Spirituality in Clinical Practice In the public domain 2017, Vol. 4, No. 4, 249–261 http://dx.doi.org/10.1037/scp0000140 Spiritual Features of War-Related Moral Injury: A Primer for Clinicians

Jennifer H. Wortmann Ethan Eisen Durham VA Medical Center, Durham, North VA Long Beach Healthcare System, Carolina, and Mid-Atlantic Mental Illness Long Beach, California Research, Education, and Clinical Centers, Durham, North Carolina

Carol Hundert Alexander H. Jordan Loyola University Chicago McLean Hospital, Belmont, Massachusetts, and Harvard Medical School

Mark W. Smith William P. Nash Naval Chaplaincy School and Center Headquarters, United States Marine Corps, Arlington, Virginia

Brett T. Litz VA Boston Healthcare System, Boston, Massachusetts, and Boston University School of Medicine

Warzone experiences that violate deeply held moral beliefs and expectations may lead to moral injury and associated spiritual distress (Litz et al., 2009). Helping morally injured war veterans who are grappling with spiritual or religious issues is part of multicultural competence (Vieten et al., 2013) and falls within the scope of practice of mental health clinicians. Moreover, practicing clinicians report that they lack adequate knowledge of the diverse spiritual and religious backgrounds of their clients and when to seek consultation from and collaborate with spiritual/religious teachers (Vieten et al., 2016). We argue that optimal assessment and treatment of psychically traumatized military personnel and veterans requires an understanding of the idioms and perspec- tives of various spiritual (religious and philosophical) traditions on transgression and their recommendations for forgiveness and healing. To this end, we (a) provide an overview of the source of moral codes associated with various traditions, (b) discuss aspects of warzone events that may violate those moral codes and spiritual reactions to those violations, (c) describe spiritual traditions’ approaches to making amends for transgressions, and (d) provide brief case scenarios that illustrate spiritual features of moral injury and point to circumstances in which collaboration with chaplains or clergy may be helpful for addressing aspects of moral injury.

Keywords: moral injury, spiritual distress, veterans, service members, forgiveness

Jennifer H. Wortmann, Mental Health and Chap- Veterans Epidemiology Research and Information Cen- laincy, Durham VA Medical Center, Durham, North ter, VA Boston Healthcare System, Boston, Massachu- Carolina, and Mid-Atlantic Mental Illness Research, Ed- setts, and Department of Psychiatry, Boston University ucation, and Clinical Centers, Durham, North Carolina; School of Medicine. Ethan Eisen, VA Long Beach Healthcare System, Long We thank the following individuals for their consultation Beach, California; Carol Hundert, Department of Psy- and input: Vlad Chituc; Thirburse F. Millot; Kumar No- chology, Loyola University Chicago; Alexander H. Jor- chur; Feryal Salem; Monica Sanchez; Chris Stedman; dan, The Pavilion, Division of Depression and Anxiety Shilpa Ullal; and Qingying Xue. Disorders, McLean Hospital, Belmont, Massachusetts, Correspondence concerning this article should be ad- and Department of Psychiatry, Harvard Medical School; dressed to Jennifer H. Wortmann, Mid-Atlantic Mental Mark W. Smith, Naval Chaplaincy School and Center; Illness Research, Education, and Clinical Centers, 3022 William P. Nash, Headquarters, United States Marine Croasdaile Drive, Suite 301, Durham, NC 27705. E-mail: Corps, Arlington, Virginia; Brett T. Litz, Massachusetts [email protected]

249 250 WORTMANN ET AL.

