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Moral Injury – Distress to Your Conscience

Moral Injury – Distress to Your Conscience

By  Mark Worrell, U.S. Army Chaplain, ACBC Certifed Biblical Counselor

Moral injury—a newer term that captures an age-old challenge. Let me paint a couple of scenarios for you as we start to discuss the subject.

1) He had just lost a few of his buddies. He thought he made the right choice by shooting the armed child running toward them. The soldiers from his unit rushed in to check on the child; then a lady, presumably his mom, came, running, crying, and clutching a box. She dropped to her knees next to the child. Then the box exploded, killing the lady and some soldiers and wounding others. (1)

How does this soldier handle the video of this, repeatedly playing in his head? Did he do the right thing by pulling the trigger? Was there a different way to handle this situation? Could he have let the child live? Could he have kept his battle buddies from rushing to the child’s defense? Could he have saved their lives? How was he to know that this mother figure would do this?

2) She was out a bit late, let her friend go home, and was raped. She thought she could trust the guy and didn’t expect it to go that far.

Again, the tape plays over and over in her head. What if her friend had stayed? What if she hadn’t accepted a ride home with the rapist? Should she tell anybody? What would happen if she filed a report with the civilian police or with the military?

3) Their leader was a bit confusing, chewing out some soldiers for minor things, sometimes enforcing standards . . . sometimes not. He had his favorites and they were good all the time, but most of the soldiers felt as if they were on pins and needles. More and more started struggling, feeling uneasy even when the leader wasn’t in the room, wondering what would get back to him. Would he punish them for hearsay? Would he randomly chew them out?(2)

How do those soldiers handle this scenario? A great thinker doesn’t always make the best leader. Do they "play well with others"? Would those who follow trust the decisions the leader makes? Do they have good morale because of their leaders or despite them? Could they trust their leader if they had to fight?(3)

Some may capture it this way: I have done wrong. I have seen others do wrong. I have taken lives. I have seen lives taken. I gave or received orders that were grossly immoral.  (4) I have been sinned against.

Let each of those phrases hang in your mind for a few moments. Which memories can you identify with?

Brett Litz of the VA in Boston defined moral injury this way: "The lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations." (5)

Again, Brett Litz said, "Service members are confronted with numerous moral and ethical challenges in war. They may act in ways that transgress deeply held moral beliefs or they may experience conflict about the unethical behaviors of others." (6)

Dr. Rita Brock, the Senior Vice President, Moral Injury, and Director of the Shay Moral Injury Center Volunteers of America, relates the following:

Moral injury. A broken spirit. In that situation, is not a disorder or a psychiatric condition, though it profoundly effects our mental health. Moral injury is the feeling that one is no longer possible to be good anymore. It is the loss of the capacity for trust and empathy, of a sense of meaning, and even of faith in God. I have a friend whose father fought in World War II, and he says, "My grandmother sent four good Christian boys into that war, and three atheists came home." (7)

This is the real question: Why do bad things happen? How do we go from "there’s no atheist in a foxhole" to statements like the above? Combat, traumatic events, even grief, and other challenging situations boil the human soul down to the bones, causing the injured one to consider, "What do I believe about God? What do I believe about man? What do I believe about evil?"

Matthew 13 relates the parable of the sower and the seed. Three seeds did not prosper, yet one did. The soil where the seed grew was receptive to the gospel and had depth of earth. The others were choked out in various ways. When three of those four boys went to combat, I would argue that they did not have a relationship with God to begin with. They may have believed in God, but James 2:19 says, "even the demons believe—and shudder." A belief in God can help with morals, values, and relationships but outside of a Christian faith that captures a belief that God is good and does good and can teach us His statutes (Psalm 119:68), we can easily be swayed from recognizing that God is working in us to make us like Christ—even through the trials of combat.

