MORAL INJURY
https://dworakpeck.usc.edu/events/moral-injury-talk
Eduardo C. Gerding
“We thought we had managed all right,” he told Holmes, “we kept the awful things out
of our minds, but now I’m an old man and they come out from where I hid them.
Every night.”(Grossman, David. On Killing. New York: Little, Brown
& Co. 1995.)
Foreword
The link
between mental illness and moral injury (MI) was explicity drawn in the
1990s by Jonathan Shay,a psychiatrist at the Department of Veterans Affairs in
Boston,Massachusetts when attempting to explain the enduring nature of PTSD
suffered by US veterans of the Vietnam war. 12
Police
officers, media professionals and military personnel are required to make
challenging ethical or moral decisions in their line of work which expose them
to MI. 7,9,25
When someone experiences a moral injury, the guilt,
sadness, and shame that come with it can be debilitating. It can create a deep
wound at the center of a person’s identity.
In this article we insert testimonies from the 1982
conflict that could perfectly respond to the MI established criterisa. These
testimonies come from opublished and widely disseminated books.
e.g:
¨Suddenly we heard screaming, a
high-pitched 'Mama, mama]' A dull shot was heard and we saw an Argentinian fall
over the cliff.¨ ¨A group of our guys had assembled some Argie prisoners on a
cliff above where we had dug a body pit for their dead. Now, with the battle
over, they were shooting prisoners and toppling them down to be buried. It
was an outrage and senior officers stepped in immediately before the executions
could get out of hand. But in the cauldron of emotions after the battle
they decided not to take further action. Court martials were the last thing we
needed.¨ (Excursion to Hell, by former Lance
Corporal Vincent Bramley) 3
Some guys collected Argentinian ears, but most regarded
this as going over the top. Having collected trophies in the night, one
person had been slighlty injured a Goose Green. The boys regarded this injury
as a warning to him, and started to avoid him because he didn't change his
behaviour. He was subsequently killed. (McManners ,Hugh-The Scars of War,
p. 347, HarperCollins, 1993) 18
Although MI is
most oftern associated with violence and aggression within the context
of combat, military personnel may also experience inner turmoil secondary to non violent events such as
exposure to dead bodies or human remains ,reported by 65% of Irak and
Afghanistan veterans.4
Potentially
morally injurious events (PMIE)
Potentially
morally injurious events (PMIE) are events that violate one's deeply held moral
values or beliefs, and that have the potential to create significant inner
conflict and psychological distress.Significant degrees of such distress have
been termed ‘moral injury’.
Moral
Injury (MI)
Moral injury (MI) is when one feels they have
violated their conscience or moral compass when they take part in, witness or
fail to prevent an act that disobeys their own moral values or personal
principles.
MI is based in
judgments of conscience and emerges in the aftermath of traumatic events, when a person has time to evaluate the
experience.
Although MI is
not currently categorized as a form of mental illness, a systematic review of
13 studies made by Victoria Williamson et al, representing 6373 participants
,found that PMIEs accounted for 9.4% of the variance in PTSD, 5.2% of the
variance in depression and 2.0% of the variance of suicidality. 16,25
MI and PTSD
MI is considered a syndrome separate and distinct from PTSD, although with some definitional overlap between the two (particularly in the affective domain)
Avoidance
and Isolation 23
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PTSD
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Moral Injury
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Veterans with PTSD may avoid persons, places or
situations that remind them of the traumatic event. It is out of fear
|
Veterans with moral injury may also avoid others,
however, it is not out of fear. This kind of avoidance is out of lost hope,
disillusionment, and self-judgment
|
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They remain concerned for their safety and are
uncomfortable when they have less control over what “could” happen.
|
Individuals with moral injury judge that no one
else would understand or accept what they have done. A life of secrecy
develops, and they do not want to talk about the military or specific
missions. Many persons with moral injury describe it as hiding the “real me”
from others while seeing, in the mirror, a shattered or monstrous self.
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Veterans with PTSD believe that the world is
dangerous.
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After the military, Veterans with PTSD avoid
situations that “could” present danger, including crowds. They scope out
“escape” routes. They have well developed plans for family and personal
safety (home alarms, weapons, etc.).
|
Veterans with moral injury isolate themselves
because they feel “unworthy,” and they may stop previous religious/spiritual
practices.
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Someone with PTSD may avoid talking about the
military or specific missions because it raises anxiety. The person may avoid
movies or TV shows about the military because they trigger memories of the
trauma and raise anxiety or result in distress.
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Negative
Thinking 23
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PTSD
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Moral Injury
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Veterans with PTSD believe that the world is not
safe. They remain ready to protect and defend themselves and their families
from harm. They believe they have to take extra safety measures
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Veterans with moral injury develop hopeless,
negative thinking over what happened.
|
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Veterans generalize what happened in thecombat
zone or deployment location to their current life.
