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Combat Trauma and Moral Fragmentation: A Theological Account of Moral Injury

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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.

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... 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). ...
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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.
... And it still keeps on festering." Philip's words recall the concept of moral injury, which gained traction a decade ago and was quickly embraced in academic, clinical and public discourses (Currier, Holland, & Malott, 2015b;Frame, 2015;Kinghorn, 2012;Litz, Lebowitz, Gray, & Nash, 2015;Litz et al., 2009;Shay, 2014). The concept is intended to capture what the current concept of post-traumatic stress disorder fails to sufficiently address, namely the moral dimensions of deployment-related suffering. ...
... More critical attitudes suggest that the notion of moral injury may need modification. Several scholars have criticized the concept for focusing mainly on 'the injury' while attending too little to 'the moral' (Beard, 2015;Kinghorn, 2012;Molendijk, Kramer, & Verweij, 2018, forthcoming;Wilson, 2014). When questions about 'the moral' go unaddressed, tacit, unsubstantiated assumptions are easily incorporated, leading to a relatively insubstantial basis for the development of both the concept itself and the clinical practices based on moral injury. ...
... Moral injury is currently described as a transgression of one's moral belief system (Kinghorn, 2012;Litz et al., 2009;. However, it seems that this conceptualization can be refined. ...
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While the concept of moral injury has been embraced in academic, clinical and public discourses, it is still nascent and needs development regarding the ‘moral’ in ‘moral injury’. When questions about the complex nature of morality go unaddressed, clinical practice is based on unsubstantiated and possibly reductive assumptions about the moral dimensions of traumas. Current conceptualizations of moral injury approach morality implicitly as a harmonious belief system. However, people always have multiple moral commitments that may co-exist in tension. What are the implications of moral tension in the experience of distress, and what are the implications of the complex nature of morality for the theoretical understanding of moral injury? This article addresses these questions, drawing on relevant literature from the fields of philosophy and social sciences, and on 80 in-depth qualitative interviews with Dutch veterans, thus contributing to a refined, interdisciplinary concept of moral injury.
... 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. ...
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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.
... 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. 57) Beard (2015) 'Moral injury involves the difficulties an individual faces when forced to integrate the wrongdoing of a moral authority into their broader conception of the world as a morally reliable place' (p. ...
... Likewise Brock and Lettini's (2011) definition from a theological perspective, in their work 'How do we repair the souls of those returning from Iraq', argues that '…moral (2002); g 'core and secondary symptoms' refer to article text injury is a wound in the soul, 2 an inner conflict based on a moral evaluation of having inflicted or witnessed harm…it can also involve feeling betrayed by persons in authority' (refer Table 1). Another moral theologian, also a psychiatrist, Kinghorn (2012) in 'Combat trauma and moral fragmentation', defines moral injury as 'the experience of having acted (or consented to others acting) incommensurably with one's most deeply held moral conceptions' (p. 57) (refer Table 1). ...
... Winright's (2015) work notes, however, that moral injury is too often couched in purely psychological and/or cognitive terms, rather than within a philosophical or theological paradigm, and subsequently, moral injury has been boxed within the therapeutic or clinical realm, instead of the spiritual or pastoral. A further key writer along this argument is Kinghorn (2012;noted earlier), who argues that the treatment of moral injury should move beyond the constraining structures of psychology to that of moral theology. Further, Kinghorn believes that responding to moral injury should be through 'specific communal practices' rather than a 'medical model', so as to allow for an honest and real narration and recovery from moral injury experiences. ...
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Abstract Only. This article explores the developing definition of moral injury within the current key literature. Building on previous literature regarding moral injury, spiritual care and the role of chaplains’, this article notes the complexity that has developed due to definitional variations regarding moral injury – particularly with respect to the concepts of ‘betrayal’ and ‘spirituality’. Given the increasing recognition of moral injury and noting the relevance and importance of utilizing a bio-psycho-social-spiritual model, this article argues that betrayal and spirituality should be core components for understanding, defining and addressing moral injury. It also supports the role of chaplains being involved in the holistic care and rehabilitation of those affected by moral injury. For full article please go to: https://rd.springer.com/article/10.1007/s10943-017-0407-z
... 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). ...