Chaplain (Colonel) Timothy Mallard defines moral injury as "rupture to foundational religious values, beliefs, and attitudes . . . Permanent loss of a transcendent relationship with God (manifested particularly in questions about forgiveness, doubt, truth, meaning, and hope) . . ." (8)

So, you might ask, how does moral injury differ from Post-Traumatic Stress (or PTS with "disorder" added)?(9) Some would suggest that it’s a subset, that breaking our sincerely held beliefs can lead to stress following a traumatic event. Imagine the young Christian who was taught the sixth commandment as "Do not kill" (Exodus 20:13) and not "Do not murder." It might sound like I’m mincing words, but there is a significant difference here. Murder is what Jesus is addressing in Matthew 5:21–26. Murder begins in the heart, so Jesus condemns hating your brother. It’s the heart attitude that is plotting against someone when a person wants to execute his justice for his own purposes, taking away the authority of God to give and take away life.

Rita Brock says this:

Moral injury can feel like a war inside because people’s consciences cannot make sense of experiences that derailed their identities. Among the most challenging of moral injuries is being betrayed by people we trust and who violate what we believe is right. Such betrayals can lead to outrage, humiliation and distrust.

Anyone can have moral injury. It is not a mental health disorder, yet the suffering is intense. Those afflicted can be crushed by guilt; tortured by anxiety; trapped by emotional solitary confinement; immobilized by meaninglessness; haunted by the dead; frayed by overwork; seduced by drugs, gambling, or sex; consumed by outrage. Often, they can experience all of the above. (10)

Public servants such as service members, police officers, and firefighters must make split- second decisions based on the information they know at the time, decisions that may take lives or save one seemingly at the expense of losing another. Those split-second decisions to return fire, pursue rescuing someone, or a make routine traffic stop are sliced up over time in that person’s mind, asking repeated questions like "Why didn’t I see that? What if I had reached out to the other person? Why couldn’t I have done something different?" or "If only I had . . ."

This over-analyzing is where moral injury begins to manifest itself. We take the information we have following an event and expect ourselves to have responded in the situation, knowing information that we did not have. The over-thinking of an event causes us to further analyze our own actions. Instead of realizing we could only do what we did with the facts we had at the time, we make ourselves liable for information we did not have.

Just War Tradition

Killing under a government that develops its stance of war on the "Just War Tradition," gives us a legitimate authority that the soldier can answer to. The United States holds to this tradition, which includes three critical things: 1) just reasons for going to war, 2) just actions in war, 3) just actions after war. Those principles say that our government regulates what we do and when we do it in combat. We take positive identification (is it a known enemy or can we tell where the shots came from) as critical and the leaders that make those calls execute that authority.(11)

President Lincoln was reportedly asked at one point if God was on the Union’s side. His response is telling for the tradition of Just War: "My concern is not whether God is on our side; my greatest concern is to be on God's side, for God is always right." (12)

Secular Approach to Moral Injury

Secular literature refers to potential spiritual injury among other effects of moral injury (to include emotionally, psychologically, behaviorally, . . . and socially)  (13) but does not define what is meant by the term spiritual. Much of what these writers point to is shame and guilt that religion may assuage.

They use existing tests and behavioral treatment, such as emotional-processing theory, which proposes that pre-trauma schemas, the memory of the event, and the memory of experiences prior to the event can interact and interfere with the emotional-processing of the trauma, leading to the development of chronic PTSD. Although many negative events are emotionally reexperienced, the frequency and intensity of the emotions usually decrease naturally (i.e., via extinction). Yet, if the individual does not allow himself or herself to remember and experience the emotions associated with the event, extinction and habituation are disrupted and decreases in the emotions' frequency and intensity do not occur, resulting in PTSD. (14)

This body of literature tends to seek out the religious. They seek out aspects of ritual (memorial ceremonies, funerals, traditional religious rites, such as cleansing ceremonies, etc.) (15). Since Moral Injury is a newer concept in the psychological realm that points to the image of God in man, counselors seek to bridge the gap. From my perspective, the image of God is in our reasoning, our core values, and our desire to find something much bigger than ourselves. Pascal would call this our "God shaped vacuum." Rita Brock states this:

Increased mental health services can help, but without understanding it, a counselor might not address it. We run a week-long peer-facilitated moral injury program (https://www.voa.org/moral-injury-center/the-war-inside) at Volunteers of America (VOA) called Resilience Strength Training (https://www.voa-gny.org/veteran-peer-support) (RST). Many of the veterans who have gone through our program note that what they shared with their peers is something they would never have told their therapists.  (16)

Integrational Approach

The integrational approach seeks to combine empirically researched counseling techniques with Scripture, thus "using the best of both worlds." Techniques such as EMDR are thought to provide some mental healing, as follows:

EMDR (Eye Movement Desensitization and Reprocessing) is a psychotherapy that enables people to heal from the symptoms and emotional distress that are the result of disturbing life experiences. Repeated studies show that by using EMDR therapy people can experience the benefits of psychotherapy that once took years to make a difference. It is widely assumed that severe emotional pain requires a long time to heal. EMDR therapy shows that the mind can in fact heal from psychological trauma much as the body recovers from physical trauma. (17)

The concept of forgiving self comes up a lot regarding moral injury but here's an interesting dynamic. Moral injury comes as a result of breaking a moral code. We believe that moral code comes from our country's Just War Tradition (the legitimate authority for sending us to war), and ultimately from God; however, if I have the ability to forgive myself, aren't I then saying that I'm the absolute authority?

Biblical Counseling Approach

Addressing moral injury comes back to the basis of the Christian faith: the gospel, sin, redemption, repentance, and sanctification. It also requires accountability, genuine biblical relationships, and soul care.

When we understand that God is involved in our lives, that He cares enough about us that He gave His life for us in the ultimate combat deployment (leaving heaven and coming to earth—a place that did not recognize Him and sent Him to His death). Servicemembers, like all people, are sinners. We live in a broken world and need God’s hand in our lives. We also understand authority and the responsibility of Romans 13 "to bear the sword."

God has redeemed us, as Christians, from our sin–past, present, and future. While we should not "continue in sin that grace may abound" (Romans 6:1 ESV) as we pursue the mind of Christ, we understand how to honor others, even our enemies. (18) Paul walks through a list of ways to address our hearts in Philippians 4:6–13. We can follow these lists that challenge us to consider our thought life.(19) What information did I have at the time? Did I do the best with what I had? Do I need to ask God’s forgiveness? Do I need to reconcile with those who were there and saw me act sinfully?(20)

Relationships are also a critical component of growth in this area. Sufferers of moral injury should get involved in a biblical church and connect with small groups of people from all walks of life. (21) The tendency will be to connect only with those who have served in the military, but this confines them to only a part of the body of Christ. Genuine biblical relationships cross all domains and all aspects of life, as God challenges the spiritual to "restore such a person with a gentle spirit" (Galatians 6:1 CSB). Though this is specifically referring to those overtaken in trespass, that gentle spirit is required to help these people look to God and His grace in their lives.

The Havok Journal states the following about servicemembers and suicide:

We talk of Brotherhood all the time. Brotherhood is belonging. Brotherhood is family. Brotherhood is anytime, anywhere. So what can we learn when one of our family, one of our brothers takes his own life?

Surely, we must take stock and learn something. We talk about the depth of our bond forged of long nights and moments best forgotten, but are we hiding a shallow truth in plain sight from one another? Are we really being honest with each other? Are we truly sharing how we feel inside? (22)

Who can capture what brotherhood really is besides those who walk with Jesus? Acts 2:44–47 tells us the early believers "…were together and held all things in common. They sold their possessions and property and distributed the proceeds to all, as any had need. Every day they devoted themselves to meeting together in the temple, and broke bread from house to house. They ate their food with joyful and sincere hearts, praising God and enjoying the favor of all the people. Every day the Lord added to their number those who were being saved" (CSB).

Regarding soul care, consider the way Jesus addressed challenging situations in His life. In Matthew 14:1–12, we read of the death of John the Baptist. Verse 13 tells us that Jesus "left in a boat to a remote area to be alone" (NLT). While I believe Jesus knew the ambush of the 5,000 wanting to see Him and eventually needing something to eat, Jesus took some time with the Father. In our constant information-flow world, we "zone" to get away from the problem, but it’s still there. God set an example for us by getting away before walking through a traumatic event. Normal sleep, eating, and restoration to a normal schedule are critical (23), as are biblical spiritual disciplines.

