Chapter’s Summary

The Moral Injury Spectrum: From Conflict to Healing in Individual and Cultural Contexts

C. Richard Spates & Karis L. Callaway

Summaries of Moral Injury Book - Chapter by Chapter

Preface: Two Psychologists Journey into the Realm of Moral Injury

In the preface, C. Richard Spates, a clinical psychologist with extensive experience in mental health, reflects on his career and the evolution of his understanding of moral injury. He highlights his work in treating and supervising cases of PTSD across various settings, including military, law enforcement, healthcare, and education.

Spates shares a specific case from 1992 involving a priest who had experienced multiple traumatic events. The priest had accidentally killed a mother while target practicing with live ammunition; as a teenager, he experienced a panic attack during a lecture on masturbation in seminary school and witnessed the aftermath of a mass killing of his priestly colleagues in Central America. Spates treated the priest using Eye Movement Desensitization (EMD; its contemporaneous designation), a controversial new treatment at the time.

During the treatment, the priest experienced spontaneous insights related to self-forgiveness for each traumatic event. Spates suggests that self-forgiveness, although not explicitly guided by him as the therapist, played a vital role in the treatment’s success and may have been overlooked by other treatment protocols the priest had undergone.

Spates also discusses his sabbatical research project in Australia during the breakup of the former Yugoslavia, studying “Secondary PTSD” among torture treatment therapists. He discovered that the therapists experienced a significant impact from listening to clients’ trauma and torture narratives, requiring support and debriefing. Spates suggests that moral injury, rather than Secondary PTSD, was likely of more central importance in this context.

Spates acknowledges that these case reports and observations cannot be overgeneralized but offers them as working hypotheses that helped shape his perspective on moral injury and for further exploration in the ongoing discourse concerning moral injury. He expresses gratitude for the early work of those in the Veterans Administration who called attention to the significance of the moral injury construct and its extension beyond military relevance.

The preface concludes with an invitation to readers to join Spates and his colleague, Karis Callaway, on a journey through the intricate landscape of moral injury, navigating the complexities of human experience, resilience, and healing while reviewing the remaining work to be done in this field.

Introduction: Exploring the Landscape of Moral Injury: Contexts, Analysis, Interventions, and Societal Implications

The introductory chapter provides an overview of the book “The Moral Injury Spectrum: From Conflict to Healing in Individual and Cultural Contexts” which comprehensively explores moral injury, its relevance in various life domains, and evidence-based interventions for clinical practice. The authors, C. Richard Spates and Karis Callaway, also extend the construct to societal challenges that have not been fully viewed through the lens of moral injury.

The book begins by defining moral injury and tracing its historical roots, drawing upon the seminal work of Jonathan Shay and Brett Litz. It examines the concept’s evolution and broader implications beyond the military context. The authors then delve into specific domains where moral injury manifests, including the military, healthcare, law enforcement, corporate and manufacturing occupations, and academia.

To provide a theoretical foundation, the authors review standard models of moral development and integrate Jonathan Haidt’s moral foundations theory as a basis for understanding the concept of “injury” in the moral landscape. They explore the psychological processes involved in moral injury and examine individual differences in moral development, the influence of parenting styles, and the role of pre-existing psychological factors.

The book also examines the complex interplay between faith, moral values, and psychological well-being, and provides a review of evidence-based psychological interventions for moral injury. The authors critically evaluate the current state of construct validation and treatment outcome research, highlighting the need for further empirical investigation.

In a closing chapter, the authors address remaining challenges in the field, such as the need for definitional clarity, the risk of construct reification, the importance of considering a dimensional approach to moral conflict, and the need for resolution that also entails motivated growth opportunities.

Finally, in an epilogue, the book addresses the extension of moral injury as a lens through which to view several historical and contemporary macro-societal, cultural, and collective moral transgressions and their impacts.

The authors acknowledge the seminal works of early investigators in this field and hope that the book will serve as a valuable resource for clinicians, researchers, and anyone seeking to understand the complex nature of moral injury.

Chapter 1:

Defining Moral Injury: Origins, Evolution, and Illustrations

The initial full chapter begins by discussing the origins of the term “moral injury,” which was first introduced by psychiatrist Jonathan Shay in the context of war and combat. Shay used the term to describe the psychological, emotional, and spiritual harm that can result from participating in, witnessing, or failing to prevent acts that violate one’s deeply held moral beliefs and expectations.

