Spiritual Wounds and Injuries (Part 2)
Moral Injury and Spiritual Damage
DOI:
https://doi.org/10.1558/hscc.25399Keywords:
Moral Injury, spiritual damage, spiritual wounds, chaplainsAbstract
As part of a series on moral injury in HSCC (see Davies, 2023; Part 1), this Part 2 will propose that the current conceptions of moral injury (MI) may be inadequate, and that there is a need to recognize a distinct conceptualization of “spiritual damage”. Just as MI was, and still is, sometimes mistakenly and unhelpfully conflated with some criteria of post-traumatic stress disorder, it may also be a mistake to conflate spiritual damage with “spirituality injury” under the MI paradigm. The breadth and depth of spirituality and its basis in a divine, mysterious creator, or God(s), are such that their scope may extend beyond impacts that can be accounted for in terms of medicine, psychology and, in some respects, morality. As such, this article argues that the current discussion on spirituality within the MI framework may need to be revised to account for “spiritual damage” more comprehensively. It is suggested that a new approach to this area of MI is necessary to acknowledge the fundamentally important role of spirituality in a MI context, but also to expand the horizon to include spiritual damage that occurs before, during and after traumatic, difficult or horrific events. Further, deeper consideration needs to be given to encompassing both the institutional and personal aspects of religion and spirituality, and how damage in these areas can both wound and injure an individual’s spiritual schema, while also providing the potential for spiritual
growth. This study will consider five areas, in particular, that require deeper consideration: (i) spirituality and science; (ii) a relationship with the divine; (iii) the use of spiritual tools; (iv) the recognition of spirituality as more than just an “aftermath” issue; and (v) spiritual growth.
References
American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders: DSM III. Washington D. C.: American Psychiatric Association Publishing.
American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders: DSM IIIR (3rd edn revised). Washington D. C.: American Psychiatric Association Publishing.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorder: DSM VR (5th edn revised). Washington D. C.: American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425596
Anderson, M. R. (2020). The spiritual heart. Religions, 11(10), 506. https://doi.org/10.3390/rel11100506
Australian Department of Defence (2023). ADF Glossary. Canberra: Australian Defence Force.
Baker, D. (2021). Morality and ethics at war: Bridging the gaps between the soldier and the state. London: Bloomsbury Academic. Retrieved 27 February 2023 from http://dx.doi.org/10.5040/9781350104587
Barnes, H. A., Hurley, R. A., & Taber, K. H. (2019). Moral injury and PTSD: Often co-occurring yet mechanistically different. Journal of Neuropsychiatry Clinical Neuroscience, 31(2), A4–103. https://doi.org/10.1176/appi.neuropsych.19020036
BBC (2009). The Four Noble Truths. Religions. https://www.bbc.co.uk/religion/religions/buddhism/beliefs/fournobletruths_1.shtml
Berg, G. B. (1994). The use of the computer as a tool for assessment and research in pastoral care. Journal of Health Care Chaplaincy, 6(1), 11–25. https://doi.org/10.1300/J080v06n01_03
Berg, G. (2011). The relationship between spiritual distress, PTSD and depression in Vietnam combat veterans. Journal of Pastoral Care & Counseling, 65(1), 1–11. https://doi.org/10.1177/154230501106500106
Bishop, J., & McKaughan, D. J. (2022) Faith. Stanford Encyclopaedia of Philosophy. https://plato.stanford.edu/entries/faith/?fbclid=IwAR0i_FM3hHMcJoGTNSFOuYdyZlfZ3ZYJ9rN9u0_fbRNFRX2h1n2NvTVLuUk
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, 12(S1), S138–S140. https://doi.org/10.1037/tra0000698
Brock, R. N., & Lettini, G., (2011). How do we repair the souls of those returning from Iraq? Huff Post. http://www.huffingtonpost.com/rita-nakashima-brock-ph-d/the-war-is-coming-home-so_b_1027499
Brock, R. N., & Lettini, G. (2012). Soul repair: Recovering from moral injury after war. Boston: Beacon Press.
