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Moral Injury MORAL INJURY Rita Nakashima Brock, Ph.D. Senior Vice President and Director of the Shay Moral Injury Center Volunteers of America, 1660 Duke St., Alexandria, VA 22314 703-341-5000 • [email protected] voa.org Moral Identity and Meaning Increasing evidence from neuroscience 4. Rituals and psychology that human beings are a. Deliver meaning system by enacting born moral and that moral conscience important values in symbolic ways or is part of human empathy, pattern via stories so that they are part of body- making, and social existence. memory as well as conscious memory. “As moral injury takes Content of moral systems and b. Teach meaning and values through individual identity have at least five repeated behavior that includes stories its place in the common dimensions (See Seligman, A, R. P. or other forms of delivering meaning. Weller (2012) Rethinking Pluralism: c. Often bodily re-enactment of a parlance, we need to Ritual, Experience, and Ambiguity. ritual can evoke the emotions of the Oxford.): meaning system. ask what it provides our 1. Habits d. Provide opportunities to enact a. Learned by mimicry, repetition, aspirational aspects of meaning— practice, and coaching. Largely performing ideal self v. real self. consciousness and what subconscious behavior that determines e. Used to integrate ambiguity or daily human interactions. Habitual threats to meaning via story, myth, and behaviors carry moral content. Embed it limits, and how we connection to ideal self. gender, culture, race, and context. 5. Experience could more fully address b. Difficult to change and constitute most moral behavior on a daily basis. a. Can reinforce or challenge all of the above. the human experience of 2. Meaning-Orienting Systems b. Trauma=Experience of Suffering: a. Overarching philosophical, (Keefe-Perry, L. C. & Moon, Z. (2018) moral suffering.” mythical, and/or religious-theological • Hard to assimilate into normal value system that defines crucial aspects life; --Zachary Moon, Warriors of relationships and life purpose. Between Worlds, Forthcoming • Overwhelms beliefs, values, b. Assumed, rather than explicitly behaviors, and/or relationships; discussed unless challenged. • Can be an event, a harmful social c. Questions of meaning emerge when structure, or life circumstance ambiguous situations arise. (poverty, gender oppression, incarceration); 3. Rules • Requires new, functional coping a. Hard moral cultural/social strategies that facilitate survival boundaries that cannot be crossed and meaningful relationships. without penalty. c. Devastating, traumatic experiences b. In complex, pluralistic society, can destabilize meaning and identity at where informal custom fails, rules are any point in life—this is moral injury. often laws. d. Coherence can only be reestablished c. How rigidly a society or person in the struggle to create a new meaning relates to rules varies greatly and system and identity adequate to involve what is customary, legal, taboo, integrating trauma. and moral. Moral Injury Shay defi nition: Moral Injury is 1) Brock Defi nition: Moral injury is a Some Moral the violation of what is right by 2) response to trauma when a person or Emotions someone in authority 3) in a high group's existing core moral foundations stakes situation. Th is kind of moral are unable to justify, process, and • Guilt injury correlates to betrayal and rage integrate trauma into a reliable identity and to higher rates of co-morbidity and meaning system that sustains • Shame with PTSD (Jordan, 2017). relationships and human fl ourishing. It results from: • Embarrassment Litz, et. al., defi nition: Moral A. Being betrayed by people and/ Injury’ is a syndrome of shame, • Alienation or institutions that should have been self-handicapping, anger, and trusted to be moral and do the right demoralization that occurs when • Sorrow thing; deeply held beliefs and expectations • Remorse about moral and ethical conduct B. Committing, witnessing, imagining, are transgressed. It is distinct from a or failing to prevent acts or events that • Outrage/Anger life threat as it is also not inherently can be judged as harmful or evil and fear-based; it can arise from killing, that violate foundational social and • Disgust perpetration of violence, betrayals of ethical rules; • Contempt trust in leaders, witnessing depraved C. Being involved in events or contexts behavior, or failing to prevent serious where violations of taboos or acts of • Revenge unethical acts. harm leave one feeling contaminated -- Litz, B. T., et al. Adaptive Disclosure, by evil or “dirty;” or 2016): p. 21, paraphrased. D. Surviving conditions of degradation, oppression, and extremity. Relation of PTSD to Moral Injury Moral feelings include guilt, shame, despair, remorse, outrage, grief, disgust, and