Serving in a warzone puts service members at by self relate to shame, guilt, anxiety, depres- risk of experiencing events that violate deeply sion, and suicidal ideation, and betrayal-based held moral beliefs and expectations (Litz et al., events are associated with anger and suicide 2009; Nash, 2007). Potentially morally compro- attempts (Jordan et al., 2017; Wisco et al., mising circumstances in war can involve pre- 2017). scribed roles (e.g., maiming and killing), bear- In addition to poorer mental health and ad- ing witness to the aftermath of violence or terror justment, quantitative and qualitative research (e.g., handling or uncovering handling human has demonstrated negative spiritual impacts of remains), proscribed behaviors (e.g., the use of moral injury. Veterans carrying guilt due to excessive force or cruelty), failing to live up to killing others, enjoying the excitement of killing the warrior ideal (e.g., making a mistake or others, participating in atrocities, failing to ful- losing control with dire consequences), or being fill duties or responsibilities, accidentally con- a victim of the failure of others to uphold a tributing to the death of a buddy, being unable moral code. Experiences such as killing enemy to effectively treat and save the wounded, or combatants, being responsible for the deaths of experiencing the death of a buddy, derived less noncombatants, witnessing atrocities, and par- comfort from their religious faith and reported ticipating in atrocities have been reported by weakened faith (Fontana & Rosenheck, 2004). five percent to over half of samples of service Qualitative data from Vietnam veterans further members and veterans (reviewed in Frankfurt & describes existential and spiritual impacts (e.g., Frazier, 2016; also see Wilk et al., 2013). “religion doesn’t mean as much to me as it did Such transgressions by self or others may, in when I went in” and “life means nothing; life is turn, lead to moral injury, characterized by cheap”) associated with civilian deaths, within- guilt, shame, anger, social withdrawal, posttrau- ranks violence, and betrayals of one’s own stan- matic symptomatology, and spiritual distress dards for oneself (Vargas, Hanson, Kraus, Dre- (Jordan, Eisen, Bolton, Nash, & Litz, 2017; Litz scher, & Foy, 2013). et al., 2009; Maguen & Litz, 2012). Recent Because spiritual distress may encompass efforts to estimate prevalence of moral injury doubt in one’s beliefs or worldview, worry indicate that a significant minority of military about past transgressions, disrupted relation- personnel and veterans report potentially mor- ships with family or community, or negative ally injurious experiences associated with mili- feelings toward a higher power (Exline, Parga- tary service. In a sample of active duty Marines ment, Grubbs, & Yali, 2014), moral compro- that engaged in heavy ground combat while mise can create spiritual distress in people with deployed to Afghanistan, one quarter of the or without religious faith. Moral injury may sample reported violating one’s own moral damage foundational assumptions about self be- code, and nearly one third reported feeling be- ing good and others being dependable that fa- trayed by persons they once trusted (Jordan et cilitate connection with others and thereby al., 2017). In a nationally representative sample bring comfort, meaning, and happiness to life of combat veterans, about one in 10 veterans (Epstein, 2003; Janoff-Bulman, 1992). Service endorsed transgressions by self, and one in four members and veterans who have been exposed endorsed transgressions by others and feelings to morally injurious experiences may suffer and of betrayal (Wisco et al., 2017). struggle as a result of violating societal, philo- Exposure to potentially morally injurious sophical, or religious prohibitions. For example, events is associated with symptoms of posttrau- war veterans who engaged in prescribed killing matic stress disorder (PTSD) and depression or proscribed brutality may experience incapac- (Bryan et al., 2016; Currier, Holland, Drescher, itating guilt or shame and may wonder whether & Foy, 2015; Jordan et al., 2017; Nash et al., forgiveness is possible (Bryan, Theriault, & 2013; Wisco et al., 2017); less social support Bryan, 2015; Maguen & Burkman, 2013). and cohesion (Nash et al., 2013); poorer social Those who suffered betrayals of trust (e.g., and work adjustment (Currier et al., 2015); hope- leaders making wrong decisions) may feel dis- lessness, pessimism, and anger (Bryan et al., illusioned or embittered (Bryan et al., 2016). 2016; Jordan et al., 2017); and suicide risk (Bryan, Research has linked negative spiritual im- Bryan, Morrow, Etienne, & Ray-Sannerud, 2014; pacts of war-related moral injury with poorer Wisco et al., 2017). In particular, transgressions mental health. Struggles with guilt, lack of SPIRITUAL FEATURES OF WAR-RELATED MORAL INJURY 251 meaning, doubt in religious beliefs, alienation ally injured war veterans, psychologists should from God, and religious fear and doubt, have explore their own capacity to address spiritual been correlated with depression (Berg, 2011) distress from a secular psychotherapeutic van- and PTSD symptoms in Vietnam veterans tage point as well as be open to collaboration (Berg, 2011; Ogden et al., 2011). Veterans’ with chaplains and clergy. Doing so is consis- punitive religious beliefs (e.g., thinking that a tent with proposed spiritual and religious com- higher power is inflicting punishment or with- petencies for psychologists to obtain knowledge drawing love) and failure to forgive oneself of diverse backgrounds, and to recognize when were related to depression, anxiety, and PTSD to seek consultation from and collaborate with symptom severity (Witvliet, Phipps, Feldman, spiritual/religious teachers (Vieten et al., 2013, & Beckham, 2004). In contrast, spirituality 2016). through forgiveness (self, interpersonal, and di- To those ends, we describe spiritual and re- vine forms) led to greater quality of life for ligious tenets that may be involved in the de- veterans with PTSD (Currier, Drescher, Hol- velopment and maintenance of moral injury, land, Lisman, & Foy, 2016). and we review various faiths’ prescriptions for Although religious faith and practice are not healing from moral injury. We also provide prerequisites for experiencing war-related brief, illustrative case examples. We aim to moral injury or an essential vehicle to address enhance clinical care for morally injured war these psychic wounds and achieve moral repair veterans by (a) increasing understanding of (and (cf. Fritts, 2013), clinicians need to appreciate empathy for) the spiritual dimensions of moral the degree to which faith informs morality and injury, (b) providing language to communicate whether transgressions are tacitly or explicitly more effectively with service members and vet- faith-determined in the service members and erans with strong religious and spiritual convic- veterans they treat. Helping morally injured war tions, (c) deepening knowledge of the paths to veterans who are grappling with spiritual or moral repair embedded in patients’ spiritual tra- religious issues is an element of multicultural ditions, and (d) building awareness of circum- competence (Vieten et al., 2013). American stances in which collaboration with chaplains or Psychological Association (2010) ethical guide- clergy may be helpful for addressing aspects of lines describe the need for psychologists to moral injury. demonstrate awareness, respect, and compe- tence concerning religion, and to seek consul- Spiritual Sources of Moral Codes tation or make referrals as appropriate. Practic- ing clinicians agree that psychologists should Moral injury is a potential (but not inevitable) possess knowledge of the diverse spiritual, re- consequence of transgressing deeply held moral ligious, and secular backgrounds of their clients beliefs and expectations (Litz et al., 2009). For and skill in recognizing when to seek consulta- many people, these beliefs and expectations are tion from and collaborate with spiritual/ linked to the code of ethics or moral law pre- religious teachers, and yet they lack adequate scribed by their faith or spiritual tradition. In some training in these areas (Vieten et al., 2016). instances, texts or central authorities explicitly Moreover, researchers have called for more at- identify expected and proscribed behavior. Fre- tention to spiritual features of combat trauma quently, subjective conscience-driven moral eval- (Currier, Drescher, & Harris, 2014), and others uation is required to make sense of varied inter- have argued that assessing spiritual distress and pretations that may exist within the same faith offering complementary services (i.e., chap- tradition. For example, most denominations of laincy) to support persons struggling in this Christianity require fidelity to the ethical princi- domain are within the purview of all clinical ples that emerge from the Old and New Testa- care providers (Kopacz & Connery, 2015). Spir- ments, but also allow for individuals to use com- itual features of moral injury such as guilt, loss mon sense and their own consciences to determine of faith, and loss of meaning lead service mem- what is proper (Richards & Bergin, 2000). In bers and veterans to seek care from both mental Roman Catholicism, which professes central au- health professionals and chaplains (Fontana & thority in the Pope and its church’s magisterium, Rosenheck, 2005; Morgan, Hourani, Lane, & practitioners are still afforded some latitude to use Tueller, 2016). We argue that to best help mor- their own moral judgment. To a large degree, 252 WORTMANN ET AL.

