Moral and Spiritual (Soul) Injury 

Moral Injury

The Marines in the RWRP were confronted with the life and death of war. The young men and women who join our military are raised in a culture that makes murder a federal crime. United States Marines are trained to respect human life and protect it; however, when given a mission, they are often asked to take a life. When faced with killing, many begin to think about the moral implications of war and killing; especially when they experienced an enemy who did not fight by the Laws of Armed Conflict, the Geneva Conventions, or other just war ethics and virtues. Combat can put warriors in circumstances that lead to moral dilemmas and contribute to moral injury.

Maguen et al. (2010) discovered in a study of 2,797 OIF veterans that approximately 40% of these service members reported to have killed someone in combat. These researchers found that being directly involved in killing was a contributing factor to PTSD or other negative symptoms such as depression or behaviors such as alcohol abuse. Thus, thinking about the morality of war and killing in ways that help service members cope positively is critical to their well-being. If a person is experiencing a moral conflict, this can lead to distress, which limits an individual’s ability to actively cope, use positive reframing, and come to acceptance about the dramatic and traumatic experiences of war. Coping positively with CSE requires that the warrior be able to process internal moral conflicts through adaptive and active coping.

The concept of moral injury is complicated and is a subject gaining attention in the literature. Drescher et al. (2011) defined and described moral injury as the:

disruption in an individual’s confidence and expectations about one’s own or others’ motivation or capacity to behave in a just and ethical manner. This injury is brought about by bearing witness to perceived immoral acts, failure to stop such actions, or perpetration of immoral acts, in particular actions that are inhumane, cruel, violent, bringing about pain, suffering, or death of others. (p. 2)

Nancy Sherman (2010) commented about moral injury when she stated:

But what we miss in being afraid to talk about a soldier's emotions is that psychological anguish in war is also moral anguish. Soldiers wrestle with what they see and do in uniform, even when their conflicts don't rise to the level of acute psychological trauma. And they feel guilt and shame even when they do no wrong by war's best standards. (p. 1)

Moral injury is an invisible war wound and is directly related to combat stress injury. In order to cope with moral injury, one must be able to process the negative and often traumatic experiences of combat in a positive way similar to that described under moral dilemma. Not all moral injury associated with being in combat happens in combat. Two of the participants in my study experienced drama and trauma at home through failed marriages and the death or illness of a loved one that made coping with CSE more challenging especially with their moral reasoning asking “why is this happening to me?” Interestingly, both of these Marines sought mental health services and the assistance of a chaplain; they adapted and are coping positively. In the study it was found that those who cope positively with CSE are less likely to use self-blame and denial coping strategies and are more likely to use positive reframing and acceptance when coping.

Finally, what is the essence of the resilient warrior’s moral processing that makes his or her lived experience different from that of others? Facing moral dilemmas and being morally injured can happen to any person anywhere; however, combat puts an individual in a particularly risky environment that most people never will experience. The moral decisions of the resilient warrior require him or her to instantaneously make life-and-death choices. Often, these warriors are only 18 or 19 years old; at this age, the prefrontal cortex and executive decision making system are not fully developed. The wrong decision can shatter lives and take the life of a human being, which could result in PTSD and a moral injury that can haunt an individual for life. The resilient warrior is trained to make the best moral decisions possible in the most difficult of environments. Thus, a resilient warrior is able to make snap moral decisions that protect lives and achieve the mission without sustaining moral injury; if a moral injury is sustained they are able to cope with their combat experience and rebound positively.

Measuring MORal injury

Nash et al. (2013) developed the Moral Injury Events Scale, which purports to measure moral injury in combatants. This scale was developed as part of a larger longitudinal study entitled the Marine Resiliency Study.  Recently new instruments have emerged to measure moral injury to include the Moral Injury Symptom Scale- Military Version (Koenig, et al, 2018) and the Expressions of Moral Injury Scale - Military Version - EMIS-M (Currier, et al. 2017).

spiritual (SOUL) injury

Another dimension of an invisible wound from war is spiritual or soul injury. Many warriors have religious or spiritual beliefs that serve as an anchor to their soul. Similar to moral injury a warrior’s soul or spirit can be injured by the horrors of war. When someone’s soul is violated this is a wound at the very core one’s being. Larry Dewey in his work with warriors he treated at a VA hospital provides incredible insight to this injury in his masterful text “War and Redemption.” Over the past decade there has been a lot of research on spiritual and soul injury (see references below). In the fall of 2019, I was asked to present to a group of providers attending the “Bearing the Burden Summit” on “The Influence of Faith on the Recovery from a Moral or Spiritual/Soul Injury.” This annotated presentation is a very thorough review of moral and spiritual injury. Caring for our wounded, ill and injured warriors whether it is physical, psychological, relational, or spiritual injuries is essential; recovering from the wounds of war can result in post-traumatic growth. 

