt not only physically but also morally as a result of their wartime experience.
Military personnel deployed to war zones or assigned to other morally challenging military duties are likely to be exposed to potentially morally injurious events (PMIE) that may inflict a moral injury (MI). This qualitative study formed ‘Phase 1’ of a larger study into PMIEs experienced by Australian veterans and the potential pastoral/spiritual care role of chaplains. Two seminars were conducted that involved 10 veterans being interviewed and audio recorded about their deployment experiences to evaluate whether there was any evidence among Australian veterans of a PMIE. Narrative data analysis indicated that all participants had been exposed to, or were involved in, a PMIE of one kind or another. Seven key themes were identified from the analyzed qualitative data: (i) immoral acts, (ii) death and injury, (iii) betrayal, (iv) ethical dilemmas, (v) disproportionate violence, (vi) retribution and (vii) religious/spiritual issues. Given this preliminary PMIE evidence identified, there is a need for further research, as well as the development of a suitable moral injury assessment scale appropriate for Australian veterans. Furthermore, given the ethical, moral, and spiritual issues involved, the implementation of a rehabilitation program suitable for Australian veterans which can be provided by chaplains is also suggested—namely ‘Pastoral Narrative Disclosure.’ It is argued that moral injury needs to be recognized, not just as an issue affecting individual personnel and their families, but is also a community health, organizational and government responsibility.
As a lifelong Christian with an early fascination with philosophy, I was drawn to what psychiatry could offer the human condition. My Christian patients in the northeastern USA have both struggled with and been helped by their faith, which is often intertwined with their emotional lives. A number of mentors and resources have helped me better understand my role as a clinician, and our need for a vision of an integrated life worth living.
Drawing upon moral injury (MI) definitional research and the oral histories of combat-exposed Veterans, this paper explores the role of moral paradox (MP) as a precondition of MI. Research is recommended to clearly delineate MP as a causative factor leading to more intractable cases of MI in the definitional literature, beyond the recognized impact of perpetration and betrayal-based conditions. Veteran stories collected during the normal course of providing spiritual care to combat-exposed Veterans and used by permission will provide insight into the theoretical concepts and interrelations of MP; proposed here as: circumstances in which moral obligations and/or ethical values come into conflict, forcing a choice between sides, none of which can be honored without violating the other. Acquainted with religious traditions that elucidate the perplexity and liberating effects of paradox, the work of Chaplains will also be recommended to address the problem of MP in wartime situations, highlighting the efficacy of acceptance based spiritual interventions and therapeutic programs. Psychological and spiritual interventions that facilitate self-transcendence and non-dual awareness through experiential acceptance and a subscale measuring paradox-induced injury will be recommended for future research as well.
Drawing upon qualitative and construct validity evidence within MI research and the oral histories of combat-exposed Veterans, this paper explores the role of moral paradox (MP) as a precondition of moral injury (MI). This paper recommends research to clearly delineate MP as a causative factor leading to more intractable cases of MI in the definitional literature, beyond the recognized impact of perpetration and betrayal-based conditions. Veteran stories collected during the normal course of providing spiritual care to combat-exposed Veterans and used by permission will provide insight into the theoretical concepts and interrelations of MP; proposed here as: circumstances in which moral obligations and/or ethical values come into conflict, forcing a choice between sides, none of which can be honored without violating the other. Acquainted with religious traditions that elucidate the perplexity and liberating effects of paradox, the work of Chaplains will also be recommended to address the problem of MP in wartime situations, highlighting the efficacy of acceptance-based spiritual interventions and therapeutic programs. Psychological and spiritual interventions that facilitate self-transcendence and non-dual awareness through experiential acceptance and a subscale measuring paradox-induced injury will be recommended for future research as well.
In the current political theater of the United States, one in which the de rigueur is partisan deadlock and a refusal to ‘reach across the aisle,’ nothing brings both major political parties together like war. At the center of this theater is the heroic veteran. This reification overlooks the lived experience of veterans. For some veterans, their experience has entailed multiple combat deployments, frayed relationships, and moral injury. Veterans deserve to see creative change in the support given them. This essay in pastoral theological intervention explores one possibility. Borrowing from Antonio Gramsci, I will argue for the positionality of military chaplains to stand in as Gramscian organic intellectuals in order to accompany veterans through trauma and to move toward not only their own liberation but also an end to these, our longest, wars.