... 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. ...
... 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. ...
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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.
... Alleviating the post-traumatic stress symptoms is the priority of the medical establishment, often pursued through a combination of pharmacological and therapeutic measures; however, symptoms often persist when the stories that lie beneath are left unheard or are minimized or misunderstood (Kinghorn 2012;Stallinga 2013, p. 14). It is here that religious leaders who provide spiritual care can and must situate ourselves. ...
... Sometimes when I see the children in the youth group with which I work, who are surrounded by loving parents and church members, who anticipate lives of opportunity, my mind wanders to the streets of Baghdad and to the children who asked me for candy, who grew up in the midst of war. (Yandell 2015, p. 13) Scholars from various disciplines who are engaging with moral injuries suffered by military service members all emphasize the importance of communities that can hear and respond to the stories of moral suffering and live together into new possibilities (Brock and Lettini 2012;Graham 2017;Kinghorn 2012;Litz et al. 2016;Shay 1994Shay , 2002Sherman 2011Sherman , 2015. Jonathan Shay calls this Ba living community to whom [a veteran's] experience matters^ (Shay 1994, p. 198). ...
Article
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The purpose of this article is to describe and analyze how communities of faith can overcome key barriers and fulfill their responsibility to respond to the moral injury of military veterans and military families. Moral injury is a concept within the broader discourse concerning traumatic experiences and responses that pertains particularly to experiences that overwhelm a person’s internalized moral covenant within their social relational world. Communities of faith offer unique resources for many veterans and military families in the process of transitioning into civilian life. However, limited understanding of military experiences and culture and discomfort with moral anguish, including intense forms of guilt, shame, disgust, and contempt as well as traumatic experiences more broadly, too often diminish the efficacy of such ministries with veterans and military families.
... 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). ...
Article
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.
... Especially when forgiveness from the aggrieved party is not feasible, healing may be fa-cilitated by being (re)integrated into a spiritual community. Kinghorn (2012) has charged Christian communities in particular to appreciate the societal burden of war and their role in grieving with returning service members and veterans. He describes reconciliation through patience, confession, and forgiveness, which spiritual traditions have been exploring for millennia. ...
... Making amends through ethical action may thus help to repair personal spirituality as well as connection to the religious community. The community also has a role in providing a supportive welcome (Kinghorn, 2012). A clinician can help facilitate this connection by seeking knowledge about communities that strive to welcome service members and veterans, becoming familiar with resources to educate communities about what they can do welcome and support service members and veterans, and developing relationships with local clergy and chaplains. ...
Article
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Warzone experiences that violate deeply held moral beliefs and expectations may lead to moral injury and associated spiritual distress (Litz et al., 2009). Helping morally injured war Veterans who are grappling with spiritual or religious issues is part of multicultural competence (Vieten et al. 2013) and falls within the scope of practice of mental health clinicians. Moreover, practicing clinicians report that they lack adequate knowledge of the diverse spiritual and religious backgrounds of their clients and when to seek consultation from and collaborate with spiritual/religious teachers (Vieten et al., 2016). We argue that optimal assessment and treatment of psychically traumatized military personnel and Veterans requires an understanding of the idioms and perspectives of various spiritual (religious and philosophical) traditions on transgression and their recommendations for forgiveness and healing. To this end, we: (1) provide an overview of the source of moral codes associated with various traditions; (2) discuss aspects of warzone events that may violate those moral codes and spiritual reactions to those violations; (3) describe spiritual traditions’ approaches to making amends for transgressions; and (4) provide brief case scenarios that illustrate spiritual features of moral injury and point to circumstances in which collaboration with chaplains or clergy may be helpful for addressing aspects of moral injury.