Protestant denominations involve decentralized good to others (Pattanaik, 2010). Similarly, authority and rely more heavily on personal judg- wrongdoing in the secular humanist view involves ment and guidance from local clergy to interpret violation of the obligation to treat others in a way moral teachings in the Bible. that enhances long-term happiness (Kurtz, 1983). Different denominations within Judaism rely Buddhist thought includes the notion of transgres- to varying degrees on ancient traditions that sion, but the focus is less on concretely defined stem from Talmudic and medieval interpreta- transgressions and more on describing the condi- tions of the rules of the Old Testament as well tions that promote wrongdoing (e.g., clinging to as subjective judgment in determining accept- the impermanent and lacking compassion) and able behavior. In Orthodox Judaism, the faithful consequences of wrongdoing (e.g., suffering; Finn are expected to follow the instruction of rab- & Rubin, 2014). Although a tremendous amount binic authorities more closely, while in Conser- of theological, religious, and secular thought is vative and Reform Judaism individuals and simplified here, shared among all these traditions communities play a greater role in generating are variants of the “golden rule,” an exhortation to practical applications of traditional ethical prin- treat others as one wishes to be treated (Becker & ciples. Similarly, in Islam, a single central au- Becker, 2001). thoritative body does not exist, although the source of ethical principles is the Qur’an and the Perpetration, Guilt, and Shame hadiths and Sunna, which are compilations of the words and deeds of the Prophet Muhammad Psychologists should be mindful of the dis- (Hedayat-Diba, 2014). tinction between “objective guilt” and “guilt- In Hinduism, various Sanskrit texts describe feelings” (Meehl, 1960). A Veteran may be codes of moral conduct and law (Sharma & objectively guilty of some infraction according Tummala-Narra, 2014). The Mahabharata is an to a given ethical (or legal) system, such as a epic poem that describes dharma, or moral con- sacred text; it is a separate question whether the duct, and includes the Bhagavad Gita, which Veteran harbors feelings of guilt because of this deals literally with a warrior’s moral struggles objective guilt, or despite its absence. The psy- and allegorically with universal internal human chologist’s role in determining a patient’s ob- struggles (Davis, 2014; Pattanaik, 2010). Addi- jective guilt is limited; when therapists do not tionally, the Dharmashastras are an ancient re- fully appreciate the patient’s ethical system and cording of jurisprudence, focused on right con- insinuate that the patient is not objectively duct in many dilemmas. Some Hindu texts and guilty, this may unintentionally convey that the additional historical texts, including some at- patient’s ethical system is invalid, causing a tributed to the Buddha himself, characterize the therapeutic rupture. At the same time, some various forms of Buddhism, although there is no patients may hold corrosive religious views that single official canon (Finn & Rubin, 2014). are not supported by their chosen religious au- In other traditions, a code of ethics or conduct thorities, but are instead common misconcep- is less developed but is no less important. For tions of nominal faith group participants, de- example, secular humanism has a relatively rived from familial connection to a faith, limited young history, as the first Humanist Manifesto knowledge, or leaders with extreme views. For was composed in 1933 (American Humanist instance, researchers have posited that a pa- Association, 1933/1973). The past few decades tient’s difficult early attachment experiences have seen a dramatic increase in publications may contribute to a distortedly vindictive image and written materials developing the secular of their faith tradition’s deity (Huguelet & Koe- humanist worldview and its application to con- nig, 2009, p. 211). Discussions with clergy may temporary moral and ethical challenges. thus be helpful for patients when the accuracy Within the Abrahamic traditions (e.g., Judaism, of their understanding of their spiritual tradi- Christianity, and Islam), a transgression, or sin, is tion’s moral code is in question. defined as a violation of divine law (i.e., God’s/ Each of the spiritual traditions described above Allah’s will or commands). In Hinduism, the con- strongly prohibits killing people in most contexts, cept of papa (which might be likened to sin or and yet war often involves the intentional or un- evil) refers to harming others and contrasts with intentional killing of enemy combatants, innocent punya (virtue, merit, or good), which is doing civilians, or fellow service members. Each tradi- SPIRITUAL FEATURES OF WAR-RELATED MORAL INJURY 253 tion permits killing only under very limited cir- Although some service members and veter- cumstances. For example, self-defense is typically ans may adhere to spiritual traditions that pre- considered a legitimate justification (e.g., Num- scribe proportionate guilt or shame as useful bers 25:17, Exodus 22:2), and this rationale may and morally correct responses to transgression, apply not only to immediate threat but also to the clinicians should appreciate that these traditions temporally distant general threat that is common tend to view overwhelming, persistent feelings in modern warfare. In Islam, for example, lethal of guilt or shame as a consequence of failing to warfare can be considered just on the grounds of appreciate the concepts of mercy (which in- defending one’s home against invaders (e.g., Al- volves compassion and lenience), grace (unmer- Hajj 22:39–40; for a discussion, see Shah, 2008 ited favor, in the Christian tradition), or forgive- and Bashier, 2015) and defending one’s religious ness from God (facilitated through various freedom (Hedayat-Diba, 2014). Similarly, the means across religions, described below; Rye et Bhagavad Gita includes text justifying war in al., 2000). Warriors may feel disgusted with response to oppression and demonstrating free- themselves and permanently tainted by their dom from guilt or remorse following killing in past actions (Rachman, 2010); if they believe particular circumstances (as Krishna advises Ar- this intensity of negative self-evaluation is in juna; Pattanaik, 2010; Stoler Miller, 1986). De- line with the dictates of their faith, they may spite these justifications, violence and other as- thus benefit from discussion of their belief sys- pects of combat deployments can conflict with tem with clergy. When patients condemn them- service members’ moral codes. Moreover, some selves because they believe that their religious religions include practices designed to facilitate tradition judges them as unforgiven or unfor- personal awareness of transgressions. For in- givable, it is reasonable to respectfully wonder stance, Buddhist mindfulness practices are in- whether the belief is accurate and offer that the tended to draw attention to one’s actions that may patient consider consulting with an authority cause suffering; the Catholic practice of confes- within their faith background who can provide a sion functions in part to identify transgression; and compassionate response as well as corrective based on the Talmud, Jewish tradition encourages guidance. It may be ideal if the clinician and periodic, even daily, reckoning of one’s actions clergy can collaboratively hold this discussion, (Babylonian Talmud tractate Shabbat 153b). Ac- based in a preexisting collegial relationship. counting for one’s actions is typically viewed as positive and necessary, allowing the individual to Betrayal and Anger gain an appreciation of his or her moral and im- moral deeds. Aside from perpetrating violence, another Awareness of one’s transgressions may, in cause of war-related moral injury is other peo- turn, elicit feelings of guilt (remorse about a ple’s betrayal of trust or failure to uphold the specific action) or shame (a global negative expectations of the warrior ethos (Litz, Lebowitz, appraisal of self-value; Baumeister, Stillwell, & Gray, & Nash, 2015), which may elicit powerless- Heatherton, 1994; Tangney, 1996). In many ness, resentment, or externalizing (seeking retri- spiritual traditions, the emotional experience of bution, justice, repair outside the self), and is guilt is considered appropriate and useful associated with anger (Bryan et al., 2016; see when confronting wrongdoing, as it is thought Pargament, McCullough, & Thoresen, 2000,p. to motivate moral improvement and the seek- 311). In religious traditions, anger tends to be ing of forgiveness, and to demonstrate that viewed with suspicion as something that needs one recognizes the gravity of the transgres- restraining or mastering, as illustrated by an sion. Shame tends to be viewed by clinicians array of Old and New Testament verses (e.g., as unduly judgmental and incapacitating; yet Psalm 37:8, Matthew 5:21–26, Ephesians 4:25– religious traditions tend to frame shame like 27), ancient traditions in Judaism and Islam guilt, as motivating reparative behavior or (e.g., Qur’an 3:134), and statements in various reconnection with the divine (e.g., as a peni- Hindu (e.g., Bhagavad Gita 3:43, 7:11) and tent David in Psalm 25). In response to ob- Buddhist (Dhammapada 17:221–234) texts. In jective wrongdoing, these responses are con- particular, certain types of behavior that may sistent with psychological development of follow from anger (e.g., revenge-seeking) are genuine self-forgiveness (McConnell, 2015). discouraged (e.g., Leviticus 19:18; Romans 254 WORTMANN ET AL.