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They think that the world should be safe and that
some things should never have happened. They become bitter over negative
outcomes that, using hindsight, they think might have been avoided.
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Veterans do not trust others, who remind them of
insurgents.
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Their thinking is more depressive than fearful.
|
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Veterans with PTSD engage in negative thinking
that is unrealistic and black-and-white.
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They may judge that they have “failed” or that
what they have done is “unforgivable.”
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Their nightmares reinforce their beliefs about
safety, and they “replay” situations that involve inescapable danger.
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They lose faith in themselves and others and no
longer trust their judgment. u They may have dreams about being hunted,
haunted or chased by those they think they “failed.” They may dream about
being helpless in the face of death.
|
Mixed
Event
A mixed event is when we have a simultaneously moral injurious and
traumatic.25
Moral Dissonance
Moral dissonance arises when the displayed behavior is experienced
to conflict with a morally more desirable behavior (ought).
Veterans who suffered a PMIE described that central to the distress
caused by PMIEs was the experience of moral dissonance, or a clash between
concurrently held sets of values (e.g. military values versus civilian
values)which provoked considerable psychological distress.25
e.g:
1.
If I was to go into a town and shoot five people,I
would be a mass murder.Yet,if I was to shoot five people in uniform overseas
you are legally entitled to do that because you have rules of engagement and
all the rest of the stuff.But murder is murder at the end of the
day.Killling is killing (Verbatim quote in European
Journal of Psychotraumatology 2020,Vol 11)25
2.
As we went through
the enemy positions, we saw gruesome sights — heads blasted off and faces with
gaping holes. One man was still alive but his arms lay yards away from him on
either side of the trench.It was staggering — and dangerous in the long run —
how quickly we became used to these macabre scenes. We would take the boots,
which were better quality, and wear them instead of our own, literally stepping
into dead men’s shoes.
I came home
little more than two months later hard and cynical, tormented by harrowing
memories. Back in my home town of Dundee, I spent long nights with only a
bottle of whisky for company, drinking myself into a haze to evade the
nightmares. I became angry, moody and difficult, and my marriage disintegrated
as a result.
One day my mother sat me down and spelled it out to me. I
had no heart any more, she said. I’d left it 8,000 miles away on the Falklands.
For a long time, I doubted whether the sacrifice of my friends’ lives and
the trauma inflicted on those of us who survived had really been worth it.
But I came to see the value of what we achieved and be proud of it.Two hundred
and fifty eight British servicemen paid with their lives for the recapture of
the islands, and a further 775 were wounded. Many of the rest of us paid
with our peace of mind. (ex-Para Tony Banks- Mail Online 2 March
2012) 1
Williamson observed that some veterans resolved this moral dissonance by
identifying a different source to blame for the events rather tan themselves
(e.g: Ministry of Defense or chain of command)
Discussion of the PMIE with Friends, colleagues or family members was
considered cathartic but did not help to resolve their moral dissonance.
The MI Symptom Scale
The 45-item
Moral Injury Symptom Scale-Military Version, Long Form (MISS-M-LF) is probably the
most comprehensive, assessing ten dimensions of moral injury ,including the
psychological and spiritual aspects. 4,12,26
MI Symptoms
Veterans who experience moral injury
can be overwhelmed by negative feelings. Feelings of guilt, shame, remorse from past acts that violated
their code of morals. Often they feel disinterest in previously enjoyable
activities, or genuinely find it hard to feel happy.26
Moral Injury in US personnel
In 2020, Maguen et al examined PMIEs in a national sample of
post-9/11 Veterans and found that 55.4%
of Veterans reported any PMIE exposure. Veterans endorsed exposures stemming
from perpetration (18.8%), witnessing (27.9%) and betrayal (41.1%). This was the first study to examine gender differences
in PMIE exposures. 19
In 2022, Boscarino
et al studied MI among 1,032 deployed veterans who were outpatients in a large
non-profit multi-hospital system in central Pennsylvania. The study included
active duty and Guard/Reserve members, as well as veterans who were not
Department of Veterans Affairs (VA) service users. 2
Most veterans
studied were deployed to Vietnam (64.1%), while others were deployed to
post-Vietnam conflicts in Iraq and Afghanistan and elsewhere.
