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


P Haas said...

Divine moral injury . . . this is an interesting concept, but I'm not sure what to make of it. If I believe that God is the source of morality, to feel divine moral injury must, I assume, shake even my basic understanding of the concept of morality in the first instance. If God causes moral injury, what's the point of morality in the first place? Is there even such a concept? Is that what you mean by demoralization, i.e., the undoing of a sense of morality in an individual? I think that moves the injured toward sociopathy, where there are no moral governors on behavior.

Divine moral injury would seem like the most difficult type to address. At some level, a person can understand the moral failing of those in authority, and even his own moral failing, as a function of their humanity. I'm not sure how a person of faith overcomes moral injury that he believes is God's responsibility.

It seems to me that people of faith must try to prepare themselves in order to mitigate this sort of effect. Theologians in some faiths have been tackling this question -- i.e., how can a just God let this happen? -- for many centuries and I am sure there is ample literature that one might consider as "mitigation-in-advance" of such an occurrence. I would think that chaplains have a great responsibility to help prevent divine moral injury. Unfortunately, we in the military are afraid to talk about religion outside of the chapel's four walls. With the right preparation, commanders and chaplains can do this without coming across as proselytizing (which they must avoid). But we can't take this sort of moral injury on if we're afraid to talk about religion and God.

Anyway, this was a layman's stream-of-consciousness reaction to your blog post. It was not a well-considered theological argument, so take it or what it's worth and don't judge me!

Pete Haas

Pete said...

Pete: Excellent comments!

This category of moral injury effects only those who believe in a good and powerful God. The soldiers who have witnessed the horrors of war cannot reconcile the evil of the world with the the goodness of God, and since they can see the evil, they begin to doubt God. When a person of faith doubts God's existence, they enter an existential crisis. What's the meaning of life? Why be good? Does anything really matter?

These crises aren't limited to soldiers in war. Parents who lose children, victims of particularly sadistic crimes, etc, also ask themselves these questions.

A theodicy is an argument that reconciles the existence of an all-powerful loving God with the reality of a world in which hateful, unfair acts sometimes occur.


Italiana said...

If you look at James Fowler's work, you'll see that an existential crisis is an integral element of maturing faith. Yet our culture sees it as a "bad" thing. It is instead an opportunity to deepen one's understanding/search for God, one that casts aside immature notions of God as a cosmic puppet-master for something infinitely richer. Spiritual care providers have a responsibility to shepherd people through this transitional phase. We can assist the soldier in identifying embedded theologies that are no longer applicable to his/her life. We can support them as they identify life-giving theologies.

Rita Brock said...

I wonder if we shouldn't just say there are several kinds of moral injury that result in moral emotions such as shame, guilt, self-condemnation, grief, and despair. "By someone in authority" might exclude some forms that do not involve actually doing something to violate core moral foundations, but involves being immersed in work that makes one feel terrible in a more vague way. It might be useful to turn to more collectivist-group oriented societies for understanding some forms that don't have an individual willing agent but infect the collective. Given unit cohesion and the subordination of individual identities in the military, I think there may be forms of moral injury that are hard to squeeze into the "an agent did it" box. I am thinking of the kind of work that mortuary units do, which involves immersion of death already inflicted. There may be grief or anger at enemies involved, but there is also the visceral kind of disgust that is probably hard-wired into the human brain as a survival mechanism. Deep cultural/religious taboos proscribe contamination by human carnage, and the taboos carry a lot of implicit moral freight--even accidental exposure places a person outside acceptable society (hence the aversion to morticians, executioners, and others who process dead flesh, even leather tanners in some societies). I think these morally inflected taboos especially devastate mortuary units. See Synder, J. (2014). ’Blood, Guts, and Gore Galore’: Bodies, Moral Pollution, and Combat Trauma. Symbolic Interaction. September. DOI: 10.1002/SYMB.116. Jess Goodell describes this kind of moral injury in Shade it Black. She notes after 8 months in Iraq, her entire unit was haunted by ghosts.

Jon said...

A worthy topic. I am a Veteran and contributor to some study on Moral Injury.

The context (or rather, the change in context) is elemental to moral injury.
I liked your quote “Do you think of your subordinates primarily as soldiers who happen to have personal lives on the side, or as people just like you who happen currently to be soldiers?”. Understanding this fact - that soldering is a temporary state - will help understand and overcome moral injury.
Soldiers are trained to act and react in ways that will preserve their lives and the lives of others, and it is not just OK, it is expected and encouraged. The problem occurs when the soldier departs the situation where his/her (deadly) lifesaving actions are the right thing to do, and their actions are judged by a different set of standards. We, the civilian community to which the soldier returns, has a significant role in healing the moral injury of our veterans.