Spiritual Wounds and Injuries (Part 1)

Moral Injury – A Prelude for Spiritual Care Practitioners

Authors

  • Murray J Davies University of New South Wales

DOI:

https://doi.org/10.1558/hscc.23758

Keywords:

spirituality, defence, spiritual, Australian Defence Force, veteran

Abstract

Moral injury (MI) has become a significant area of study and debate with regard to veterans’ mental health and general well-being. Due to the nature and intensity of coalition operations in Iraq and Afghanistan over a prolonged period, MI has become one of the “signature wounds” of these conflicts. Spiritual damage is a critical aspect of the MI paradigm. For some people, exposure to complex and demanding environments and situations creates threats to their spiritual understanding and belief systems. These threats may be expressed through doubt about their beliefs surrounding the concept of an omniscient, omnipotent, omnibenevolent divine creator. Such doubt, uncertainty and distress can negatively affect an individual’s overall mental health and well-being. This article seeks to achieve two objectives. The first is to introduce some of the history, language and concepts regarding MI, in order to enable spiritual care practitioners to participate in this crucial area of veterans’ health and well-being. This participation may include, but is not limited to, definitional research, language analysis, treatment and management. This study also serves as a starting point for a deeper discussion on whether spiritual damage is best described in a MI context, or whether a deeper analysis is needed independent of MI syndrome.

Author Biography

  • Murray J Davies, University of New South Wales

    Murray J. Davies, BA (Hons), MA, M.Defence Studies, MTh, GradDipTh, is the CSO of the Wounded Spirit charity that works with Australian Defence Force (ADF) veterans. He has published nationally and internationally on a range of theological, defence and history topics. He is also a PhD candidate at UNSW Canberra looking at the prevalence of spiritual injuries among ADF veterans.

References

American Psychological Association (APA) (n. d.). Shame. APA Dictionary of Psychology. https://dictionary.apa.org/shame

American Psychological Association (APA) (n. d.). MODE theory. APA Dictionary of Psychology. https://dictionary.apa.org/mode-theory

American Psychological Association (APA) (n. d.). Cognitive dissonance. APA Dictionary of Psychology. https://dictionary.apa.org/cognitive-dissonance

Ames, D., Erickson, Z., Youssef, N. A., Arnold, I., Adamson, S., Sones, A. C., …, & Koenig, H. G. (2019). Moral injury, religiosity, and suicide risk in US veterans and active-duty military with PTSD symptoms. Military Medicine, 184(3–4), e271 e278. https://doi.org/10.1093/milmed/usy148

Australian Department of Defence (2020). ADF Glossary. Canberra: Australian Defence Force.

Australian Government (n.d.) Special Operations Command Major General Paul Kenny. Department of Defence – Army. https://www.army.gov.au/our-people/army-leadership/special-operations-command

Australian Government, Open Arms (2020). Understanding anger in veterans: Tips and strategies to support veterans struggling with anger. https://www.openarms.gov.au/sites/default/files/2020-01/webinar_5_anger_faqs_case_study_panelist.pdf

Australian Government, Open Arms (n. d.). Moral injury. https://www.openarms.gov.au/signs-symptoms/moral-injury

Baker, D.-P., & Coyle, S. (2021). Morality and ethics at war: Bridging the gaps between the soldier and the state. London: Bloomsbury Academic. https://doi.org/10.5040/9781350104587

Barr, P. (2012). A dyadic analysis of negative emotion personality predisposition effects with psychological distress in neonatal intensive care unit parents. Psychological Trauma: Theory, Research, Practice, and Policy, 4(4), 347–355. https://doi.org/10.1037/a0024228

Borges, L. M., Barnes, S. M., Farnsworth, J. K., Bahraini, N. H., & Brenner, L. A. (2020). A commentary on moral injury among health care providers during the COVID-19 pandemic. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1), S138–S140. https://doi.org/10.1037/tra0000698

Brémault-Phillips, S., Pike, A., Scarcella, F., & Cherwick, T. (2019). Spirituality and moral injury among military personnel: A mini-review. Frontiers in Psychiatry, 10(276). https://doi.org/10.3389/fpsyt.2019.00276

Brémault-Phillips, S., Cherwick, T., Smith-MacDonald, L. A., Huh, J., & Vermetten, E. (2022). Forgiveness: A key component of healing from moral injury? Frontiers in Psychiatry, 13. https://doi.org/10.3389/fpsyt.2022.906945

Brock, R. N., & Lettini, G. (2012). Soul repair: Recovering from moral injury after war. Boston: Beacon Press.