... 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). ...
Article
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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.
... 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). ...
Article
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.
... 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). ...
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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.
... 15-16). Theologically educated care providers such as chaplains, pastoral counselors, and religious leaders have the expertise to explore the religious and spiritual struggles that are often part of military moral injury (see, for example, Brock and Lettini 2012;Carey et al. 2016;Graham 2017;Hodgson and Carey 2017;Kinghorn 2012;Moon 2015Moon , 2016aStallinga 2013). Spiritual care of military moral injury needs to bring evidence from research on military moral injury and religious struggles into an intercultural approach that is exquisitely respectful of the particularities of a veteran's unique religious world and spiritual orienting system. ...
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How can spiritual care help veterans struggling with military moral injury? An evidence-based, intercultural approach to spiritual care is proposed. Evidence-based care uses research on military moral injury and religious and spiritual struggles to understand when religious and spiritual practices, beliefs, and values are helping or harming veterans. Intercultural spiritual care recognizes the complex, distinctive ways veterans’ values, beliefs, coping, and spiritual practices are shaped by interacting cultural systems, especially military training and cultures. Pastoral theologian Larry Graham’s (Sacred Spaces: The E-Journal of the American Association of Pastoral Counselors 5, 146–171, 2017) writing on moral injury and lamentation is used to develop two spiritual care strategies: sharing anguish and interrogating suffering. Spiritual care begins with lamenting the shared anguish of moral injury using intrinsically meaningful spiritual practices to help veterans compassionately accept the emotions arising from moral injury so intensely felt in their bodies. The second strategy is sharing the lament of interrogating suffering through exploring values, beliefs, and coping arising from moral injury. A literary case study of a young female veteran based on Cara Hoffman’s (2014) novel Be Safe, I Love You illustrates this evidence-based intercultural approach to spiritual care of military moral injury.
... 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). ...
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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.
... where spiritual/pastoral caregivers are commonly employed), this may be particularly helpful, especially if soul repair can be facilitated by (re)integration into a spiritual community. Individuals within such contexts may embark on established routes into S/R traditions to traverse a path to reconciliation through forgiveness and atonement, regardless of the type of transgression (Weaver et al. 2003;Kinghorn 2012;Zippert 2014). As S/R traditions offer paths towards forgiveness for anyone who is committed to seek it, they also offer paths towards forgiveness for others who have harmed veterans, for example through malfunctioning leadership. ...
Article
To better understand how deployment in war zones and/or combat may inflict emotional wounds upon veterans, researchers, clinicians, and caregivers it was recently started to focus on the concepts of moral and spiritual injuries. Such injuries may remain undiscovered during psychiatric screening for posttraumatic stress disorder. What is often missing, however, is a conceptualization of the part of the self which is implicitly related to emotional wounds caused by moral and spiritual injuries. This article utilizes a number of historical and contemporary conceptualizations of what is called the soul, and their implications for pastoral and spiritual care of emotionally wounded veterans. Moreover, it explores the use of biblical stories in pastoral and spiritual care among veterans suffering from moral and spiritual injuries.
... 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. ...
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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.
... Recent clinical/treatment developments in combatrelated PTSD and MI have begun to recognize and highlight the positive impact of forgiveness within spiritual/religious traditions as a path forward to help recovery or healing from psychological wounds (Currier, Drescher, Holland, Lisman, & Foy, 2016;Harris, Park, Currier, Usset, & Voecks, 2015;Koenig et al., 2017;Vieten et al., 2016;Wortmann et al., 2017). In addition to this, the social dimension of a spiritual/religious community has been perceived as a nurturing and important aspect for recovery (Kinghorn, 2012;Lindsay et al., 2016;Sippola, Blumenshine, Tubesing, & Yancey, 2009;Weaver, Flannelly, & Preston, 2003). These two components particularly should be further investigated and applied to the Saul type, for those who may have developed a complex PTSD wherein the destruction of social trust may to varying degrees be at hand. ...