The chapter then explores earlier concepts related to moral injury, such as “moral distress,” “moral pain,” “moral wounds,” and “soul wound,” which were used in different contexts to describe similar experiences. However, Shay’s work provided a more specific and well-defined framework for understanding moral injury in the context of war and military service.

The chapter presents several definitions of moral injury in different contexts, including military, healthcare, first responder, organizational, and personal settings. These definitions highlight the common theme of psychological distress resulting from actions or inactions that transgress an individual’s moral beliefs.

To illustrate the concept of moral injury, the chapter provides a detailed military case illustration based on the experiences of General Roméo Dallaire, the force commander of the United Nations Assistance Mission for Rwanda (UNAMIR) during the Rwandan genocide. The case highlights the moral dilemmas faced by Dallaire and his peacekeeping forces, such as the limitations of their rules of engagement, the need to prioritize limited resources, witnessing atrocities, collaborating with perpetrators, and abandoning civilians. The cumulative impact of these moral dilemmas led many UNAMIR soldiers, including Dallaire, to experience moral injury.

The chapter then analyzes the case illustration using Jonathan Haidt’s moral foundations theory, identifying the relevant moral foundations, such as Care/Harm, Fairness/Cheating, Sanctity/Degradation, and Authority/Subversion. The case demonstrates the mixture of PTSD and moral injury resulting from the violation of these moral foundations.

The chapter concludes by emphasizing the need for better definition and research on moral injury, as well as collaboration across specialties to advance assessment, interventions, education, and prevention efforts. It also raises the question of how clinicians should proceed with treating moral injury in the absence of the highest level of evidence-based practice, setting the stage for a discussion of evidence-based treatments and the application of the moral foundations framework in both military and non-military settings.

Chapter 2:

The Spectrum of Moral Injury: From Conflict to Outrage

This chapter explores the landscape of moral injury, providing examples of how it manifests in various contexts, such as military personnel, healthcare professionals, law enforcement officers, whistleblowers, corporate employees, academics, and individuals grappling with the climate crisis. The chapter also introduces the concept of solastalgia, which describes the distress experienced due to negative environmental changes in one’s surroundings, and draws parallels between this concept and moral injury.

The chapter then discusses the assessment of moral injury, distinguishing between objective features (external circumstances or events) and subjective features (internal psychological and emotional experiences). It highlights the importance of understanding the individual’s context, beliefs, identity, and values when assessing the difference between these features.

The chapter also explores the relationship between moral injury and moral narcissism, authoritarian parenting styles, authoritative parenting styles, and the influence of religious training. It notes that while authoritarian parenting may contribute to the development of moral injury, authoritative parenting is generally associated with positive moral development and a reduced likelihood of moral injury. The impact of organized religion on moral injury can be both positive and negative, depending on the specific religious context and individual experiences.

The chapter clarifies the distinction between moral foundations (underlying principles or values that guide moral judgments) and firmly held beliefs (specific convictions or values that individuals hold deeply). It also discusses the relationship between sociopathic personality and moral foundations, noting that sociopaths may experience moral conflict, tension, and distress differently compared to individuals with a solid moral compass.

The chapter then examines the impact of neuroticism on moral injury, highlighting how neurotic individuals may be more sensitive to moral transgressions, experience excessive guilt and self-blame, and engage in rumination and overthinking. Finally, the chapter identifies childhood adversity as a factor that may increase the likelihood of developing moral injury.

The chapter concludes by proposing a continuum of moral experiences, ranging from “moral conflict (or dilemma),” “moral tension,” “moral distress,” “moral injury,” to “moral outrage,” emphasizing the importance of a dimensional approach to conceptualizing preventive and therapeutic interventions for moral injury.

Chapter 3:

Moral Development Frameworks: Setting the Stage for Understanding Moral Injury

This chapter explores various moral development frameworks to set the stage for understanding moral injury. It begins by discussing the importance of understanding the concepts of “right and wrong” and the moral foundations on which these concepts rest. The chapter then delves into several seminal works on moral development, providing an overview and critique of each theory.