Brock, R. N., Lettini, G., Bica, C., Keizer, H., Lightsey, P., & Mejia, C. (2012). Soul repair: Recovery from moral injury after war. Study guide for congregations. Boston: Beacon Press.
Cappuccio, M. L., Galliott. J. C., & Alnajjar, F. S. (2022). A taste of Armageddon: A virtue ethics perspective on autonomous weapons and moral injury, Journal of Military Ethics, 21(1), 19–38. https://doi.org/10.1080/15027570.2022.2063103
Cambridge Dictionary (2023a). Sequela. https://dictionary.cambridge.org/dictionary/english/sequela
Cambridge Dictionary (2023b). Soul. https://dictionary.cambridge.org/dictionary/english/soul
Cambridge Dictionary (2023c). Therapeutic. https://dictionary.cambridge.org/dictionary/english/therapeutic
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., 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, 1218–1245. https://doi.org/10.1007/s10943-016-0231-x
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. (2023). Spiritual wounds and injuries (part 1): Moral injury – a prelude for spiritual care practitioners. Health and Social Care Chaplaincy, 11(1). https://doi.org/10.1558/hscc.23758
Drescher, K., & Foy, D. W. (2008). When they come home: Posttraumatic stress, moral injury, and spiritual consequences for veterans. Reflective Practice: Formation and Supervision in Ministry, 28, 85–102. https://journals.sfu.ca/rpfs/index.php/rpfs/article/view/158
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
Eddington, P. (2017). Fixing moral injury. Cincinnati: United Church of God. https://www.ucg.org/members/united-news/fixing-moral-injury
Farnsworth, J., Drescher, K. D., Nieuwsma, J. A., Walser, R. B., & Currier, J. M. (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. https://doi.org/10.1037/gpr0000018
Frame, T. (2015). The influence of religious conviction. In T. R. Frame (Ed.), Moral injury: Unseen wounds in an age of barbarism. Sydney: New South Publishing.
Gibson, S. (2015). Moral injury: Whose responsibility? In T. R. Frame (Ed.), Moral injury: Unseen wounds in an age of barbarism. Sydney: New South Publishing .
Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz, M., Villierme, C., Walsh, J., & Maguen, S. (2019). Moral injury: An integrative review. Journal of Traumatic Stress, 32(3), 350–362. https://doi.org/10.1002/jts.22362
Grimell J. (2018). Contemporary insights from Biblical combat veterans through the lenses of moral injury and post-traumatic stress disorder. Journal of Pastoral Care and Counseling, 72(4), 241–250. https://doi.org/10.1177/1542305018790218
Heim, M. (2007). Buddhism. In J. Corrigan (Ed.), The Oxford handbook of religion and emotion (pp. 17–34; online edn). Oxford Academic. https://doi.org/10.1093/oxfordhb/9780195170214.003.0002
Hepburn, B. & Andersen, H. (2021). Scientific method. Stanford Encyclopedia of Philosophy. https://plato.stanford.edu/entries/scientific-method/
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. (2022). Pastoral Narrative Disclosure: A strategy for chaplains to address moral injury. Canberra: Australian Department of Defence.