Altogether,
95.1% of the veterans were male and their mean age was 61.6 years. Among the
veterans, 24.4% had high combat exposure , 10.9% had PTSD, 19.8% had major
depressive disorder, and 11.7% had a history of suicidal thoughts.2
MI was also
associated with pain, sleep disorders, fear of death, anomie, use of
alcohol/drugs to cope post-deployment, and poor unit support/morale during
deployment.2
Having an in-service concussion,
current pain, sleep problems, and a history of heavy marijuana use were
positively associated with having a high MI score (all p-values p <0.01) .Having
mental health treatment in the past year was also associated with high MI
(OR = 3.23, p < 0.001).
Conversely,
serving in the National Guard/Reserve (OR = 0.67, p = 0.009) was related to lower MI scores.
The reasons why some veterans are at
greater risk for MI is still unclear and may involve personality and moral
value issues, as well as factors related to sensory processing of stimuli. 2
MI among UK military veterans 25
Victoria
Williamson et al published in 2020 a most thorough research on PMIEs among UK
military veterans (93.3% British Army) which included mistreating civilians or
enemy combatants, being ordered to break rules of engagement, and disrespecting
dead bodies (Williamson et al., 2019).
To determine
whether a participant had experienced a moral injury, all participants were
asked whether they had experienced an event(s) during military service that challenged their view of who they are,
the world they live in, or their sense of right and wrong and to provide a
brief summary of the event
All
participants (average age of 46.3 years
) reporting having been deployed during their military service on average five
times, with deployment areas including Iraq, Afghanistan, Sierra Leone, Bosnia,
Kosovo and the Malvinas. 25
Fifteen
participants experienced exposure to a PMIE, nine had experienced a ‘mixed’
event where the event was both potentially morally injurious and
traumatic/life-threatening, and six experienced a traumatic or life-threatening
(non-morally injurious) event.
In both the
‘mixed’ and moral injury samples, veterans who experienced PMIEs reported that
their feelings of shame and self-loathing contributed to poor self-care as well
as risk-taking behaviours (e.g. driving while intoxicated, speeding).
There was also
substance misuse (i.e. alcohol, illicit drug use)and efforts to atone or make
amends for the PMIE like being involved in organizations
to support fellow veterans, visiting the grave of enemy combatants they had
killed and actively campaigning against bullying.
Morally injurious events among aid
workers 6
Aid workers
frequently encounter human distress and witness numerous injustices that are
inherent to humanitarian crises . Aid workers are exposed to ethical issues and
moral conflicts.
Dewar et al found
that struggling to “understand global injustices and acts of inhumanity,” to
“bring meaning to confronting situations,” and to cope with “a sense of helplessness
in horrific situations” were major issues that resulted from the participant’s
aid experience.
McCormack and
Joseph (2013) reported that many aid workers questioned their own actions,
particularly when they chose to prioritize their own safety over that of
others. Such situations generated a great
deal of shame and the fear of being judged.
Experiencing PMIE in the context of aid
work appears to be the norm rather than the exception, as 81.1% aid workers reported
PMIE. 22.8% reported having committed a
PMIE, 75.3% reported having witnessed others committing a PMIE, and 27.4%
reported PMIE that stemmed from being betrayed.
A total of 583
nurses and 2423 physicians were recruited from across mainland China. An online
survey was conducted from March 27 to April 26, 2020 (during the middle of the
COVID-19 pandemic) using the Chinese version of the MISS-HP(Moral Injury
Symptoms Scale-Health Professional)
The MISS-HP is unique in that it
assesses both psychological and religious/spiritual dimensions of MI. The results indicated that the
MISS-HP is a reliable and valid measure of MI in both nurses and physicians.
the MISS-HP can be used to screening for MI symptoms and follow response to
treatment among healthcare professionals in China. 27
MI and Religiosity
In Williamson’s
research, veterans in the mixed and MI with religious beliefs prior to the PMIE
reported losing their faith or trust in a just God. Notwithstanding, a
small number of veterans with exposure to PMIE described a growth in their
spirituality or religious beliefs which was a source of great comfort.This
was not described in non-MI injured veterans.
Koenig et al
studied 103 Active Duty U.S. Military (ADM) and examined the association
between moral injury (MI) and religiosity, the modifying effects of PTSD
severity on this relationship, and the receptivity to a spiritual intervention.
Among those
with significant PTSD, two-thirds were
interested in a spiritually-integrated treatment for their MI. Symptoms of
MI were common in these ADM.14
In a study on Vietnam veterans those
who had a positive view of God and sought forgiveness faired better that those
who felt alienated by God for various reasons.This seems to coincide with
religious “common sense.”
The fase of the enemy
The thesis developed by Seth is that
the process of recognizing the face of another person, including an
enemy, brings one into a position of responsibility for the person being faced
and that denying this responsibility by killing creates an ethical and
religious conflict leading to moral injury. 24
The value of religious authority as
found in the Old and New Testaments, in addition to teaching responsibility for
the other, is an acceptance of accountability that lies beyond the self for
every action taken. For where there is accountability, there is the possibility
of reconciliation, and where one finds reconciliation there lies the essence of
religious authority, not as a tool to be mastered, but as source of love that
dismantles the grip of fear.