12:14; 1 Thessalonians 5:15), although angry the details of their reparative work. For exam- behaviors are occasionally portrayed as righ- ple, Hinduism defines various paths of practice teous (e.g., Jesus overturning money-changers’ to achieve moksha or emotional liberation, and tables in the temple; Matthew 21:12). the concept of karma encourages making repar- Progressive religious viewpoints tend to pro- ative actions to ensure a better future (Sharma & scribe only aggressive behaviors rather than the Tummala-Narra, 2014). emotion of anger itself (Häring, 1967), but ser- vice members and veterans whose spiritual tra- Divine Forgiveness and Self-Forgiveness ditions treat feelings of anger as a transgression After Perpetration may hesitate to acknowledge their anger and may experience guilt in response to the mere For theistic traditions, seeking forgiveness feeling. Clinicians will encourage the expres- from God is required for repairing one’s spiri- sion of angry feelings because they are a critical tual well-being after sin. Modern Christian source of information about a patient’s motiva- (e.g., Graham, 2015) and Muslim (e.g., Abdu- tion, unmet needs, and frustrations. However, roaf, 2011) writers have asserted that there is no secular clinicians need to bear in mind that sin beyond the reach of God’s forgiveness. Is- some warriors may view their faith traditions as lam, Judaism, and many denominations of prohibiting the emotional response of anger and Christianity share similar processes for achiev- not just anger-triggered behaviors, a potential ing forgiveness. Each requires remorse for challenge in treatment and recovery. Discus- wrongdoing and a confession either to a repre- sions with clergy who can frame feelings of sentative of God, such as a priest for Catholics, anger as a source of strength for preventing or directly to God, as in Protestantism, Islam, future violations, without letting it become self- and Judaism. Repenting, or committing to turn consuming (e.g., Meninger, 1996), may help away from sin in the future, is described by some individuals to accommodate anger within several texts as an additional crucial step in their religious perspectives. assuring God’s mercy (e.g., Isaiah 55:7; Qur’an 25:70, 39:53; Sahih Bukhari Volume 4, Book Spiritual Healing From Moral Injury 56, Hadith Number 676). In Hinduism, reparative behaviors may focus Across spiritual traditions it is generally ac- on developing the Samanya Dharma or com- cepted that any form of transgression can be mon virtues, especially daya (compassion; Ma- repented and amends can be made, and, if this habarata Book 14, Anugita Parva, Section 38). happens, all people, regardless of the type of Achieving moral restitution may be particularly transgression, deserve and will be provided for- important to a Hindu Veteran because the soul giveness. A similar psychological process has (atma) is deathless and eternal. Because karmic been posited to develop genuine self-forgive- time connects wrong actions and thoughts in the ness after transgression, which requires taking past to pain in the present (Sharma & Tummala- responsibility and using conciliatory behaviors Narra, 2014), the notion that pain in the next life when possible (McConnell, 2015, p. 155). Re- will be felt due to actions in war may amplify garding forgiving others, psychological re- distress but also motivate reparative behaviors. search has focused on defining what interper- In nontheistic codes, there is no god from sonal forgiveness is not (i.e., condoning, whom one would seek forgiveness. Nevertheless, excusing, or denying; McCullough, Pargament, some aspects of making spiritual repairs and & Thoresen, 2000). Agreement seems to be that achieving self-forgiveness are similar to those in forgiveness of self or others is not a disavowal theistic traditions. For example, reciting confes- of responsibility but rather a path to emotional sion liturgies is fundamental in Buddhism (i.e., the healing and the repair of broken interpersonal concept of patidesaniya), as is acceptance of an- bonds (McConnell, 2015; McCullough et al., other’s confession (samyutta nikaya 1:35). A Bud- 2000). Some faith traditions such as Catholi- dhist approach to persistent guilt would involve cism and Orthodox Judaism provide specific nonjudgmental mindful detachment. Buddhism rituals to make amends, whereas other spiritual views emotions like guilt and shame to be tempo- perspectives provide a general framework and rary expressions of suffering and disturbances in give adherents greater autonomy in determining achieving peace in one’s mind. Buddhism encour- SPIRITUAL FEATURES OF WAR-RELATED MORAL INJURY 255 ages focus on the present moment, which may cilitated by being (re)integrated into a spiritual provide relief from the feelings of guilt that are community. Kinghorn (2012) has charged Chris- tied to an action in the past. The secular humanist tian communities in particular to appreciate the view of excessive guilt is similar, regarding severe societal burden of war and their role in grieving guilt as an unhelpful impediment to human hap- with returning service members and veterans. He piness (Kurtz, 1983). describes reconciliation through patience, confes- The question of who can facilitate forgive- sion, and forgiveness, which spiritual traditions ness is a potentially contentious issue. Whereas have been exploring for millennia. some individuals, religious or nonreligious, may accept an approach in which forgiveness is Forgiving Others After Betrayal offered and received intrapsychically (as in Litz et al., 2015), others may feel strongly that ab- Some spiritual traditions, including the Abra- solution may only be granted by a religious hamic religions, command their followers to authority figure (e.g., Fritts, 2013). Notably, this offer forgiveness to others who have trans- belief may exist even if the actual authority for the gressed against them. However, interpretations faith does not require it. Consultation with clergy of this imperative vary widely, such as whether may provide an opportunity for collaboratively granting forgiveness is contingent on the of- addressing these concerns in a thoughtful and fender’s contrition or whether forgiveness ne- compassionate manner. cessitates reconciliation (Rye et al., 2000). For some individuals, forgiveness entails releasing a Forgiveness From Others After debt that the transgressor owes the aggrieved Perpetration party; for others, the aggrieved must forswear any ill-will or intent to retaliate. Psychologi- Many spiritual traditions emphasize the need to cally, the act of forgiveness is expected to re- seek forgiveness not only from divine figures but lease the victim from the emotional burden of also from other people. In some Orthodox Jewish the transgression (e.g., Meninger, 1996) traditions, for example, atonement cannot be through a process of uncovering and letting go achieved without first obtaining forgiveness from of anger that, researchers contend, is distinct the wronged party (e.g., Dorff, 1998). Apart from from pardoning or forgetting (Enright & any religious edicts, humanist writers have also Fitzgibbons, 2000). Premature declarations of argued that people may benefit from making forgiveness may cause betrayed individuals to amends with others when unethical actions have feel resentful; psychologists and clergy alike damaged relationships (e.g., Garrard, 2010). may help morally injured service members and For veterans of war, however, the aggrieved veterans to accept that time, processing, and parties with whom one wishes to make amends expression of the full extent of one’s hurt may may be geographically remote or even de- be necessary before forgiveness can be offered ceased, or their identities may be unknown, freely and deliberately, without resentment, as thwarting conventional avenues for seeking for- may be required for the act of forgiveness to be giveness. Some spiritual traditions provide al- a healing one (e.g., Enright & Fitzgibbons, ternative strategies for at least partial atonement 2000; Meninger, 1996). in the absence of tangible forgiveness from the harmed party. For example, perpetrators may be encouraged to confess and request forgiveness Applications: Illustrative Examples and from the deceased symbolically, such as by Clinical Recommendations beseeching them at their place of burial (Dorff, 1998). Secular approaches to symbolic forgive- The following cases are compiled from real ness involve letter-writing or an imaginal con- scenarios, based in the individual and group versation with the deceased (Keenan, Lumley, clinical experiences of the authors, and identi- & Schneider, 2014; Litz et al., 2015; Maguen & fying details have been altered. Religious affil- Burkman, 2013), which may be beneficial to iation is omitted to avoid suggesting that any religious or nonreligious persons. one faith tradition is more likely to experience Especially when forgiveness from the ag- guilt, shame, or anger, and to allow readers to grieved party is not feasible, healing may be fa- apply the concepts to diverse contexts. 256 WORTMANN ET AL.