Hodgson, T. J., Carey, L. B., & Koenig, H. G. (2021). Moral injury, Australian veterans and the role of chaplains: An exploratory qualitative study. Journal of Religion and Health, 60, 3061–3089. https://doi.org/10.1007/s10943-021-01417-0
Hughes, B., & Handzo, G. (2009). Spiritual care handbook on PTSD/TBI: Handbook for the provision of spiritual care to persons with post-traumatic stress disorder and traumatic brain injury. United States Navy. https://www.researchgate.net/publication/09347023_The_Handbook_on_Best_Practices_for_the_Provision_of_Spiritual_Care_to_Persons_with_Post_Traumatic_Stress_Disorder_and_Traumatic_Brain_Injury/citation/download
Jones, C. R., Soundias, L., Drakopoulos, E., & Carey, L. B. (2020). Police force personnel, moral injury and the role of chaplains: An exploratory scoping review. La Trobe Report. https://doi.org/10.26181/5fbb4edeca164
Jones, K. A., Freijah, I., Carey, L. B., Carleton, R. N., Devenish-Meares, P., Dell, L., Rodrigues, S., Madden, K., Johnson, L., & Hosseiny, F. (2022). Moral injury chaplaincy and mental health provider approaches to treatment: A scoping review. Journal of Religion and Health, 61, 1051–1094. https://doi.org/10.1007/s10943-022-01534-4
Kelle, B. E. (2021). Moral injury and biblical studies: An early sampling of research and emerging trends. Currents in Biblical Research, 19(2), 121–144. https://doi.org/10.1177/1476993X20942383
Kilner, P. 2017. Moral injury – personal, organizational, and divine betrayals: Thoughts of a soldier-ethicist. http://soldier-ethicist.blogspot.com/2018/01/causes-of-moral-injury-perceived.html
King James Bible. (2017). King James Bible Online. (Original work published 1769). https://www.kingjamesbibleoline.org/
Koenig, H. G. (2018). Measuring symptoms of moral injury in veterans and active duty military with PTSD. Religions, 9(3), 86. https://doi.org/10.3390/rel9030086
Koenig, H. G., & Al Zaben, F. (2021). Moral injury: An increasingly recognised and widespread syndrome. Journal of Religion and Health, 60(5), 2989–3011. https://doi.org/10.1007/s10943-021-01328-0
Koenig, H. G., Carey, L. B., & Wortham, F. (2023). Moral injury: A handbook for military chaplains. New York: Amazon Books.
Lettini, G. (2013). Engaging the moral injuries of war: A call to spiritual leaders. Spirituality in Formation and Supervision, 33. https://journals.sfu.ca/rpfs/index.php/rpfs/article/view/260
Litz, B. T., & Kerig, P. K. (2019). Introduction to the special issue on moral injury: Conceptual challenges, methodological issues, and clinical applications. Journal of Traumatic Stress, 32(3), 341–349. https://doi.org/10.1002/jts.22405
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
Litz, B. T., Contractor, A. A., Rhodes, C., Dondanville, K. A., Jordan, A. H., Resick, P. A., Foa, E. B., Young-McCaughan, S., Mintz, J., Yarvis, J. S., & Peterson, A. L. for the STRONG STAR Consortium (2018). Distinct trauma types in military service members seeking treatment for posttraumatic stress disorder. Journal of Traumatic Stress, 31(2), 286–295. https://doi.org/10.1002/jts.22276
Lukoff, D., Lu, F. G., & Yang, C. P. (2011). DSM-IV religious and spiritual problems. In J. R. Peteet, F. G. Lu, & W. E Narrow (Eds.), Religious and spiritual issues in psychiatric diagnosis: A research agenda for DSM-V (pp. 171–198). Arlington: American Psychiatric Association.
Maguen, S., Nichter, B., Norman, S., & Pietrzak, R. (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
McGilchrist, I. (2014). What happened to the soul? RSA Social Brain Centre’s project: Spirituality, tools of the mind, and the social brain. London: Royal Society for the Encouragement of Arts, Manufactures and Commerce. https://www.thersa.org/blog/2014/12/what-is-the-soul-and-why-does-it-matter
Molendijk, T., Verkoren, W., Drogendijk, A., Elands, M., Kramer, E. H., Smit, S., & Verweij, D. (2022). Contextual dimensions of moral injury: An interdisciplinary review. Military Psychology, 34(6), 742–753. https://doi.org/10.1080/08995605.2022.2035643
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
Nasr, S. H., Dagli, C. K., Dakake, M. M., Lumbard, J. E. B., & Rustom, M. (2015). The study Quran: A new translation and commentary. New York: Harper One.
