By Pat Devine, Chaplain, US Army (Retired)
In March, I attended the 2024 World Congress on Moral Injury, Trauma, Spirituality, and Healing hosted virtually by The Human Flourishing Program at Harvard University’s Institute for Quantitative Social Science. I wanted to understand better the current research and beliefs about behaviors associated with the syndrome labeled "moral injury." Before I share a few observations, it’s important to note that the conference was full of compassionate, caring professionals who wanted what they believed was best for those in their care. I appreciate the efforts and resources invested in seeking to help those who are hurting, especially our veterans and first responders.
Here are a few observations from the event:
1. What is moral injury? Well, it depends on who you ask.
According to Dr. Tyler VanderWeele, Director of the Human Flourishing Program, moral injury is "persistent distress that arises from a personal experience that disrupts or threatens: (a) one’s sense of goodness of oneself, of others, of institutions, or of what are understood to be higher powers, or (b) one’s beliefs or intuitions about right and wrong, or good and evil."[1]
Did you get that?
If you're still grappling with the concept, you're not alone. Dr. VanderWeele referenced a staggering twenty-two definitions of moral injury, each highlighting a different aspect of the syndrome and area of research focus. From potentially morally injurious events (PMIE) to the sense of betrayal by authorities, these definitions underscore the complexity of the behaviors described as moral injury.
Dr. Lindsay Carey, an Australian Defense Force chaplain and researcher, remarked, "It seemed to me that nearly every kangaroo and cute koala had a definition for what they considered was their moral injury . . . it was, and is, ridiculous."[2] His point was that the lack of consensus on a definition results in a lack of unity in the research effort.
2. Really, what is "moral injury?"
Moral injury is a term generally accepted as it originated with Jonathan Shay from his books Achilles in Vietnam[3]3 and later Odysseus in America.[4] As he related the experiences of Vietnam veterans to the Greek heroes and their experiences, he observed something happening alongside post-traumatic stress behaviors and labeled that finding as moral injury.
At the risk of oversimplifying twenty-plus years of behavioral science’s definitional evolution, moral injury can be described as the thoughts, feelings, and behaviors that result from partaking in, observing, or failing to prevent a moral transgression. The numerous definitions directly relate to attempts to engage the symptoms, which researchers readily acknowledge are complex and varied in scope and intensity.
Researchers and practitioners disagree about creating a moral injury entry in the Diagnostic and Statistical Manual of Mental Disorders (DSM). I don’t have space to discuss the larger in-house debate among researchers of the DSM’s utility except to say the DSM’s advocates and detractors presented at the congress.
3. A spiritual awakening is occurring in the behavioral sciences at many academic institutions.
I’m using "awakening" to describe the growing awareness and interest in spiritual realities in the behavioral sciences. The essence of the awakening is an acknowledgment that the spiritual part of humanity plays a considerable role in human function and flourishing.
To be clear: biblical counselors and secular researchers remain "worldviews apart" regarding the nature of man. I don’t mean to suggest that there is a movement toward a dichotomist understanding, only that the significance of the spirit in the body-soul-spirit construct is increasing. Now is an excellent time to dust off your Journal of Biblical Counseling back issues and pull out Winston Smith’s "Dichotomy or Trichotomy? How the Doctrine of Man Shapes the Treatment of Depression."[5] My assessment of the state of current interventions and the lack of consensus of definitions result directly from the incorrect doctrine of man. This is 1 Corinthians 2:14 in living color: "The natural person does not accept the things of the Spirit of God, for they are folly to him, and he is not able to understand them because they are spiritually discerned" (ESV).
One thing is clear: spirituality is gaining traction in the behavioral sciences. Interest in its role in addressing moral injury is on the rise, indicating a shift in how counselors and researchers approach and attempt to understand this complex issue.
4. The biblical counseling movement has an open door to speak biblical realities to the moral injury syndrome.
Dr. Brett Litz is a leading researcher on moral injury at Boston University and the Department of Veteran Affairs. His definition (which I won’t list here) is generally regarded as the first comprehensive, working description of the symptom set. During his presentation, he stated:
I've been doing this work for at least 15 years, probably more…we are far from having an
interdisciplinary discourse. At best there is some talking between the clergy community and the clinical community, especially at the VA and the military….but what I yearn for is a true interdisciplinary discourse where each of us is very familiar with our models, our perspectives and we can come together and develop a broad-spectrum consensus, multi-systemic kind of discourse and paradigm about moral injury. And that does not exist right now, and that's a real challenge . . . we kind of preach to our own choirs…I've given a lot of different talks to [military chaplains, clergy, the VA], and I don't think it's moved the needle, to be honest, and that's a problem.