  1. Kohlberg’s Stages of Moral Development: Kohlberg proposed a stage theory of moral development based on the idea of justice. The chapter critiques Kohlberg’s theory for its emphasis on justice to the exclusion of other moral values, its assumption of a linear progression, and its potential cultural and gender bias.

  2. Piaget’s Theory: Piaget’s theory focuses on the cognitive aspect of moral development and the understanding of justice. While influential, the theory has limitations in capturing the emotional and intuitive aspects of moral judgments and may not directly translate to complex moral scenarios encountered in adulthood.

  3. Gilligan’s Ethics of Care: Gilligan’s framework emphasizes the importance of caring relationships and responding to others’ needs. The chapter critiques Gilligan’s theory for potentially perpetuating gender essentialism, lacking clear guidance for impersonal relationships, and needing more empirical grounding.

  4. Turiel’s Social Domain Theory: Turiel proposed that individuals differentiate moral rules from social conventions. The chapter critiques the theory for its Western bias, underestimating the impact of authority and power structures, and downplaying the role of emotions and intuition in moral judgment.

  5. Litz et al.’s Moral Injury Model: This model focuses on the psychological damage that arises when a person perpetrates, fails to prevent, or witnesses acts that transgress deeply held moral beliefs. While influential, the theory has been critiqued for its overlap with PTSD and the need for more empirical data on effective treatments.

  6. Haidt’s Moral Foundations Theory: Haidt proposes that human morality is based on six innate, modular foundations: care/harm, fairness/cheating, loyalty/betrayal, authority/subversion, sanctity/degradation, and liberty/oppression. The chapter acknowledges critiques of Haidt’s theory, including its limited cross-cultural applicability, neglect of socio-cultural factors, and potential conservative bias.

The chapter concludes by arguing that while each moral framework offers valuable insights, Haidt’s moral foundations theory has several strengths for understanding moral injury. It recognizes a broad range of moral values, does not assume a particular developmental sequence or gender bias, and is designed to be applicable across different cultures. The chapter sets the stage for a more detailed discussion of Haidt’s moral foundations framework in the next chapter.

Chapter 4:

Haidt's Moral Foundations Theory: A Lens for Understanding Moral Injury

In Chapter 4, the authors discuss Jonathan Haidt’s moral foundations theory and its relevance to understanding moral injury. Haidt’s theory posits six moral foundations that guide human moral reasoning and behavior: (1) care/harm, (2) fairness/cheating, (3) loyalty/betrayal, (4) authority/subversion, (5) sanctity/degradation, and (6) liberty/oppression.

The chapter explains how these moral foundations are acquired developmentally through a combination of innate tendencies, direct experiences, social support, and cultural contexts. Children learn to recognize and respond to violations of these moral foundations, which become both observational and prescriptive. Complexities arise when individuals are prevented from doing the “right thing” or are forced to engage in morally questionable behavior by those in authority, leading to self-recrimination, guilt, shame, and anger.

The chapter then illustrates the evolution of such patterns concerning each of the six foundations and their relationship to moral injury:

  1. Care/Harm Foundation: Violations of this foundation, such as witnessing or participating in acts that cause harm to others, can lead to guilt, shame, and a loss of trust in oneself and others.

  2. Fairness/Cheating Foundation: When individuals witness or are involved in unfairness, dishonesty, or exploitation, it can lead to a sense of moral betrayal, injustice, and erosion of trust in institutions, friends, colleagues, or even themselves.

  3. Loyalty/Betrayal Foundation: Witnessing or experiencing acts of betrayal, disloyalty, or abandonment can profoundly impact individuals’ sense of identity and belonging, leading to feelings of isolation, anger, and a loss of trust in others.

  4. Authority/Subversion Foundation: Engaging in acts that challenge or subvert authority can create a moral conflict within individuals, leading to feelings of guilt, shame, and a loss of moral identity.

  5. Sanctity/Degradation Foundation: Witnessing or participating in actions that desecrate or degrade what is considered sacred can profoundly impact individuals’ sense of moral purity and integrity, contributing to moral injury.

  6. Liberty/Oppression Foundation: This foundation, related to the authority/subversion foundation, emphasizes the moral right to freedom, autonomy, and self-rule, with oppression suppressing this moral right.