Risk and protective factors 25
- · Veterans
perceived the lack of social support as a factor increasing their vulnerability
to distress.
- · Predeployment
briefing can be somewhat protective against later psychological distress during
deployment.
One way to prepare combatants
for war is to teach respect for the
enemy as a means of responsibility
that holds the enemy within the
boundaries of humanity.
- · Collaborative,informal
support from military chaplains was linked to better mental health in service
personnel
- · How the psychological consequences following morally
injurious events compare to those encountered after a traumatic,but not morally
injurious events,remain poorly understood.25
MI and the 1982 South Atlantic conflict
The 1982
conflict has become a heavily morally
charged subject. Its unfolding remains difficult to assess and its lessons
hard to learn (Tessey, Citation2020), partly because the hegemonic narrative of
Malvinas tends to exclude the military from the social memorialization of the
conflict. This ultimately assigns them a pre-confected role without questioning
of their experiences.10, 17,22,
Mount
Longdon, which occurred in Malvinas (11 jun 1982 – 12 jun 1982), was the
bloodiest battle fought by the British Army since the Korean War .
It
was fought between the British 3rd
Battalion, Parachute Regiment and elements of the Argentine 7th
Infantry Regiment.
Allegations emerged of incompetence, cowardice and murder
by British soldiers. 3,10,11,17
British war veteran Tim Lynch described in Vincent Bramley´s Two Sides
of Hell how Sargeant John Pettinger shot twice Argentine prisoner José
Carrizo in the head. 3 (Taught to
kill,not to pity:Falklands veteran Tim Lynch believes Army training creates men
capable of atrocities-The Independent-Sunday 21,March 1993)
“The causes of war and the way it is
fought have to be judged independently. You can be right to go to war and fight
it in a stupid way, and you can be wrong to go to war and fight it in a very
intelligent way.” (An interview with Sir Hew Strachan-The Telegraph-17 Jul
2014)
“Where
a society has lost the ability to make sound moral judgments and there are no
restraints on what is considered evil; when human life is not accorded dignity
and people are treated as commodities; when expectations of civilised conduct
are ignored and the imposition of political will becomes paramount, the
likelihood of moral injury is increased substantially in each instance.”
(pp.193-94) 8
Father’s war:
An anecdotal story from Madeleine L'Engle:
“Father's war was not like our wars
today. In his war the enemy still had a face. Once, a good many years after
the war, my parents were eating dinner in a Spanish inn, and suddenly Father
got up from the table in great excitement and rushed across the dining room to
a man who, in his turn, was hurrying to greet Father. The two men embraced warmly,
and Father brought his friend over to the table to meet Mother: the man was a
German; he had been an officer in the
Kaiser's army; he and Father had fought against each other at the front. It is
difficult to understand such an incident today. These two ‘enemies’ were
genuinely happy to see each other; they had shared an extraordinary experience;
they respected and honored each other. I wonder if that can happen today." ( L'Engle, Madeleine. The Summer of the
Great-Grandmother. The Seabury Press: New York,1974)
Treatment
In America,
specific treatments have been used like acceptance and commitment therapy and
adaptive disclosure. In UK, trauma focused, cognitive behavioral therapy and
compassion-focused therapy have been used.12
These findings
indicated too that there may be a role for chaplains in supporting the
wellbeing of morally injured personnel. MI in the absence of PTSD might
plausibly be resolved by a priest or an ethicist. 12
The Moral
Injury Psychoeducation Group published a Program Handbook whose material was
developed at the South Texas Veterans Health Care Service.
The Handbook
analyzes the types and sources of MI.23
Moral Injury
can result in problems with body, mind, community and spirituality. Resolving
moral injury requires a moral repair, a healing of the whole person. kind of multidimensional
restoration . 15,21
The multidimensional
Veteran care considers:
·
BODY:
Sleep, Stress Load, Physical Health (diet, exercise, play), Restoration of
Focus and Concentration
·
MIND:
Emotions, Guilt, Distorted Thinking
·
COMMUNITY:
Connecting with Others
·
SPIRITUALITY:
Meditation, Forgiveness, Beauty/Nature, Prayer, Higher Power/God From
(William P.
Nash, “Common Goals for Preventing and Repairing Moral Injury,” DCoE Chaplains
Working Group Teleconference, 4 March 2015)
There are many excellent books on this issue such as:5,20
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war:British soldiers shot dead by enemy tropos waving the White flag and Argentinian
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