A Case of Perpetration During War Moral repair following transgression (as opposed to moral reassurance) involves respecting that the John described killing both armed and un- patient is typically the expert about objective guilt armed enemies and feeling no remorse at the vis-a`-vis their own ethical system; that guilt and time. Now, years removed from the war, he shame are not the products of a misconception struggles with his actions and his response at about culpability, per se; and guilt is adaptive in the time, stating that his failure to feel immedi- that it can be used to motivate repairing action. ate guilt was inconsistent with his religion’s Clinicians should also appreciate that the Veter- teachings. John stated that he had a break- an’s goal may not be to eliminate guilt. Seemingly through with an individual treatment provider (a benign therapeutic efforts to reduce guilt and cognitive therapist) who placed John’s actions shame to cognitive distortions may actually be and peri-event feelings in the context of the fog inconsistent with veterans’ values, whether de- of war as well as his young age at the time of the rived from religious sensibilities or military ethos events, suggesting ultimately that it was not (Verkamp, 1988, p. 223). It has been posited that your fault. Despite this breakthrough, John re- self-forgiveness is not achieved “through moral ported an ongoing heavy burden of guilt and justifications...orself-exoneration” (McConnell, continued to participate in a weekly supportive 2015, p. 146). Rather, self-forgiveness is achieved therapy group with fellow veterans. His ongo- through interpersonal and intrapersonal actions— ing distress indicated that the therapy may have public and private reparative activities—and guilt provided palliative reassurances but failed to feelings may serve to motivate these behaviors allow John to fully come to terms with his past (McConnell, 2015). and present emotions and actions. The therapist’s goal is thus to help the patient In cases like this, we recommend assessment to figure out how he or she can be who he or she clarify the degree to which the Veteran’s religious wants to be moving forward in life, even while beliefs are influencing his current distress and the carrying their objective guilt and consequent guilt- extent to which he has sought spiritual support feelings with them (e.g., repentance in the Abra- (Saunders, Miller, & Bright, 2010). John’s ongo- hamic traditions). Values identification and behav- ing struggle with failure to feel remorse years ior change efforts are central to this work. Mental prior suggests religious belief is relevant to his health care providers need to appreciate that moral healing process. Cognitive therapy tends to ad- repair is only partially intrapsychic; compassion dress guilt-feelings by challenging objective guilt, and forgiveness may require sustained actions which may sometimes be appropriate, such as over the life span and may involve the support of when a war Veteran has an obviously distorted the surrounding community. understanding of the ethical system to which they try to adhere and how their purported infraction A Case of Spiritual Alienation Following fits into this system. We argue, however, that the Perpetration therapist’s role is not to adjudicate the patient’s objective guilt; a spiritual figure would be better Jesse returned home feeling changed by his suited to help a patient do so (Litz et al., 2015). If combat experiences, particularly by some inci- assessment indicates that religious belief is rele- dents that he viewed as serious moral transgres- vant to the healing process, the clinician should sions. He believes his and others’ actions re- inquire whether the Veteran wishes to discuss his sulted in the deaths of enemy combatants and belief with a religious adviser, and if so, offer to civilians. Although he has resumed attending facilitate a referral to a sensitive and compassion- religious services and reports a desire to be ate spiritual caregiver from the local faith commu- reconnected with his faith, he reports feeling nity or chaplain from the health care setting. separate from the congregation, describing a The therapist’s primary role, equipped with a general felt difference in him that he and others basic understanding of the patient’s spiritual can detect but have trouble articulating. framework, is to compassionately and empathi- In this situation, the clinician should consider cally appreciate the inherent validity of the war having a dialogue with Jesse about creative Veteran’s assignment of blame and responsibility, ways though which a welcoming religious com- which is typically informed by the military culture munity might be able to facilitate his healing, and ethos and colored by faith (when present). particularly because apologies to harmed parties SPIRITUAL FEATURES OF WAR-RELATED MORAL INJURY 257 are unfeasible. If Jesse were provided the op- member. Experiencing such compassion might portunity to engage in service-related activities facilitate her learning to direct compassion to alongside other congregation members, this herself, and in turn allow her to direct compas- may demonstrate to himself and others that he sion and even forgiveness to the leadership she retains the capacity to do good. Certainly these holds responsible, without feeling she is relin- steps could be taken outside a religious com- quishing her moral principles. munity, yet it may be meaningful to a religious Clergy with military backgrounds (e.g., former individual to consider that historically the reli- and current military chaplains), who have been gious act of penance served to prove to oneself side-by-side with fellow service members in wit- and to others the penitent’s capacity for good nessing, even themselves experiencing, the psy- (Verkamp, 1988). Making amends through eth- chological and spiritual consequences of war, may ical action may thus help to repair personal be particularly well-positioned to collaborate in spirituality as well as connection to the religious the above cases, through consultation and poten- community. The community also has a role in tially the provision of complementary care for providing a supportive welcome (Kinghorn, spiritual distress. Table 1 summarizes our recom- 2012). A clinician can help facilitate this con- mendations for when clinicians may wish to con- nection by seeking knowledge about communi- sult or collaborate with chaplains or clergy and the ties that strive to welcome service members and desired outcomes of doing so. veterans, becoming familiar with resources to The above vignettes are relatively straightfor- educate communities about what they can do ward, but moral injury in war veterans some- welcome and support service members and vet- times presents in more complex ways. For ex- erans, and developing relationships with local ample, a service member may at once feel clergy and chaplains. betrayed by leaders who made decisions that got people killed, and also feel responsible for not A Case of Betrayal of Expectations for having done more to prevent leadership’s deci- Fellow Warriors’ Conduct sions or the consequences thereof. Thus, al- though we have provided some basic examples Anya described leadership failures that resulted of how spiritual healing from war-related moral in near-misses on the battlefield; her attempts to injury might be encouraged in clinical settings suggest safer tactics went unheeded. She attributes in collaboration with spiritual care providers, all the stateside suicides of fellow unit members to cases must be conceptualized individually. the psychological sequelae of these events. She describes having held a high standard for ethical Summary and Implications action since her youth, which was intensified by her military service and challenged by the ethical War-related moral injury emerges from a ser- failures she witnessed. She copes with intense vice member’s transgressive acts of commis- anger and anxiety by heavy substance use. Her sion and omission, being affected by the moral upbringing was characterized by an appreciation violations of others, or bearing witness to events for the punishing side of authority figures (i.e., that severely contradict moral expectations. parents, God) and lack of relationship with loving Moral repair may be facilitated or complicated authority figures. by war veterans’ faith traditions. We contend As part of the spiritual assessment (Saunders that greater awareness by psychologists of spir- et al., 2010), the clinician and Anya might ex- itual issues in secular treatment will enhance plore the model of authority that her upbringing their care for service members and veterans and provided and her willingness to seek exceptions their ability to effectively consult and collabo- to the rule of unloving authority. The clinician rate with spiritual care providers when indi- might explore how the high standard of virtuous cated. Detailed spiritual competencies (Vieten behavior demanded by her religion and by the et al., 2013, 2016) and guidelines for clinicians warrior ethos are comparable, taking care not to regarding consultations with and referrals to minimize Anya’s valuing of either. The process religious professionals (McMinn, Aikins, & of healing for Anya might involve the receipt of Lish, 2003; Saunders et al., 2010) have been a compassionate response from a loving author- elaborated upon elsewhere. We recommend that ity figure, who might be a chaplain or clergy- clinicians consult these resources and explore 258 WORTMANN ET AL.