The US Army Chaplain Corps motto is "Bringing God to Soldiers and Soldiers to God." As counselors, how can you help us come alongside servicemembers, veterans, and public servants to do just that? We can’t do it without you!

by  Mark Worrell
U.S. Army Chaplain, ACBC Certifed Biblical Counselor

FSM DISCLAIMER: The above represent the views of the particular author(s) and do not necessarily represent the official views of this organization or any of its members.

As in all areas of life, the Bible has the answers on how we can all cope with the "Consequences of War" in ways that glorify God.

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1 - Much of this situation is a personal account related to the author.
2 - A combination of soldiers the author has spoken to over the years have related similar stories of a general mistrust of their leaders.
3 - I’ve often thought about leaders like this, looking specifically at an infantry squad getting ready to clear a building. Would the leader be in the "stack" or would he send them in without having their back?
4 - Much of this was captured in concept from Brett Litz, as quoted in a Moral Injury Symposium at Joint Base Pearl Harbor-Hickam in Sep 2019.
5 - Ibid.
6 - Brett T. Litz et al., "Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy," Clinical Psychology Review 29, no. 8 (December 2009): 696, https://doi.org/10.1016/j.cpr.2009.07.003.
7 - Rita Brock, accessed November 11, 2019, https://www.voa.org/moral-injury-center/videos/rita-brock-discusses-moral-injury-soul-repair.
8 - Much of this was captured in concept from CH Mallard, as quoted in a Moral Injury Symposium at Joint Base Pearl Harbor-Hickam in Sep 2019.
9 - Challenging and traumatic situations are stressful. We will all struggle with them in different ways. The DSM-5 adds the label of "disorder" when it is a prolonged struggle that effects the individual.
10 - Rita Brock, "The War inside: America’s Veteran Suicide Epidemic Has a Silent, Unaddressed Cause," n.d., https://www.usatoday.com/story/opinion/2019/10/18/veteran-suicide-increase-first responders-moral-injury- column/4008852002/.
11 - For further information regarding Just War Tradition, consider Brave Rifles: The Theology of War by Bradford Smith.
12 - "On This Day in History… July 10th: Lincoln’s 1858 Senatorial Speech - Prof. Boerner’s Explorations," accessed December 6, 2019, https://www.boerner.net/jboerner/?p=13382.
13 - Litz et al., "Moral Injury and Moral Repair in War Veterans," 697.
14 - Litz et al., 698.
15 - Many of these can connect well with soldiers. An opportunity to coalesce the thoughts they have prior to re-entering society. Consider Numbers 31:19, etc. They need to be in the context of a relationship with the God of Creation who guards, guides, and directs the human heart to growth and change.
16 - Brock, "The War inside: America’s Veteran Suicide Epidemic Has a Silent, Unaddressed Cause."
17 - "What Is EMDR? | EMDR Institute – EYE MOVEMENT DESENSITIZATION AND REPROCESSING THERAPY," accessed November 20, 2019, https://www.emdr.com/what-is-emdr/.
18 - During WWII, two Japanese Kamikaze pilots crashed, both on the USS Missouri and at Marine Corps Base Kaneohe, HI. The commanders chose to honor these fallen aviators with a full military burial. It honored their service and challenged those present to recognize those in attendance as human. Many think this led to the honorable surrender ceremony to be held on the USS Missouri in September of 1945.
19 - The book In the Arena of the Mind by John Vandergraff addresses this more in depth.
20 - Stephen Viars, Putting Your Past In Its Place: Moving Forward in Freedom and Forgiveness (Harvest House, 2011).
21 - Ministries such as Chappy’s Outdoors connect veterans with believers on guided hunts, show them the gospel and the power it has to change lives.
22 - "Military Training Saved You in Combat but May Bury You in Life • The Havok Journal," The Havok Journal (blog), November 21, 2019, https://havokjournal.com/nation/message-rip-instructor/.
23 - Jonathan Shay captures this as critical.

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