Moral injury (MI) is gaining traction within the Department of Veterans Affairs (VA) as an essential construct for understanding an important dimension of suffering experienced by U.S. combat-deployed Veterans. A VA chaplain and a psychologist at the Corporal Michael J. Crescenz VA Medical Center in Philadelphia co-facilitate a 12-week Moral Injury Group (MIG) to provide education about MI, the collective responsibility for the consequences of warfare, and related topics. A Community Ceremony in the VA chapel, immediately following Week 10, brings together VA staff, family, and friends of MIG Veterans as well as the wider society. MIG Veterans define MI and deliver a personal testimony about their MI and its effects. As Veterans’ burdens are shared by a community made more conscious of the realities of warfare, Veterans and civilians reconcile and Veteran identity shifts from that of a disabled patient to that of an adaptive leader and “prophet.” Data on the MIG has thus far been collected for purposes of quality improvement and measurement-based care. We report outcomes, through a case study of a MIG Veteran who shows decreases in suicidality, religious struggles, and depression, along with increases in posttraumatic growth, self-compassion, and life functioning. We also discuss plans for future research and development.
It is widely recognized that, along with physical and psychological injuries, war profoundly affects veterans spiritually and morally. However, research about the link between combat and changes in morality and spirituality is lacking. Moral injury is a construct that we have proposed to describe disruption in an individual’s sense of personal morality and capacity to behave in a just manner. As a first step in construct validation, we asked a diverse group of health and religious professionals with many years of service to active duty warriors and veterans to provide commentary about moral injury. Respondents were given a semistructured interview and their responses were sorted. The transcripts were used to clarify the range of potentially and morally injurious experiences in war and the lasting sequelae of these experiences. There was strong support for the usefulness of the moral injury concept; however, respondents chiefly found our working definition to be inadequate.
Are all warriors who have killed somehow polluted and prevented from an intimate relationship with God? This essay seeks to answer this question both affirmatively and negatively by correlating biblical literature, psychology, and the experience of veterans. Although killing in war defiles soldiers with bloodguilt and mars their relationship with the divine and with humans, ritual acts of purification in conjunction with appropriate psychological and pastoral care may cleanse this bloodguilt and restore relationships.
Four conceptualizations of war zone stressor experiences were defined: traditional combat, atrocities-abusive violence, perceived threat, and malevolent environment. Items from the National Vietnam Veterans Readjustment Study (NVVRS) were reviewed for content, and stressor indexes were created. Using retrospective self-report data from the NVVRS, intercorrelations among stressor scores and between these scores and measures of posttraumatic stress disorder (PTSD) were computed for all veterans and for men and women separately. Structural equation modeling procedures followed. Results indicated that the four stressor indexes were internally consistent, reasonably distinct from one another, and influenced PTSD differentially. Men scored significantly higher than women on all 4 indexes. Whereas the pattern of relationships among the variables was comparable across genders, there was evidence that one path coefficient in the model differed for men and women.
The Epicureans, Skeptics, and Stoics practiced philosophy not as a detached intellectual discipline, but as a worldly art of grappling with issues of daily and urgent human significance: the fear of death, love and sexuality, anger and aggression. Like medicine, philosophy to them was a rigorous science aimed both at understanding and at producing the flourishing of human life. In this engaging book, Martha Nussbaum examines texts of philosophers committed to a therapeutic paradigm--including Epicurus, Lucretius, Sextus Empiricus, Chrysippus, and Seneca--and recovers a valuable source for our moral and political thought today. This edition features a new introduction by Nussbaum, in which she revisits the themes of this now classic work.
The casualties of war are numerous and widespread. Two types are most familiar to the general population of Americans: deaths and serious bodily injuries. However, there are other serious psychological effects of war, such as resentment, anger, and hatred that remain at the margins of the healthcare radar. Uncontrolled and unmanaged resentment, anger, and hatred can have destructive consequences for veterans and their families. One solution for overcoming and dealing with these vindictive passions is learning to forgive.