self-condemnation result in suff ering found in broken trust, alienation, a sense of betrayal, and social withdrawal. Grief as a Dimension of Moral Injury • Loss of closest friends; • Loss of innocence or sense of goodness • Loss of profession • Loss of mission • Loss of role / purpose for others • Loss of family or capacity for intimacy– confl ict / divorce • Loss of faith and meaning community • Loss of self—forever changed • Living with broken heart Th e above diagram created by William Nash, M.D., USN ret., Greater Los Angeles VA Aspects of Moral Injury • Close correlation of betrayal, in particular, with PTSD. (Jordan, 2017) • Can emerge long after events or experiences or immediately after an event. • Is found in every war or extremity. • Can also result from traumas such as natural disasters, sexual assault, and oppressive contexts such as poverty etc. • Creates mistrust and isolation. • Alienation hard to overcome. • Can be found in many professions and circumstances outside the military. Th e above diagram created by William Nash, M.D., USN ret., Greater Los Angeles VA RISK FOR MORAL INJURY AND BURN OUT Social Activist Mother of Teac WorkerLeader Nurse Minister Newborn Therapist her Lawyer Life and Death Consequences Y Y Y ? Y Y Y Y Physically Dependent Charges Y Y ? Y Ethical Dilemmas Y Y Y Y Y Y Y Y Emotionally Charged Participants Y Y Y Y Y Y Y Y Expected Perfection Y Y Y Y Y Limited Choices Y Y Y Y Y Y Y High Risk for Liablility Y Y Y Y Isolated Working Conditions Y Y Responsibility with Little Control Y Y Y ? Y Y Y=Yes, ?=Maybe. Chart provided by Dr. Joanne Braxton, used with permission Recovery Individual Recovery Collective Strategies and Communities • MEMORY PROCESSING: Rituals Writing/drawing/enacting personal • LAMENTATION: to process grief narratives. Need ways to externalize for various kinds of losses. inner struggle and express story Moral injury is not a many times. As they are retold, the • LIMINAL SPACES: (sequester older layers of the self and new outside ordinary time and space— perspectives can emerge in the “eternal now”) to transition from psychological disorder, retellings. military life and identity to civilian community that understands and • HOLISTIC HEALTH cares (ex. Navajo Enemy Way but a normal human PRACTICES: Sleep hygiene, Ceremonial, or ancient Christian mindful eating, and time outdoors. penance system). This process places response to extremity • TRUSTWORTHY, BENEVOLENT an individual story within the CONVERSATION PARTNERS: context of a larger one to restore Talking to benevolent moral meaning and belonging with and the disruptive impact authority to process moral and support from the entire community. theological struggles. • USE OF ARTS: such as music, • SITTING IN THE FIRE: dance, theater, writing groups, visual of violence, oppressive Processing trauma pain so it no art, to integrate all three brain areas longer dominates behavior and and process experience, to restore contexts, and moral controls a life narrative. capacities for joy and love of beauty. • INTEGRATION OF TRAUMA: • SPIRITUAL PRACTICES: that Integrating memory/story into a calm stress, enable exploration of failure. Authoritarian larger life narrative— as memory is inner feelings and emotional processed over time, it will change as intelligence, offer ways to experience systems with a lot of new experiences accumulate. trauma pain to burn through it • RESTORATION OF EMPATHY: (sitting in the fire), and create inner Re-humanization of Enemies, lessen equilibrium. coercive control are need to hate or fear, perspective- • ENACT ASPIRATIONAL taking, compassion for self. VALUES: the re-humanization especially morally • INTIMATE, CARING of enemies and values that restore RELATIONSHIPS: Reconnection collective connections to life. with estranged others, especially • PUBLIC RECOGNITION: injurious. family. commissioning for service work, • COMMUNITY: Long-term other symbols of belonging to a community to sustain meaning- larger mission and meaning system. orienting system and a provide ways Ways to validate that an individual to serve others. life matters to others. • ACCEPTANCE: Compassion for Community Acts: self and others, forgiveness, love of beauty and life, or submission • WELCOME: Prepare a welcoming to a meaning-orienting system context by adequate to the magnitude of suffering experienced. • Offering ministries of presence • Festivals that help restore through open-hearted acceptance playfulness, relaxation and opportunities to serve others • Theater or dance • Practicing deep listening (see details • Outdoor Activities below) • Prayer/meditation groups • Attending to ways to create safe • GROUPS: Organize groups that gathering spaces for those struggling facilitate telling personal stories
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