Caddick, N., Smith, B., & Phoenix, C. (2015). Male combat veterans’ narratives of PTSD, masculinity and health. Sociology of Health & Illness, 37(1), 97–111. https://doi.org/10.1111/1467-9566.12183

Callaway, K. L., & Spates, C. R. (2016). Moral injury in military members and veterans. Oxford Handbook Topics in Psychology. Oxford Academic Online. https://doi.org/10.1093/oxfordhb/9780199935291.013.69

Carey, L. B., & Hodgson, T. J. (2018). Chaplaincy, spiritual care and moral injury: Considerations regarding screening and treatment. Frontiers in Psychiatry, 9(619), 1–10. https://doi.org/10.3389/fpsyt.2018.00619

Carey, L. B., Hodgson, T. J., Soh, R. Y., Singh, T. K., & Armour, A. (2015). Moral injury: A systematic literature and resource bibliography for the Australian Defence Force Chaplaincy Branch. [An ‘Additional Report’ to the Australian Foreign Affairs, Defence and Trade References Committee, Department of the Senate regarding the ‘Mental Health of ADF Serving Personnel’.] Melbourne: Palliative Care Unit, School of Psychology and Public Health, La Trobe University. https://www.aph.gov.au/DocumentStore.ashx?id=7f3925dd-7134-4a60-8704-11314e503a51

Carey, L. B., Hodgson, T. J., Krikheli, L., Soh, R. Y., Armour, A.-R., Singh, T. K., & Impiombato, C. G. (2016). Moral injury, spiritual care and the role of chaplains: An exploratory scoping review of literature and resources. Journal of Religion and Health, 55(4), 1218–1245. https://doi.org/10.1007/s10943-016-0231-x

Crocq, M. A., & Crocq, L. (2000). From shell shock and war neurosis to posttraumatic stress disorder: A history of psych traumatology. Dialogues in Clinical Neuroscience, 2(1), 47–55. https://doi.org/10.31887/DCNS.2000.2.1/macrocq

Currier, J. M., Drescher, K. D., & Nieuwsma, J. A. (2021). Introduction to moral injury. In J. M. Currier, K. D. Drescher & J. A. Nieuwsma (Eds.), Addressing moral injury in clinical practice (pp. 3–18). Washington D. C.: American Psychological Association. https://doi.org/10.1037/0000204-001

Davies, M. J. (2020). Spiritual injuries: An Australian Defence Force experience. Journal of Veterans Studies, 6(1), 158–170. https://doi.org/10.21061/jvs.v6i1.152

Davies, M. J. (2022). The guilty veteran: The spiritual implications of veteran’s guilt. Journal of Veterans Studies, 8(1), 41–53. https://doi.org/10.21061/jvs.v8i1.256

Dobos, N. (2015). Moral trauma and moral degradation. In T. R. Frame (Ed.), Moral injury: Unseen wounds in the age of barbarism. Sydney: New South Publishing.

Dobos, N. (2020). Ethics, security, and the war-machine: The true cost of the military. Oxford: Oxford University Press. https://doi.org/10.2139/ssrn.3679000

Donaldson, M. (2013). The crossroad. Sydney: Pan Macmillan Australia.

Drescher, K. D., Foy, D. W., 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, 17(1), 8–13. https://doi.org/10.1177/1534765610395615

Edgar, J. (2020). Moral injury in the context of trauma. British Journal of Psychiatry, 216, 127–128. https://doi.org/10.1192/bjp.2020.46

Frame, T. R. (2015). Introduction. In T. R. Frame (Ed.), Moral injury: Unseen wounds in the age of barbarism. Sydney: New South Publishing.

Garrison, W. (2000). The unknown civil war: Odd, peculiar, and unusual stories of the war between the states. Nashville: Cumberland House.

Graham, L. K. (2017). Moral injury: Restoring wounded souls. Nashville: Abingdon Press.

Grossman, D. (1996). On killing: The psychological cost of learning to kill in war and society. Boston: Little Brown and Company.