Discusses the experiences, attitudes, and transformations of returning Vietnam veterans, using material obtained from interviews and conversations with the returnees. The "warrior myth" is discussed in terms of how it affects the psychological makeup of the soldier before and after his involvement in combat. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Privation and disease have mainly killed soldiers until very recently. Now that enemy action predominates, faster and better control of bleeding and infection before and during evacuation spares ever more lives today. This essay focuses on psychological war wounds, placing them in the context of military casualties. The surgeon's concepts of 'primary' wounds in war, and of would 'complications' and 'contamination', serve as models for psychological and moral injury in war. 'Psychological injury' is explained and preferred to 'Post-Traumatic Stress Disorder', being less stigmatizing and more faithful to the phenomenon. Primary psychological injury equates to the direct damage done by a bullet; the complications - for example, alcohol abuse - equate to hemorrhage and infection. Two current senses of 'moral injury' equate to wound contamination. As with physical wounds, it is the complications and contamination of mental wounds that most often kill service members or veterans, or blight their lives.
This study examined the mental health impact of reported direct and indirect killing among 2,797 U.S. soldiers returning from Operation Iraqi Freedom. Data were collected as part of a postdeployment screening program at a large Army medical facility. Overall, 40% of soldiers reported killing or being responsible for killing during their deployment. Even after controlling for combat exposure, killing was a significant predictor of posttraumatic disorder (PTSD) symptoms, alcohol abuse, anger, and relationship problems. Military personnel returning from modern deployments are at risk of adverse mental health conditions and related psychosocial functioning related to killing in war. Mental health assessment and treatment should address reactions to killing to optimize readjustment following deployment.
Throughout history, warriors have been confronted with moral and ethical challenges and modern unconventional and guerilla wars amplify these challenges. Potentially morally injurious events, such 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 (what we label as moral injury). Although there has been some research on the consequences of unnecessary acts of violence in war zones, the lasting impact of morally injurious experience in war remains chiefly unaddressed. To stimulate a critical examination of moral injury, we review the available literature, define terms, and offer a working conceptual framework and a set of intervention strategies designed to repair moral injury.
All wars are “hell.” Certain aspects of the Vietnam War, however, differentiated it from World War II and the Korean Conflict: guerrilla tactics predominated; this war was undeclared and became increasingly unpopular; and for the first time the exposure of war atrocities committed by Americans became a national issue. Many Vietnam veterans reflect the impact of these differences in their conflictual attitudes toward their combat experiences and in their psychopathology. The Vietnam combat veteran who reports atrocities presents a special therapeutic challenge. The therapist's countertransference and real, natural response to the realities of the patient's experience must be continually monitored and confronted. If the therapist is honest with him/herself, a therapeutic relationship becomes possible for men whom many therapists are, or would be, repulsed and frightened by and would never treat.
Vietnam combat veterans (N = 151) with chronic posttraumatic stress disorder (PTSD) completed measures of atrocities exposure, combat exposure, PTSD symptom severity, guilt and interpersonal violence. PTSD symptom severity, guilt and interpersonal violence rates were similar to previously reported studies that examined treatment seeking combat veterans with PTSD. Controlling for combat exposure, endorsement of atrocities exposure was related to PTSD symptom severity, PTSD B (reexperiencing) symptoms, Global Guilt, Guilt Cognitions, and cognitive subscales of Hindsight-Bias/Responsibility and Wrongdoing. These results are discussed in the context of previous research conducted regarding atrocities exposure and PTSD.
We present a theoretical model of field placement, war zone stressors (fighting, death and injury of others, threat of death or injury to oneself, killing others, participating in atrocities, harsh physical conditions and insufficiency of resources in the environment) and posttraumatic stress disorder (PTSD). Theater veterans from the National Vietnam Veterans Readjustment Study were divided randomly into two subsamples of 599 each. The model was developed on the first subsample and cross-validated on the second using structural equation modeling. The model provides a theoretically and empirically satisfactory description of the anatomy of war zone stressors and their role in the etiology of PTSD, but it leaves unanswered important questions regarding the etiological role of insufficiency of resources in the environment.