Measuring Spiritual (soul) injury

Measuring psychological human factors quantitatively and qualitatively is challenging but a validated and trustworthy measures are important. Three instruments for measuring spiritual (soul) injury are Religious and Spiritual Struggles Scale (Exline, et al. 2014), Posttraumatic Cognitions Inventory - PCTI (Foa, et al. 1999) and Spiritual Injury Scale –SIS (Berg, 2011).

additional resources

The VA has a very good online toolkit especially for clergy related to moral and spiritual injury. Syracuse University has a robust online moral injury research tool along with veteran resources. The preeminent International Society for Traumatic Stress Studies (ISTSS) continues exemplary research on traumatic stress and provide resources for treating stress related illness. In addition, there are new therapies and interventions for moral and spiritual (soul) injury to include: Adaptive Disclosure Therapy (Litz, et al. 2009), Acceptance and Commitment Therapy for MI: Moving with Moral Pain Towards a Meaningful Life (Borgens, VA), Pastoral Narrative Disclosure Intervention (Carey and Hodgson, 2018), Building Spiritual Strengths Intervention (Harris and Usset, 2018).

References

Berg, G. (2011). The Relationship between Spiritual Distress, PTSD and Depression in Vietnam Combat Veterans. Journal of Pastoral Care and Counseling. doi.org/10.1177/154230501106500106

Borgens, L. (2019). Acceptance and Commitment Therapy for MI: Moving with Moral Pain Towards a Meaningful Life. Retrieved on 10 Oct from https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/video_archive.cfm?SessionID=3592

Carey, L. & Hodgson, T. (2018). Chaplaincy, Spiritual Care and Moral Injury: Considerations for Screening and Treatment. Frontiers in Psychiatry. doi 10.3389/fpsyt.2018.00619

Currier, J., Farnsworth, J., Drescher, K., McDermot, Sims, B., & Albright. (2018). Development and evaluation of the Expressions of Moral Injury Scale-Military Version. 25(3), 474-488. doi: 10.1002/cpp.2170

Dewey, L. (2004). War and Redemption: Treatment and Recovery in Combat-Related Posttraumatic Stress Disorder. Burlington, VT: Ashgate

Drescher, K., Foy, D. Kelly, C., Leshner, A., Schutz, K., & Litz, B. (2011). An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology. doi:10.1177/1534765610395615

Exline, J. J., Pargament, K. I., Grubbs, J. B., & Yali, A. M. (2014). The Religious and Spiritual Struggles Scale: Development and initial validation. Psychology of Religion and Spirituality, 6, 208-222. DOI: 10.1037/a0036465

Farnsworth, J. K., Drescher, K. D., Nieuwsma, J. A., & Walser, R. D. (2014). The role of moral emotions in military trauma: Implications for the study and treatment of moral injury. Review of General Psychology, 18(4), 249-262.

Farnsworth, J. K., Borges, L. M., Drescher, K. D., & Walser, R. D. (2019). Acceptance and commitment therapy for the treatment of moral injury (ACT-MI). Unpublished treatment manual.

Foa, E. B., A. Ehlers, et al. (1999). "The posttraumatic cognitions inventory (PTCI): Development and validation.“ Psychological Assessment 11(3): 303-314.

Gray, M. J., Schorr, Y., Nash, W., Lebowitz, L., Amidon, A., Lansing, A., ... Litz, B. T. (2012). Adaptive disclosure: An open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behavior Therapy, 43, 407–415.

Harris, J., Usset, T., Voecks , C. Thuras, P., Currier, J., Erbes, C. (2018). Spiritually integrated care for PTSD: A randomized controlled trial of “Building Spiritual Strength” Psychiatry Research, 267, 420-428. doi.org/10.1016/j.psychres.2018.06.045

Koenig, H.G., Ames D, Youssef N, Oliver JP, Volk F, Teng EJ, Haynes K, Erickson Z, Arnold I, O’Garo K. Pearce MJ (2018). Screening for Moral Injury – The Moral Injury Symptom Scale – Military Version Short Form. Military Medicine. doi.org/10.1093/milmed/usy017

Larson, D. & Zust, J.  (2017).  Care for the Sorrowing Soul:  Healing Moral Injury from Military Service and Implications for the Rest of Us.  Eugene, OR: Cascade Books.

Litz, B. T., Lebowitz, L., Gray, M. J., & Nash, W. P. (2015). Adaptive disclosure: A new treatment for military trauma, loss, and moral injury. New York, NY: Guilford Publications.

Maguen, S., Lucenko, B., Reger, M. A., Gahm, G. A., Litz, B., Seal, K. H.,…Marmar, C. R. (2010). The impact of reported direct and indirect killing on mental health symptoms in Iraq War veterans. Journal of Traumatic Stress, 23 (1), 86-90. doi:10.1002/jts.20434

Nakashima, R. & Lettine, G. (2012). Soul Repair: Recovering from Moral Injury After War. Boston: Beacon Books.

Nash, W. P., Marino, T. L., Mills, M. A., Au, T., Goldsmith, A., & Litz, B. (2013). Psychometric evaluation of the Moral Injury Events Scale. Military Medicine, 178, 646-652. doi:10.7205/MILMED-D-13-00017

Sherman, N. (2010). Soldiers' moral wounds. The chronicle of higher education. Retrieved from http://chronicle.com/article/Soldiers-Moral-Wounds/64987/