Hansen, K. T. (2019). Prevalence of moral injury in Canadian Forces members deployed to Afghanistan. Electronic Thesis and Dissertation Repository, 6204. https://ir.lib.uwo.ca/etd/6204

Held, P., Klassen, B. J., Coleman, J. A., Thompson, K., Rydberg, T. S., & Van Horn, R. (2021). Delivering intensive PTSD treatment virtually: The development of a 2-week intensive cognitive processing therapy-based program in response to COVID-19. Cognitive and Behavioral Practice, 28(4), 543–554. https://doi.org/10.1016/j.cbpra.2020.09.002

Hodgson, T. J., & Carey, L. B. (2017). Moral injury and definitional clarity: Betrayal, spirituality and the role of chaplains. Journal of Religion and Health, 56(4), 1212–1228. https://doi.org/10.1007/s10943-017-0407-z

Hodgson, T. J., Carey, L. B., & Koenig, H. G. (2022). Moral injury, betrayal and retribution: Australian veterans and the role of chaplains. Journal of Religion and Health, 61, 993–1021. https://doi.org/10.1007/s10943-022-01507-7

Holmes, A. F. (1975). War and Christian ethics: Classic readings on the morality of war. Grand Rapids: Baker Book House.

Inspector-General of the Australian Defence Forces (IGADF) (2020). Report of inquiry under division 4A of part 4 of the Inspector-General of the Australian Defence Force regulation 2016 into questions of unlawful conduct concerning the Special Operations Task Group in Afghanistan. Canberra: IGADF. https://www.defence.gov.au/sites/default/files/2021-10/IGADF-Afghanistan-Inquiry-Public-Release-Version.pdf

Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs: Prentice-Hall.

Jamieson, N., Usher, K., Ratnarajah, D., & Maple, M. (2021). Walking forwards with moral injury: Narratives from ex-serving Australian Defence Force members. Journal of Veterans Studies, 7(1), 174–185. https://doi.org/10.21061/jvs.v7i1.214

Jinkerson, J. D. (2016). Defining and assessing moral injury: A syndrome perspective. Traumatology, 22(2), 122–130. https://doi.org/10.1037/trm0000069

Koenig, H. G., & Al Zaben, F. (2021). Moral injury: An increasingly recognised and widespread syndrome. Journal of Religion and Heath, 60(5), 2989–3011. https://doi.org/10.1007/s10943-021-01328-0

Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706. https://doi.org/10.1016/j.cpr.2009.07.003

Maguen, S., Nichter, B., Norman, S. B., & Pietrzak, R. H. (2021). Moral injury and substance use disorders among US combat veterans: Results from the 2019–2020 National Health and Resilience in Veterans Study. Psychological Medicine, 1–7. Cambridge University Press Online. https://doi.org/10.1017/S0033291721002919

Marshall, S. L. A. (1968). Men against fire: The problem of battle command in future war. New York: William Morrow.

McKenzie, N., & Masters, C. (2021). The untouchables: Top detectives to investigate “disgraceful” kill squad. The Age, July 10, 2021 – 5.00 a.m. https://www.theage.com.au/national/the-untouchables-top-detectives-to-investigate-disgraceful-kill-squad-20210708-p58850.html

Nash, W. P., & Litz, B. T. (2013). Moral injury: A mechanism for war-related psychological trauma in military family members. Clinical Child and Family Psychological Review, 16, 365–375. https://doi.org/10.1007/s10567-013-0146-y

Nelson, B. (2016). Anzac Day 2016: Dawn Service commemorative address. Australian War Memorial. https://www.awm.gov.au/commemoration/speeches/anzac-day-dawn-service-address-2016-dr-brendan-nelson#:~:text=Australians%20all%20let%20us%20rejoice,passed%20now%20to%20our%20generation

Norman, S. B., & Maguen, S. (n. d.). Moral injury. US Department of Veterans Affairs. PTSD: National Center for PTSD. Retrieved 2021 from https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp

Persons, R. W. (1970). The Mosher guilt scale: Theoretical formulation, research review and normative data. Journal of Projective Techniques and Personality Assessment, 34(4), 266–270. https://doi.org/10.1080/0091651X.1970.10380249

Phelps, A. C., Lauderdale, K. E., Alcorn, S., Dillinger, J., Balboni, M. T., Van Wert, M., …, & Balboni, T. A. (2012). Addressing spirituality within the care of patients at the end of life: Perspectives of patients with advanced cancer, oncologists, and oncology nurses. Journal of Clinical Oncology, 30(20), 2538–2544. https://doi.org/10.1200/JCO.2011.40.3766

Pickard, T. (2008). Combat medic: An Australian’s eye-witness account of the Kibeho Massacre. Wavell Heights: Big Sky Publishing.

Ramsay, N. J. (2020). Spiritual care for veterans and their families affected by moral injury. In B. E. Kelle (Ed.), Moral injury: A guidebook for understanding and engagement. Lanham: Lexington Books.