Litz’s comments reveal much about the current moral injury landscape beyond the research studies. On the one hand, there is a nearly universal agreement that something spiritual is happening in the behaviors described as moral injury. On the other hand, there is a similar regard that the mental health community lacks the understanding, willingness, or both, to engage their clients regarding spirituality. Dr. Litz has written about his view that traditional CBT therapies are often not helpful. The good news is that Biblical counselors standing on Scripture have both the understanding and the willingness to move into this kind of suffering.[6]
5. The chaplain enterprise/profession is not the answer the research community thinks it is.
The conference’s representation of the chaplain profession was eclectic, to say the least. Based on the dialogue and participant interactions, calling the moral injury care presented by chaplains as an "integrationist approach" would be generous. Chaplains of every faith system attended, and the mental health community equally and heartily welcomed all to help address the "spiritual dimension" of moral injury.
The problem, of course, is that outside of a sufficiency of Scripture view of soul care, every
"spiritual intervention" system returns to research science to understand problems and, in most cases, how to address them. That paradigm was entirely on display at the World Congress. The chaplain enterprise at large is dominated by clinical pastoral education models of pastoral care, contributing to the conclusions and observations made by Litz above.
A larger issue regarding the chaplain profession is worth considering—namely, a rigorous, honest, biblical assessment of the current state of chaplaincy. A thoughtful and humble approach could help maximize ministry opportunities and address limitations in ministry settings now fenced off by "the professionals."[7]
Final Thoughts
We have ample space in the biblical counseling community to address and discuss what the mental health community calls "moral injury." Every human being, every day, personally experiences the effects of sin: our own sin, the sin of others, and of living in a world corrupted by sin. Our God-given consciences bear witness to those experiences, and the counsel of God’s Word helps us not only to think rightly about such things but also be transformed into the image of Christ amid them. As the definitions continue to evolve and expand to incorporate more and more "potentially morally injurious events," and the mental health community looks for new ways to cluster behaviors, the reassuring news is that Scripture remain sufficient to provide hope and help for people's problems.
by Pat Devine, Chaplain, US Army (Retired)
FSM Advisory Board Profile: https://fallensoldiersmarch.com/chaplain-pat-devine
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[1] Tyler VanderWeele, "Moral Injury and Moral Trauma: Definitions and Assessment" (March 11, 2024), https://members.spiritualcarepartners.com/spaces/13051754.
[2] Moral Injury & Pastoral Narrative Disclosure, 2024, https://www.youtube.com/watch?v=RZFIJALaKtQ.
[3] Jonathan Shay, Achilles in Vietnam:Combat Trauma and Undoing of Character (New York: Simon & Schuster, 1995).
[4] Jonathan Shay, Odysseus in America: Combat Trauma and the Trials of Homecoming (New York: Scribner, 2002).
[5] Winston Smith, "Dichotomy or Trichotomy? How the Doctrine of Man Shapes the Treatment of Depression," Journal of Biblical Counseling 18, 3 (2000).
[6] The Association for Clinical Pastoral Education is the self-described "Standard for Spiritual Care & Education." ACPE mandates integration of psychological and social science theory into the practice of their certified chaplains. The resulting heterodoxy precludes the kind of distinctive faith-group understanding of moral injury Litz longs for. See https://acpe.edu/about-acpe/impact-of-professional-spiritual-care, accessed 5/22/24. For an understanding of historical CPE influence in the SBC, see T. Dale Johnson, The Professionalization of Pastoral Care: The SBC’s Journey from Pastoral Theology to Counseling Psychology, Eugene, OR: Wipf and Stock, 2020, 121-130.
[7] See "The Impact of Professional Spiritual Care," ACPE - About ACPE, 2018, 7, https://indd.adobe.com/view/2d555e8f-5d1a-47bf-ad94-760092053d0b.
