Tuesday, March 28, 2017

A Third Form of Moral Injury

By Pete Kilner, Ph.D.
version: 3-28-2017
w/ addendum at end, 3-29-2017

Currently, the literature on moral injury recognizes two forms of moral injury. I think that it’s overlooking a third form--a third cause--of moral injury.

Combat-related moral injury is caused not only (1) by feeling betrayed by an authority figure and (2) by doing actions that violate your own moral beliefs, but also (3) by encountering large-scale, senseless violence and suffering.

Comparing the 3 Forms of Moral Injury
Level of violation
Perceived violator of moral goodness
Soldier himself
Leader who wielded authority over the soldier
Whoever is responsible for the world, aka, God.
Victim’s response
“I did something terrible. I’m a bad person.”
“I was screwed by ‘higher.’ I trusted them literally with my life but was used and abused. I risked my life and took others’ lives, and my buddies died, for someone who didn’t care.”
“No real God would allow this situation to take place. This is irrational, horrifying, unfair, more than I can handle. This world sucks.”
Likely symptoms
Guilt, shame, self-harm, risky behavior.
Anger at the organization, inability to trust.
Anger at God, loss of faith, doubt goodness of world, demoralization.

substance abuse, suicidality

  1. The first form of moral injury (described initially in the 1990s by Dr. Jonathan Shay) results from feeling betrayed by a legitimate authority. Shay argues that moral injury is caused by three elements:
    • A betrayal of what’s right
    • By someone who holds legitimate authority (e.g., in the military--a leader)
    • In a high-stakes situation

2. Over the past seven years, a second form of moral injury has been discussed--where the injury is caused by the soldier’s own actions that violated his/her deeply held moral values. This view was first published in peer-reviewed journals by Litz, Nash, Maguen, and others in 2009. See https://www.ptsd.va.gov/professional/co-occurring/moral_injury_at_war.asp

 In the decade previous, I'd written about this form of moral injury--calling it PTSD or PITS--in non-peer-reviewed media:

Military Leaders’ Obligation to Justify Killing in War (JSCOPE 2000, Military Review 2002)
The Military Leader’s Role in Preventing Combat-related, Perpetration-Induced, Psychological Trauma (JSCOPE 2005)
A Moral Justification for Killing in War (Army Magazine 2010)

3. My interviews and conversations with combat veterans whose faith in God has been shattered reveal experiences in which they felt overwhelmed by the injustice and suffering of war. They came face to face with what theologians call “the mystery of evil” and suffered a moral injury. Instances of senseless, unfair evil that have been described to me include: good people dying horrible deaths and bad people escaping death, due to “luck”; the carnage after a VBIED, including innocent children grievously wounded or blown literally into pieces; encountering the victims of sectarian cleansing, tortured to death by power drills to their heads or other inhumane methods.

A definition of moral injury that accounts for all three forms is:
    • A betrayal of what’s right
    • By "someone" you previously trusted, which may be:
      • yourself--your own moral judgment/courage; and/or
      • a legitimate authority in your chain of command (from NCO to President); and/or
      • God
    • In a high-stakes situation such as war

Said another way…

Moral injury is the psychological, social, and/or spiritual harm that results from experiencing a violation of a deeply held moral belief, perpetrated by a trusted authority, in a high-stakes situation such as war.

The “trusted authority” who betrays and loses that trust can be:
  1. the soldier, when he/she does something that violates their own moral code.
  2. senior leaders, when they disregard the humanity of the soldiers.
  3. God, or the soldier's sense of the divine, when soldiers encounter senseless, unfair suffering.

This is a first-draft blog post to start the conversation. Thoughts?

Addendum (3-29-2017): I am grateful to Chaplain (LTC) Peter Dissmore for bringing to my attention an outstanding article by Chaplain (COL) Timothy Mallard, Ph.D.--"The Twin Wounds of War"--published in the Winter 2016 issue of Providence Magazine. What I outline above in a chart, CH Mallard analyzes deeply and thoughtfully.

Mallard defines "spiritual injury" as: "the intra and inter-personal damage to souls brought on by significant trauma, including the rupture to foundational religious values, beliefs, and attitudes, the inability to healthfully participate in an immanent human faith community, and the temporary or permanent loss of a transcendent relationship to God (manifested particularly in questions about forgiveness, doubt, truth, meaning, and hope)."

I recommend the entire article, available at https://providencemag.com/2017/02/twin-wounds-war-spiritual-injury-moral-injury/

Also, if you're interested in how leadership can prevent or reduce moral injury, I invite you to read "Military leaders' role in mitigating moral injury" posted here last November: http://soldier-ethicist.blogspot.com/2016/11/the-military-leaders-role-in-mitigating.html