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This psychological exegesis reconsiders biblical characters through recent theories on moral injury and post-traumatic stress disorder (PTSD). The purposes of this article are to shed new light on these characters and to engage in conversations of what the findings may mean for pastoral care and their connections to theology. The findings include the proposal of four categorical types of combat veterans that illustrate the development of PTSD, resilience, moral injury, and unfaltering abidance to the warrior ethics.
... Such an endeavor seems particularly worthwhile given the fast-growing scholarly concern with what has been called 'moral injury' (Currier, Holland, & Malott, 2015;Frame, 2015;Kinghorn, 2012;Litz et al., 2009;Litz, Lebowitz, Gray, & Nash, 2015;Shay, 2014). The term is used to describe the suffering caused by perpetrating, witnessing or falling victim to an act that violates one's moral beliefs and expectations. ...
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While much research has been conducted on military trauma, conceptualizations of deployment-related suffering have been predominantly approached through a medical, individual-focused lens. Since the military is an instrument of the state, it is crucial to expand the conceptual scope to include political processes, particularly for the fast-growing literature on 'moral injury', which refers to the emotional impact of perpetrating, witnessing or falling victim to perceived wrongdoing. This article examines the role of political practices in the onset of moral injury as well as the micro-political responses of morally injured veterans. A study of the Dutch mission in Uruzgan, Afghanistan, shows that decisions and frames at the political level helped create distressing quandaries on the ground, and that in all the ways the political leadership acknowledged the problems that veterans subsequently developed, it also maintained a silence on its direct contribution to these problems, as such perpetuating them. Consequently, veterans tried to make the political leadership take a material and symbolic share in their burden. Clearly, moral conflict may exist both in the veteran and between the veteran and the political domain, and therefore, experiences of institutional betrayal and a resultant search for reparations should be included in theory on moral injury.
... 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. ...
... 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]. ...
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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.
... The level of dissonance-and frequently induced conflict and injury-may have variable determinants, including such factors as psychological and biological predispositions, but it is the marked incongruities represented by such contrasting communities that set the experiential framework for the contextual aggregation of these variables into the painful manifestation of personal dysfunction and social disruption. Warren Kinghorn (2012), psychiatrist and theologian, has noted that moral injury is most aptly interpreted as "embodied in specific communities with specific contextually formed practices" (59). The characteristics of these communities and the commitments to practices embedded within them are all important. ...
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Amidst the return of military personnel from post-9/11 conflicts, a construct describing the readjustment challenges of some has received increasing attention: moral injury. This term has been variably defined with mental health professionals more recently conceiving of it as a transgression of moral beliefs and expectations that are witnessed, perpetrated, or allowed by the individual. To the extent that morality is a system of conceptualizing right and wrong, individuals’ moral systems are in large measure developmentally and socially derived and interpreted. Thus, in seeking to provide care and aid in reintegration for combat veterans, it is necessary to consider communities that have contributed to an individual’s formation and that might have participated in the interpretation of his/her suffering. This can take many forms, but given that morality is often complexly intertwined with issues of religion, faith, and spirituality for many individuals, and recognizing that much of the current focus on moral injury is emanating out of healthcare contexts, we devote particular attention to how chaplains might be more intentionally engaged in healthcare systems such as the Veterans Health Administration to provide non-judgmental, person-centered, culturally-relevant care rooted in communities of practice to veterans with moral injury.
... 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). ...
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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.
... 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. ...
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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.
... 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. ...
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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.