Reynolds, S. J. (2006). Moral awareness and ethical predispositions: Investigating the role of individual differences in the recognition of moral issues. Journal of Applied Psychology, 91(1), 233–243. https://doi.org/10.1037/0021-9010.91.1.233

Rozek, D. C., & Bryan, C. J. (2021). A cognitive-behavioural model of moral injury. In J. M. Currier, K. D. Drescher & J. A. Nieuwsma (Eds.), Addressing moral injury in clinical practice (pp. 19–33). Washington D. C.: American Psychological Association. https://doi.org/10.1037/0000204-002

Shay, J. (1991). Learning about combat stress from Homer’s Iliad. Journal of Traumatic Stress, 4(4), 561–579. https://doi.org/10.1002/jts.2490040409

Shay, J. (1994). Achilles in Vietnam: Combat trauma and the undoing of character. New York: Atheneum.

Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182–191. https://doi.org/10.1037/a0036090

Shay, J., & Munroe, J. (1999). Group and milieu therapy for veterans with complex posttraumatic stress disorder. In P. A. Saigh & J. D. Bremner (Eds.), Posttraumatic stress disorder: A comprehensive text (pp. 391–413). Boston: Allyn and Bacon.

Shay, J., Cleland, M., & McCain, J. (2002). Odysseus in America: Combat trauma and the trials of homecoming. New York: Scribner.

Silver, D., & McCune, M. (2011). Beyond PTSD: Soldiers have injured souls. Truthout, September 3. https://truthout.org/articles/beyond-ptsd-soldiers-have-injured-souls

Smith-MacDonald, L., Lentz, L., Malloy, D., Brémault-Phillips, S., & Carleton, R. N. (2021). Meat on a seat: A grounded theory study exploring moral injury in Canadian public safety communicators, firefighters, and paramedics. International Journal of Environmental Research and Public Health, 18(22), 12145. https://doi.org/10.3390/ijerph182212145

Smith-MacDonald, L., Pike, A., Jones, C., & Brémault-Phillips, S. (2022). Exploration of trauma-oriented retreats: Quantitative changes in mental health measures for Canadian military members, veterans and Royal Canadian Mounted Police with posttraumatic stress disorder and moral injury. Trauma Care, 2(2), 114–130. https://doi.org/10.3390/traumacare2020010

Stancel, K., Russo, C., Koskelainen, M., Papazoglou, K., & Tuttle, B. M. (2019). Police moral injury, compassion fatigue, and compassion satisfaction: A brief report. Salus Journal, 7(1), 42–57. https://search.informit.org/doi/10.3316/informit.301282217090422

Tanielian, T., & Jaycox, L. H (Eds.) (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica: RAND Corporation. https://www.rand.org/pubs/monographs/MG720.html

Thompson, M. M. (2015). Moral injury in military operations: A review of the literature and key considerations for the Canadian Armed Forces. Toronto: Defence Research and Development Canada. https://apps.dtic.mil/sti/citations/AD1004227

Tick, E. (2014). Warrior’s return: Restoring the soul after war. Boulder: Sounds True. US Department of Veterans Affairs (n. d.). Veterans Health Administration. https://www.va.gov/health

Williamson, V., Greenberg, N., & Murphy, D. (2019). Impact of moral injury on the lives of UK military veterans: A pilot study. Journal of the Royal Army Medical Corps, 166(5), 302–306. https://doi.org/10.1136/jramc-2019-001243

Wolf, S. T., Cohen, T. R., Panter, A. T., & Insko C. A. (2010). Shame proneness and guilt-proneness: Toward the further understanding of reactions to public and private transgressions. Self and Identity, 9(4), 337–362. https://doi.org/10.1080/15298860903106843

Wood, D. (2016). What have we done? The moral injury of our longest wars. New York: Little Brown and Company.

Zerach, G., Levi-Belz, Y., Griffin, B. J., & Maguen, S. (2021). Patterns of exposure to potentially morally injurious events among Israeli combat veterans: A latent class analysis approach. Journal of Anxiety Disorders, 79, 102378. https://doi.org/10.1016/j.janxdis.2021.102378

Published

2022-12-12

How to Cite

Davies, M. J. (2022). Spiritual Wounds and Injuries (Part 1): Moral Injury – A Prelude for Spiritual Care Practitioners. Health and Social Care Chaplaincy, 11(1), 40–67. https://doi.org/10.1558/hscc.23758