Selected Testimony from the Haditha Investigation
- Sergeant Interview
- E T Major
- Sax
Interview of Sergeant Major E. T. Sax, USMC Sergeant Major, 3d Battalion, 1st Marines,
in "Selected Testimony from the Haditha Investigation," New York Times, December 15,
2011, pp. 7-8; www.nytimes.com/interactive/2011/12/15/world/middleeast/hadithaselected-documents.html?ref=middleeast.
The Things They Carried Living in Moral Pain Out of the Night: The Spiritual Journey of Vietnam VetsIt Don't Mean Nothin': The Vietnam Experience For empirical work suggesting that participation in " atrocities " or other forms of extreme violence could be associated with more
- See
- Example
- O 'brien Tim
- P William
- Mahedy
See, for example, Tim O'Brien, The Things They Carried (New York: Broadway Books,
1990); Peter Marin, " Living in Moral Pain, " Psychology Today 6 (11): 68–74; William P. Mahedy, Out of the Night: The Spiritual Journey of Vietnam Vets (Knoxville, TN: Radix Press,
2004); and William P. Mahedy, " 'It Don't Mean Nothin': The Vietnam Experience, "
Christian Century, January 26, 1983, 65–68. For empirical work suggesting that participation in " atrocities " or other forms of extreme violence could be associated with more
Warren Kinghorn @BULLET 71
Combat Trauma and the Undoing of Character On Killing: The Psychological Cost of Learning to Kill in War and Society
- Jonathan Shay
- Achilles In
- Vietnam
Jonathan Shay, Achilles in Vietnam: Combat Trauma and the Undoing of Character (New
York: Scribner, 1994); Shay, Odysseus in America: Combat Trauma and the Trials of Homecoming (New York: Scribner, 2002); David Grossman, On Killing: The Psychological Cost of
Learning to Kill in War and Society (Boston: Little, Brown, 1995); and Rachel M. MacNair,
Perpetration-Induced Traumatic Stress: The Psychological Consequences of Killing (Westport, CT:
Praeger, 2002).
Killing in Combat, Mental Health Symptoms, and Suicidal Ideation in Iraq War Veterans An Exploration of the Viability and Usefulness of the Construct of Moral Injury in War Veterans
- M A Gahm
- T J Reger
- C R Metzler
- D Kent
- David W Drescher
- Caroline Foy
- Kelly
Gahm, M. A. Reger, T. J. Metzler, and C. R. Marmar, " Killing in Combat, Mental Health
Symptoms, and Suicidal Ideation in Iraq War Veterans, " Journal of Anxiety Disorders 25
(2011): 563–67; and Kent D. Drescher, David W. Foy, Caroline Kelly, Anna Leshner, Kerrie Schutz, and Brett Litz, " An Exploration of the Viability and Usefulness of the Construct of Moral Injury in War Veterans, " Traumatology 17 (2011): 8–13.
Home from the War; and Shay
- Lifton
Lifton, Home from the War; and Shay, Achilles in Vietnam, 3-22.
What Is Mental Disorder? An Essay in Philosophy
- Derek Bolton
Derek Bolton, What Is Mental Disorder? An Essay in Philosophy, Science, and Values (Oxford:
Oxford University Press, 2008), 194.
To Relieve the Human Condition
- Gerald Mckenny
Gerald McKenny, To Relieve the Human Condition: Bioethics, Technology, and the Body (Albany, NY: SUNY Press, 1997), 17.
Moral Injury and Moral Repair
- Litz
Litz et al., "Moral Injury and Moral Repair," 699.
36. Ibid., 704.
Spirit and Trauma: A Theology of Remaining
- Shelly Rambo
Shelly Rambo, Spirit and Trauma: A Theology of Remaining (Louisville, KY: Westminster
John Knox Press, 2010).