Table 1 Recommendations: When to Consult or Collaborate With Chaplains or Clergy

Spiritual feature of Assessment questions or discussion moral injury prompts Desired outcome Persistent guilt or shame 1. What beliefs do you have about this? Receive compassion after perpetration What have you learned from spiritual communities about this? Intense, chronic negative 2. Have you sought any support from Correct misunderstandings self-evaluation linked spiritual care providers, teachers, or Process thoughts and feelings to religious beliefs communities? If not, would you be within their chosen willing to? Would it help if we religious or spiritual contacted the person together? framework or understanding Alienation from 1. Would you consider reconnecting with Receive an understanding community a spiritual community? and supportive welcome a. How do you think that might help? Experience opportunities for b. What are you concerns about doing moral repair so? 2. Would you consider speaking with a leader at your community of choice? Would it help if we contacted the person together? Anger and/or mistrust 1. What do other models of authority look Receive compassion from after betrayal like? Are there more examples of religious authority authority figures who disappointed or betrayed you in your life? 2. What would the ideal leader look like? Correct misunderstandings What would be the attributes of an about anger ideal leader? 3. Might it be possible to meet an Process anger within their authority figure who is trustworthy chosen religious or and compassionate, instead of cruel, spiritual framework or absent, dismissive, etc.? understanding

novel psychological approaches to war-related here to a faith tradition, in conjunction with their moral injury and related spiritual distress (Har- faith-based work. ris, Park, Currier, Usset, & Voecks, 2015; Litz Because we have omitted many faith traditions et al., 2015; Nieuwsma et al., 2015), which and could not represent the full diversity within address spiritual concerns related to emotional each of the traditions discussed, we recommend and behavioral consequences of transgression. that clinicians always explore the individual be- It is also critical to allow for the process of liefs and assumptions held by service members healing to include conservation and/or transfor- and veterans struggling with war-related moral mation of spirituality (Pargament, 2007). injury. Given the breadth and depth of this topic, Psychologists tend to give minimal attention to maintaining an attitude of cultural humility in lieu issues of transgression and typically focus instead of striving for categorical competence (Tervalon on modifying so called “maladaptive” cognitive & Murray-Garcia, 1998) may be the most helpful and emotional states to relieve distress (e.g., Wa- frame for this aspirational care. We hope that this chen et al., 2015). Yet, perpetration- and betrayal- work provides clinicians with helpful basic infor- related distress may not be caused by failure to mation about the faith-based and philosophical fully express emotion or by faulty appraisals about origins of spiritual concerns in moral injury, in- responsibility and control. Steps toward self- and creases their comfort with discussing these mat- other-forgiveness, such as confession to compas- ters with service members and veterans, and in- sionate and caring others, and making amends, spires further investigation into the nuances of can be accomplished by nonreligious service transgression and forgiveness through collabora- members and veterans as well as those who ad- tive discussion with spiritual care providers. SPIRITUAL FEATURES OF WAR-RELATED MORAL INJURY 259

References ity of life: Testing a mediational model with mil- itary veterans with PTSD. The International Jour- Abduroaf, K. (2011, October 27). The man that killed nal for the Psychology of Religion, 26, 167–179. 99 people. Retrieved from https://fiqhulhadith http://dx.doi.org/10.1080/10508619.2015.1019793 .wordpress.com/2011/10/27/the-man-that-killed- Davis, R. H. (2014). The Bhagavad Gita: A biogra- 99-people/ phy. Princeton, NJ: Princeton University Press. American Humanist Association. (1973). Humanist http://dx.doi.org/10.1515/9781400851973 Manifesto I. Retrieved from http://americanhumanist Dorff, E. M. (1998). The elements of forgiveness: A .org/humanism/Humanist_Manifesto_I. (Original Jewish approach. In E. L. Worthington Jr. (Ed.), work published 1933) Dimensions of forgiveness: Psychological re- American Psychological Association. (2010). 2010 search and theological perspectives (pp. 29–55). Amendments to the 2002 “Ethical principles of Philadelphia, PA: Templeton Foundation Press. psychologists and code of conduct.” American Enright, R. D., & Fitzgibbons, R. P. (2000). Helping Psychologist, 65, 493. http://dx.doi.org/10.1037/ clients forgive: An empirical guide for resolving a0020168 anger and restoring hope. Washington, DC: Bashier, Z. (2015). War and peace in the life of the American Psychological Association. http://dx.doi prophet Muhammad . Leicestershire, United King- .org/10.1037/10381-000 dom: Kube Publishing Ltd. Epstein, S. (2003). Cognitive–experiential self- Baumeister, R. F., Stillwell, A. M., & Heatherton, theory of personality. In I. B. Weiner (Series Ed.) T. F. (1994). Guilt: An interpersonal approach. & T. Millon & M. J. Lerner (Vol. Ed.), Handbook Psychological Bulletin, 115, 243–267. http://dx of psychology: Vol. 5. Personality and social psy- .doi.org/10.1037/0033-2909.115.2.243 chology (pp. 159–184). Hoboken, NJ: Wiley. Becker, L. C., & Becker, C. B. (Eds.). (2001). Ency- http://dx.doi.org/10.1002/0471264385.wei0507 clopedia of ethics (Vol. 1). New York, NY: Rout- Exline, J. J., Pargament, K. I., Grubbs, J. B., & Yali, ledge. Berg, G. (2011). The relationship between spiritual A. M. (2014). The Religious and Spiritual Strug- distress, PTSD and depression in Vietnam combat gles Scale: Development and initial validation. veterans. Journal of Pastoral Care & Counseling, Psychology of Religion and Spirituality, 6, 208– 65, 1–11. http://dx.doi.org/10.1177/1542305011 222. http://dx.doi.org/10.1037/a0036465 06500106 Finn, M., & Rubin, J. B. (2014). Psychotherapy with Bryan, A. O., Bryan, C. J., Morrow, C. E., Etienne, Buddhists. In P. S. Richards & A. E. Bergin (Eds.), N., & Ray-Sannerud, B. (2014). Moral injury, sui- Handbook of psychotherapy and religious diver- cidal ideation, and suicide attempts in a military sity (2nd ed., pp. 347–369). Washington, DC: sample. Traumatology, 20, 154–160. http://dx.doi American Psychological Association. http://dx.doi .org/10.1037/h0099852 .org/10.1037/14371-014 Bryan, A. O., Theriault, J. L., & Bryan, C. J. (2015). Fontana, A., & Rosenheck, R. (2004). Trauma, Self-forgiveness, posttraumatic stress, and suicide at- change in strength of religious faith, and mental tempts among military personnel and veterans. Trau- health service use among veterans treated for matology, 21, 40–46. http://dx.doi.org/10.1037/ PTSD. Journal of Nervous and Mental Disease, trm0000017 192, 579–584. http://dx.doi.org/10.1097/01.nmd Bryan, C. J., Bryan, A. O., Anestis, M. D., Anestis, .0000138224.17375.55 J. C., Green, B. A., Etienne, N.,...Ray-Sannerud, Fontana, A., & Rosenheck, R. (2005). The role of loss B. (2016). Measuring moral injury: Psychometric of meaning in the pursuit of treatment for posttrau- properties of the Moral Injury Events Scale in two matic stress disorder. Journal of Traumatic Stress, military samples. Assessment, 23, 557–570. http:// 18, 133–136. http://dx.doi.org/10.1002/jts.20014 dx.doi.org/10.1177/1073191115590855 Frankfurt, S., & Frazier, P. (2016). A review of Currier, J., Drescher, K., & Harris, J. I. (2014). Spir- research on moral injury in combat veterans. Mil- itual functioning among veterans seeking residen- itary Psychology, 28, 318–330. http://dx.doi.org/ tial treatment for PTSD: A matched control group 10.1037/mil0000132 study. Spirituality in Clinical Practice, 1, 3–15. Fritts, P. D. (2013). Adaptive disclosure: Critique of http://dx.doi.org/10.1037/scp0000004 a descriptive intervention modified for the norma- Currier, J. M., Holland, J. M., Drescher, K., & Foy, tive problem of moral injury in combat veterans. D. (2015). Initial psychometric evaluation of the Retrieved from http://www.cgscfoundation.org/ Moral Injury Questionnaire—Military version. wp-content/uploads/2014/03/Fritts-Adaptive Clinical psychology & psychotherapy, 22, 54–63. Disclosure.pdf http://dx.doi.org/10.1002/cpp.1866 Garrard, E. (2010). To forgive, divine? Is forgiveness Currier, J., Drescher, K., Holland, J., Lisman, R., & just for the devout? Retrieved from https:// Foy, D. (2016). Spirituality, forgiveness, and qual- newhumanist.org.uk/2386/to-forgive-divine 260 WORTMANN ET AL.