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
Norman, S. B., & Maguen, S. (2021). Moral injury. US Department of Veterans Affairs. PTSD: National Center for PTSD. https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp
Park, C. L., & Carney, L. M. (2021). Religious head versus heart beliefs: Measurement development and validation. Psychology of Religion and Spirituality. 14(4), 572–584. https://doi.org/10.1037/rel0000352
Pew Research Center (2012). The global religious landscape. Washington D. C.: Pew Research Center. https://www.pewresearch.org/religion/2012/12/18/global-religious-landscapeexec
Purcell, N., Koenig, C. J., Bosch, J., & Maguen, S. (2016). Veterans’ perspectives on the psychosocial impact of killing in war. Counseling Psychologist, 44(7), 1062–1099. https://doi.org/10.1177/0011000016666156
Schorr, Y., Stein, N. R., Maguen, S., Barnes, B., Bosch, J., &, Litz, B. T. (2018). Sources of moral injury among war veterans: A qualitative evaluation. Journal of Clinical Psychology, 74(12), 2203–2218. https://doi.org/10.1002/jclp.22660
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., Cleland, M., & McCain, J. (2002). Odysseus in America: Combat trauma and the trials of homecoming. New York: Scribner.
Singer, M. (2004). Shame, guilt, self-hatred and remorse in the psychotherapy of Vietnam combat veterans who committed atrocities. American Journal of Psychotherapy, 58(4), 377–385. https://doi.org/10.1176/appi.psychotherapy.2004.58.4.377
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
Sperry, L. (2021). Moral injury in Christian organisations: Sacred moral injury. In J. R. Peteet, H. S. Moffic, A. Hankir, & H. G. Koenig (Eds.), Christianity and psychiatry. Cham: Springer. https://doi.org/10.1007/978-3-030-80854-9
Suitt, T, H. (2021). Finding resonance amid trauma: Moral injury and the role of religion among Christian post-9/11 U.S. veterans. Sociology of Religion, 82(2), 179–207. https://doi.org/10.1093/socrel/sraa044
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/content/dam/rand/pubs/monographs/2008/RAND_MG720.pdf
US Department of Veterans Affairs (n. d.). Veterans Health Administration. Retrieved 2023 from https://www.va.gov/health
Vatican (1992). Apostolic Constitution Fidei Depositum on the publication of the Catechisms of the Catholic Church prepared following the Second Vatican Ecumenical Council. https://www.vatican.va/content/john-paul-ii/en/apost_constitutions/documents/hf_jp-ii_apc_19921011_fidei-depositum.html
Vatican (2005). Compendium of the Catechism of the Catholic Church. https://www.vatican.va/archive/compendium_ccc/documents/archive_2005_compendium-ccc_en.html
Vishwanath, S. (2023). Bhagavad Gita summary: How to handle big mistakes in your life – Krishna’s strategy. https://www.bhagavadgitauniversity.com/blog/bhagavad-gita-summary-how-to-handle-big-mistakes-in-your-life-krishnas-strategy
Wortmann, J. H., Eisen, E., Hundert, C., Jordan, A. H., Smith, M. W., Nash, W. P., & Litz, B. T. (2017). Spiritual features of war-related moral injury: A primer for clinicians. Spirituality in Clinical Practice, 4(4), 249–261. https://doi.org/10.1037/scp0000140
Yeterian, J. D., Berke, D. S., Carney, J. R., McIntyre-Smith, A., St. Cyr, K., King, L., Kline, N. K., Phelps, A., Litz, B. T., & Members of the Moral Injury Outcomes Project Consortium (2019). Defining and measuring moral injury: Rationale, design, and preliminary findings from the Moral Injury Outcome Scale Consortium. Journal of Traumatic Stress, 32(3), 363–372. https://doi.org/10.1002/jts.22380