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This investigation will provide a model to make sense of why it is so inherently traumatic to kill another human – independent of normative circumstances. It will examine the construct of moral injury, a term that has entered the diagnostic and social lexicons under the guise of an explanation of why certain acts may be psychologically deleterious, and has rapidly become the ‘signature’ war-wound of contemporary engagements. Current research agendas identify existential dissonance caused by perpetrative agency, specifically killing, as the most potent causal factor. While research into why perpetration appears so etiologically significant is available under various guises, these accounts have been unable, or unwilling, to unravel the normative assignations that surround the suffering experienced. The paucity of such approaches in providing a basis for understanding why we would feel bad for certain actions which we have normative permission to perform, is the basis for an alternative, phenomenologically driven investigation, informed by the French philosopher, Emmanuel Levinas. Major topics such as death and suffering of ourselves and others, will be shown to play central roles in conceiving, and justifying, a compelling alternative to existing narratives. Through a disambiguation of the origins of one’s obligations, obligations that are inadvertently lain bare by agency, an ‘ethical model’ will be proposed that proffers a framework to accurately describe the previously unexplained distress pathway that arises from our agency (or lack there-of). In articulating a model which anchors both our ethical and moral sensibilities, a tool emerges with which to make philosophical and psychological sense of suffering that is buried deeper than normative determinations of moral expediency.
Article
Moral injury describes the effects of violence on veterans beyond what trauma discourse can describe. I put moral injury in conversation with a separate but related concept, dirty hands. Focusing on Michael Walzer's framing of dirty hands and Jonathan Shay's understanding of moral injury, I argue that moral injury can be seen as part of the dirt of a political leader's dirty hands decisions. Such comparison can focus more attention on the broader institutional context in which such dirty hands decisions are executed, while contributing to the growing vocabulary of moral conflict, trauma, and harm.
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Wartime experiences have long been known to cause ethical conflict, guilt, self-condemnation, difficulty forgiving, loss of trust, lack of meaning and purpose, and spiritual struggles. "Moral injury" (MI) (also sometimes called "inner conflict") is the term used to capture this emotional, cognitive, and behavioral state. In this article, we provide rationale for developing and testing Spiritually Oriented Cognitive Processing Therapy, a version of standard cognitive processing therapy for the treatment of MI in active duty and veteran service members (SMs) with posttraumatic stress disorder symptoms who are spiritual or religious (S/R). Many SMs have S/R beliefs that could increase vulnerability to MI. Because the injury is to deeply held moral standards and ethical values and often adversely affects spiritual beliefs and worldview, we believe that those who are S/R will respond more favorably to a therapy that directly targets this injury from a spiritually oriented perspective. An evidence-based treatment for MI in posttraumatic stress disorder that not only respects but also utilizes SMs' spiritual beliefs/behaviors may open the door to treatment for many S/R military personnel.
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It has become apparent that some combat veterans develop psychiatric problems that do not fit within the prototypical symptoms of PTSD. Rather, certain experiences may transgress deeply held moral beliefs and result in less predictable reactions to trauma, such as guilt and shame, in what has been recently referred to as moral injury. This article describes the current state of moral injury research, as well as the types of events that may lead to a moral injury, and possible symptoms of moral injury. Future research directions in this domain (e.g., assessment instruments, treatment, cultural influences) are discussed.
Chapter
This essay examines the deep contradictions of America’s moral landscape through the figures of returning US war veterans. It presses for a Christian theological response to the deployments and redeployments of veterans, noting how the operations of the state cause certain bodies to disappear and reappear. Calling for a theological intervention, it presents the vision of a God who remembers, even as the mechanisms of society plunge citizens into historical amnesia.
Chapter
As unmanned aerial vehicles (UAVs) or drones continue to play a critical role in U.S. military strategy; numerous public debates have arisen regarding their legal and moral status. One of the lesser discussed yet important questions to arise in these debates are whether drone warfare—by virtue of its disembodied character and remote proximity to the physical battlefield—is as dangerous as manned combat and thus ultimately deleterious to the cultivation of martial courage. The purpose of this paper is to respond to this question in two ways. First, it will argue that drone pilots are indeed required to demonstrate a form of bodily courage insofar as they sustain injuries both to their bodies and moral consciences at the same rate as their live theater counterparts. Second, it will also make the claim that it is precisely because drone warfare is remote and disembodied that it requires not just the cultivation of martial valor but moral valor as well. Thus rather than ushering in a post-heroic era of warfare, drone warfare makes the virtue of courage all the more central and important.