Graham, B. (2015, August 26). God yearns to forgive Maguen, S., & Burkman, K. (2013). Combat-related your past wrongs [Blog post]. Retrieved from http:// killing: Expanding evidence-based treatments for www.kansascity.com/living/liv-columns-blogs/ PTSD. Cognitive and Behavioral Practice, 20, billy-graham/article32310540.html 476–479. http://dx.doi.org/10.1016/j.cbpra.2013 Häring, B. (1967). The law of Christ: Vol. II: Special .05.003 moral theology. Cork, Ireland: The Mercier Press Maguen, S., & Litz, B. T. (2012). Moral injury in veterans Ltd. of war. PTSD Research Quarterly, 23, 1–6. Harris, J. I., Park, C. L., Currier, J. M., Usset, T. J., McConnell, J. M. (2015). A conceptual-theoretical- & Voecks, C. D. (2015). Moral injury and psycho- empirical framework for self-forgiveness: Implica- spiritual development: Considering the develop- tions for research and practice. Basic and Applied mental context. Spirituality in Clinical Practice, 2, Social Psychology, 37, 143–164. http://dx.doi.org/ 256–266. http://dx.doi.org/10.1037/scp0000045 10.1080/01973533.2015.1016160 Hedayat-Diba, Z. (2014). Psychotherapy with Mus- McCullough, M. E., Pargament, K. I., & Thoresen, lims. In P. S. Richards & A. E. Bergin (Eds.), C. E. (2000). The psychology of forgiveness: His- Handbook of psychotherapy and religious diver- tory, conceptual issues, and overview. In M. Mc- sity (2nd ed., pp. 287–317). Washington, DC: Cullough, K. Pargament, & C. Thoresen (Eds.), American Psychological Association. http://dx.doi Forgiveness: Theory, research, and practice (pp. .org/10.1037/14371-012 1–14). New York, NY: Guilford Press. Huguelet, P., & Koenig, H. G. (2009). Religion and McMinn, M. R., Aikins, D. C., & Lish, R. A. (2003). spirituality in psychiatry. New York, NY: Cam- Basic and advanced competence in collaborating bridge University Press. http://dx.doi.org/10.1017/ with clergy. Professional Psychology, Research CBO9780511576843 and Practice, 34, 197–202. http://dx.doi.org/10 Janoff-Bulman, R. (1992). Shattered assumptions: .1037/0735-7028.34.2.197 Towards a new psychology of trauma. New York, Meehl, P. E. (1960). Treatment of guilt-feelings.In NY: Free Press. 1957 Symposium of the American Catholic Psy- chological Association (pp. 34–41). New York, Jordan, A. H., Eisen, E., Bolton, E., Nash, W. P., & NY: Fordham University. Retrieved from http:// Litz, B. T. (2017). Distinguishing war-related meehl.umn.edu/files/054guiltfeelingspdf PTSD resulting from perpetration- and betrayal- Meninger, W. A. (1996). The process of forgiveness. Lon- based morally injurious events. Psychological don, UK: Bloomsbury Publishing. Trauma: Theory, Research, Practice, and Policy. Morgan, J. K., Hourani, L., Lane, M. E., & Tueller, S. Advance online publication. http://dx.doi.org/10 (2016). Help-seeking behaviors among active-duty .1037/tra0000249 military personnel: Utilization of chaplains and Keenan, M. J., Lumley, V. A., & Schneider, R. B. other mental health service providers. Journal of (2014). A group therapy approach to treating com- Health Care Chaplaincy, 22, 102–117. http://dx bat posttraumatic stress disorder: Interpersonal re- .doi.org/10.1080/08854726.2016.1171598 connection through letter writing. Psychotherapy: Nash, W. P. (2007). Combat/operational stress adap- Theory, Research, & Practice, 51, 546–554. http:// tations and injuries. In C. R. Figley & W. P. Nash dx.doi.org/10.1037/a0036025 (Eds.), Combat stress injuries: Theory, research, Kinghorn, W. (2012). Combat trauma and moral and management (pp. 33–64). New York, NY: fragmentation: A theological account of moral in- Routledge. jury. Journal of the Society of Christian Ethics, 32, Nash, W. P., Marino Carper, T. L., Mills, M. A., Au, 57–74. http://dx.doi.org/10.1353/sce.2012.0041 T., Goldsmith, A., & Litz, B. T. (2013). Psycho- Kopacz, M. S., & Connery, A. L. (2015). The veteran metric evaluation of the Moral Injury Events Scale. spiritual struggle. Spirituality in Clinical Practice, Military Medicine, 178, 646–652. http://dx.doi 2, 61–67. http://dx.doi.org/10.1037/scp0000059 .org/10.7205/MILMED-D-13-00017 Kurtz, P. (1983). In defense of secular humanism. Nieuwsma, J. A., Walser, R. D., Farnsworth, J. K., Amherst, NY: Prometheus Books. Drescher, K. D., Meador, K. G., & Nash, W. Litz, B. T., Lebowitz, L., Gray, M. J., & Nash, W. P. (2015). Possibilities within acceptance and com- (2015). Adaptive Disclosure: A new treatment for mitment therapy for approaching moral injury. military trauma, loss, and moral injury.New Current Psychiatry Reviews, 11, 193–206. http:// York, NY: Guilford Press. dx.doi.org/10.2174/157340051166615062910 Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., 5234 Nash, W. P., Silva, C., & Maguen, S. (2009). Ogden, H., Harris, J. I., Erbes, C. R., Engdahl, B. E., Moral injury and moral repair in war veterans: A Olson, R. A., Winskowski, A. M., & McMahill, J. preliminary model and intervention strategy. Clin- (2011). Religious functioning and trauma out- ical Psychology Review, 29, 695–706. http://dx.doi comes among combat veterans. Counselling and .org/10.1016/j.cpr.2009.07.003 Spirituality/Counseling Et Spiritualité, 30, 71–89. SPIRITUAL FEATURES OF WAR-RELATED MORAL INJURY 261

