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,