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The complex human experience of military service and the stress suffered by millions of military families each time a loved one deploys present unique challenges and opportunities in providing pastoral care and counseling. War and military service impact many facets of our society, as well as generational and interpersonal relationships. This article speaks to both academic and practitioner communities, and provides a vision for effective pastoral care and counseling with military families drawing on resources from family systems theory.
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Everyone experiences pain, whether it’s emotional or physical, chronic or acute. Pain is part of what it means to be human, and so an understanding of how we relate to it as individuals - as well as cultures and societies - is fundamental to who we are. In this important new book, the first in Routledge’s new Critical Approaches to Health series, Robert Kugelmann provides an accessible and insightful overview of how the concept of pain has been understood historically, psychologically, and anthropologically. Charting changes in how, after the development of modern painkillers, pain became a problem that could be solved, the book articulates how the possibilities for living with pain have changed over the last two hundred years. Incorporating research conducted by the author himself, the book provides both a holistic conception of pain and an understanding of what it means to people experiencing it today. Including critical reflections in each chapter, Constructing Pain offers a comprehensive and enlightening treatment of an important issue to us all and will be fascinating reading for students and researchers within health psychology, healthcare, and nursing.
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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.
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Cases like that of John Howard Yoder – a pacifist theorist who perpetrated sexual violence – raise difficult questions about teaching material implicated in traumatic pasts. This paper argues that “moral injury” provides a useful framework for understanding the dynamics of teaching prominent cases of tainted legacies like Yoder's and for developing best pedagogical practices across the field of religious ethics. The moral injury framework empowers students to think critically and self‐reflectively about authority, conceptions of the good, the various stakes for different persons and communities in social issues, and the need for moral repair. It establishes the importance of professor and student preparation; propels students into the moral questioning and analysis that constitutes “ethics”; draws attention to the connections between and intersectionality of various moral problems while also attending to important moral distinctions; and affords opportunities to study individual and institutional efforts at moral repair.
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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.
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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.
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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.
Chapter
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.
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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.
Article
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.
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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.
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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.
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The full article is now freely available from the publishers using the link: https://rdcu.be/6lgR Abstract: This scoping review considered the role of chaplains with regard to ‘moral injury’. Moral injury is gaining increasing notoriety. This is due to greater recognition that trauma (in its various forms) can cause much deeper inflictions and afflictions than just physiological or psychological harm, for there may also be wounds affecting the ‘soul’ that are far more difficult to heal—if at all. As part of a larger research program exploring moral injury, a scoping review of literature and other resources was implemented utilising Arksey and O’Malley’s scoping method (Int J Soc Res Methodol 8(1):19–32, 2005) to focus upon moral injury, spirituality (including religion) and chaplaincy. Of the total number of articles and/or resources noting the term ‘moral injury’ in relation to spiritual/religious issues (n = 482), the results revealed 60 resources that specifically noted moral injury and chaplains (or other similar bestowed title). The majority of these resources were clearly positive about the role (or the potential role) of chaplains with regard to mental health issues and/or moral injury. The World Health Organization International Classification of Diseases: Australian Modification of Health Interventions to the International Statistical Classification of Diseases and related Health problems (10th revision, vol 3—WHO ICD-10-AM, Geneva, 2002), was utilised as a coding framework to classify and identify distinct chaplaincy roles and interventions with regard to assisting people with moral injury. Several recommendations are made concerning moral injury and chaplaincy, most particularly the need for greater research to be conducted. Alternative access it via: http://link.springer.com/article/10.1007/s10943-016-0231-x
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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.
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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.
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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.
Article
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.
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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)
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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
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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
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  • 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.