Pargament, K. I. (2007). Spiritually integrated psy- for the Poor and Underserved, 9, 117–125. http:// chotherapy: Understanding and addressing the sa- dx.doi.org/10.1353/hpu.2010.0233 cred. New York, NY: Guilford Press. Vargas, A. F., Hanson, T., Kraus, D., Drescher, K., & Pargament, K. I., McCullough, M. E., & Thoresen, C. E. Foy, D. (2013). Moral injury themes in combat (2000). The frontier of forgiveness: Seven directions for veterans’ narrative responses from the National psychological study and practice. In M. McCullough, Vietnam Veterans’ Readjustment Study. Trauma- K. Pargament, & C. Thoresen (Eds.), Forgiveness: tology, 19, 243–250. http://dx.doi.org/10.1177/ Theory, research, and practice (pp. 299–319). 1534765613476099 New York, NY: Guilford Press. Verkamp, B. J. (1988). Moral treatment of returning Pattanaik, D. (2010). Jaya: An illustrated retelling of warriors in the early middle ages. The Journal of the Mahabarata. New Delhi, India: Penguin Books Religious Ethics, 16, 223–249. India. Vieten, C., Scammell, S., Pierce, A., Pilato, R., Am- Rachman, S. (2010). Betrayal: A psychological anal- mondson, I., Pargament, K. I., & Lukoff, D. ysis. Behaviour Research and Therapy, 48, 304– (2016). Competencies for psychologists in the do- 311. http://dx.doi.org/10.1016/j.brat.2009.12.002 mains of religion and spirituality. Spirituality in Richards, P., & Bergin, A. E. (2000). Handbook of Clinical Practice, 3, 92–114. http://dx.doi.org/10 psychotherapy and religious diversity (2nd ed.). .1037/scp0000078 Washington, DC: American Psychological Associ- Vieten, C., Scammell, S., Pilato, R., Ammondson, I., ation. http://dx.doi.org/10.1037/10347-000 Pargament, K. I., & Lukoff, D. (2013). Spiritual Rye, M. S., Pargament, K. I., Ali, M. A., Beck, G. L., and religious competencies for psychologists. Psy- Dorff, E. N., Hallisey, C.,...Williams, J. G. chology of Religion and Spirituality, 5, 129–144. (2000). The psychology of forgiveness: History, http://dx.doi.org/10.1037/a0032699 Wachen, J. S., Dondanville, K. A., Pruiksma, K. E., conceptual issues, and overview. In M. Mc- Molino, A., Carson, C. S., Blankenship, A. E.,... Cullough, K. Pargament, & C. Thoresen (Eds.), Resick, P. A. (2015). Implementing cognitive pro- Forgiveness: Theory, research, and practice (pp. cessing therapy for posttraumatic stress disorder 17–40). New York, NY: Guilford Press. with active duty U.S. military personnel: Special Saunders, S. M., Miller, M. L., & Bright, M. M. considerations and case examples. Cognitive and (2010). Spiritually conscious psychological care. Behavioral Practice, 23, 133–147. http://dx.doi Professional Psychology, Research and Practice, .org/10.1016/j.cbpra.2015.08.007 41, 355–362. http://dx.doi.org/10.1037/a0020953 Wilk, J. E., Bliese, P. D., Thomas, J. L., Wood, Shah, N. A. (2008). Self-defense in Islamic and in- M. D., McGurk, D., Castro, C. A., & Hoge, C. W. ternational law: Assessing Al-Qaeda and the inva- (2013). Unethical battlefield conduct reported by sion of Iraq. New York, NY: Palgrave MacMillan. soldiers serving in the Iraq war. Journal of Ner- http://dx.doi.org/10.1057/9780230611658 vous and Mental Disease, 201, 259–265. http://dx Sharma, A. R., & Tummala-Narra, P. (2014). Psy- .doi.org/10.1097/NMD.0b013e318288d302 chotherapy with Hindus. In P. S. Richards & A. E. Wisco, B. E., Marx, B. P., May, C. L., Martini, B., Bergin (Eds.), Handbook of psychotherapy and Krystal, J. H., Southwick, S. M., & Pietrzak, R. H. religious diversity (2nd ed., pp. 321–345). Wash- (2017). Moral injury in U.S. combat veterans: Re- ington, DC: American Psychological Association. sults from the national health and resilience in http://dx.doi.org/10.1037/14371-013 veterans study. Depression and Anxiety, 34, 340– Stoler Miller, B. (1986). The Bhagavad-Gita: Krish- 347. http://dx.doi.org/10.1002/da.22614 na’s counsel in time of war (B. Stoler Miller, Witvliet, C. V., Phipps, K. A., Feldman, M. E., & Trans.). New York, NY: Bantam Books. Beckham, J. C. (2004). Posttraumatic mental and Tangney, J. P. (1996). Conceptual and methodolog- physical health correlates of forgiveness and reli- ical issues in the assessment of shame and guilt. gious coping in military veterans. Journal of Trau- Behaviour Research and Therapy, 34, 741–754. matic Stress, 17, 269–273. http://dx.doi.org/10 http://dx.doi.org/10.1016/0005-7967(96)00034-4 .1023/B:JOTS.0000029270.47848.e5 Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical Received January 2, 2017 distinction in defining physician training outcomes Revision received June 12, 2017 in multicultural education. Journal of Health Care Accepted June 22, 2017 Ⅲ