Among others, see Mahedy, Out of the Night; Mahedy It Don't Mean Nothin' " ; and Singer
- Odysseus In Shay
Shay, Odysseus in America, 153–54. Among others, see Mahedy, Out of the Night; Mahedy,
" It Don't Mean Nothin' " ; and Singer, " Shame, Guilt, Self-Hatred, and Remorse. "
The Moral Treatment of Returning Warriors in Early Medieval and Modern Times For a detailed account of bloodguilt in the Old TestamentYou Have Shed Much Blood, and Waged Great Wars
- Bernard J Verkamp
Bernard J. Verkamp, The Moral Treatment of Returning Warriors in Early Medieval and Modern Times (Scranton, PA: University of Scranton Press, 1993). For a detailed account of
bloodguilt in the Old Testament, see David A. Bosworth, " 'You Have Shed Much Blood,
and Waged Great Wars:' Killing, Bloodguilt, and Combat Stress, " Journal of Religion, Disability, and Health 12 (2008): 236–50.
The Things They Carried
- See
- O' Tim
- Brien
See, for example, Tim O'Brien, The Things They Carried (New York: Broadway Books,
1990);
Living in Moral Pain
- Peter Marin
Peter Marin, "Living in Moral Pain," Psychology Today 6 (11): 68-74;
The Stressors of War
- William P Nash
William P. Nash, "The Stressors of War," in Combat Stress Injury: Theory, Research, and
Management, eds. Charles R. Figley and William P. Nash (New York: Routledge, 2007);
Among others, see Mahedy, Out of the Night; Mahedy
- Odysseus In Shay
- America
Shay, Odysseus in America, 153-54. Among others, see Mahedy, Out of the Night; Mahedy,
"It Don't Mean Nothin'"; and Singer, "Shame, Guilt, Self-Hatred, and Remorse."
You Have Shed Much Blood, and Waged Great Wars:' Killing, Bloodguilt, and Combat Stress
- J Bernard
- Verkamp
Bernard J. Verkamp, The Moral Treatment of Returning Warriors in Early Medieval and Modern Times (Scranton, PA: University of Scranton Press, 1993). For a detailed account of
bloodguilt in the Old Testament, see David A. Bosworth, "'You Have Shed Much Blood,
and Waged Great Wars:' Killing, Bloodguilt, and Combat Stress," Journal of Religion, Disability, and Health 12 (2008): 236-50.
See also the Christian Peace Witness homepages and highlights on the
Truth Commission on Conscience in War, The Truth Commission Report, November 11,
2010; http://conscienceinwar.org/wp-content/uploads/2010/11/TCCW_REPORT_
FINAL_110710.pdf. See also the Christian Peace Witness homepages and highlights on
the "Conscience in War Project," http://christianpeacewitness.org/.
Disciples-seminary-receives-grant-to-start-Soul-Re.aspx. See also The Soul Repair Center at Brite Divinity School, which describes its mission as
- Christian Church
Christian Church (Disciples of Christ), "Disciples Seminary Receives Grant to Start Soul
Repair Project for Veterans," Disciples News Service, May 9, 2012; www.disciples.org/
DisciplesNewsService/tabid/58/itemId/1215/Disciples-seminary-receives-grant-to-start-Soul-Re.aspx. See also The Soul Repair Center at Brite Divinity School, which describes
its mission as "research and public education about recovery from moral injury"; http://
www.brite.edu/programs.asp?BriteProgram=soulrepair.
Transforming the Wounds of War: How Can Faith Communities Respond to the Impact of Trauma on Returning Veterans and Their Families?
Eastern Mennonite University Center for Justice and Peacebuilding, "Transforming the
Wounds of War: How Can Faith Communities Respond to the Impact of Trauma on Returning Veterans and Their Families?" Originally posted at www.emu.edu/cjp/pti/twow/.
See also Stephen Kaufman, "University Offers New Approach to Trauma Healing:
Program Works to Free Individuals and Communities from Destructive Cycles,"
America.gov Archive, March 19, 2009, www.america.gov/st/democracy-english/2009/
March/20090319115407esnamfuak0.2055933.html&distid=ucs.
- Serene Jones
- Grace Trauma
Serene Jones, Trauma and Grace: Theology in a Ruptured World (Louisville, KY: WJK Press,
2009), 149.