The chapter concludes by highlighting the complex interplay between ethical values, beliefs, and experiences that can lead to moral transgressions. Violations of these foundations can contribute to moral conflict, tension, distress, injury, and outrage as individuals grapple with the conflict between their deeply held values and the realities of their experiences. Understanding the relationship between moral injury and the six moral foundations can provide insights into the psychological and emotional impact of moral transgressions and inform the development of interventions and support systems that promote healing, resilience, and the restoration of moral well-being.

Chapter 5:

Assessing and Treating Moral Injury: Current Status and Future Directions

Chapter 5 provides an overview of the current status of moral injury measures and treatments, discussing key issues and future directions in this emerging field. The chapter begins by introducing moral injury as a distinct psychological phenomenon resulting from exposure to potentially morally injurious events (PMIEs) that transgress deeply held moral beliefs and expectations. Despite growing recognition of moral injury, significant challenges remain in its conceptualization, operationalization, assessment, and treatment.

The chapter then describes several commonly used moral injury assessment tools, including the Moral Injury Events Scale (MIES), Moral Injury Symptom Scale (MISS), Moral Injury Questionnaire (MIQ), and their variants for military and healthcare populations. The Moral Injury Outcome Scale (MIOS) is highlighted as a promising recent addition. The authors emphasize the need for further psychometric evaluation, cultural adaptations, and refinement of these measures based on evolving conceptualizations of moral injury.

Next, the chapter reviews the evidence base for existing moral injury interventions using the evidence-based practice (EBP) framework. Few interventions have been subjected to rigorous empirical tests such as randomized controlled trials (RCTs), with most treatments drawing upon clinical expertise and extrapolation from trauma and PTSD therapies. Promising approaches with preliminary supportive evidence include Adaptive Disclosure (AD), Impact of Killing (IOK) workshops, Moral Injury Group Psychotherapy, and Moral Injury Appraisal Focused Treatment (MIAPT). However, well-powered RCTs with active control conditions, long-term follow-up, and tests of mechanisms and moderators are needed to establish their efficacy.

The chapter then discusses clinical considerations and future directions for treating moral injury. Key steps include assessing the quality and relevance of available evidence, evaluating treatments’ feasibility and acceptability, incorporating clinical expertise, monitoring outcomes, engaging in shared decision-making with patients, and staying current with emerging research. The authors outline a robust research agenda for advancing the field, including refining conceptual frameworks, developing and validating measures, conducting controlled studies of interventions, examining individual differences in treatment response, leveraging technology for treatment delivery, establishing cross-disciplinary collaborations, and disseminating research findings into clinical practice.

The chapter concludes by emphasizing the importance and complexity of moral injury as a clinical phenomenon, particularly among military personnel and veterans. While scientific understanding has progressed, much work remains to establish a firm evidence base for assessment and treatment. The authors call for prioritizing high-quality research across populations and settings, collaborations among stakeholders, and the refinement and dissemination of evidence-based approaches to lessen the burden of moral injury and support recovery among affected individuals and communities. 

Chapter 6:

Integrating Moral Foundations Theory into Clinical Practice: A Framework for Addressing Moral Injury

In Chapter 6 the authors discuss the utilization of Moral Foundations Theory in the context of moral injury, providing a framework for understanding the underlying moral conflicts that may contribute to moral injury and guiding clinicians in assessment and treatment.

The chapter begins by presenting a recent provisional definition of moral injury as a syndrome characterized by four core symptom clusters: self-invalidation, social problems, trust impairment, and spiritual/existential problems. These symptom clusters are proposed to result from exposure to potentially morally injurious events (PMIEs), which transgress deeply held moral beliefs and expectations.

The chapter then outlines a four-step approach to addressing moral injury:

  1. Screening tools: Systematic reviews have identified population-specific and generic screening tools to assist in identifying morally conflictual situations and contexts that could evoke moral distress or moral injury.

  2. Symptom scales: Systematic reviews have also pointed towards the development of symptom scales, such as the Moral Injury Outcome Scale, among others, to assist in treatment outcome evaluation and quantitatively describe the effects of treatment interventions.

  3. Treatment interventions: The status of available treatment interventions is reviewed using Evidence-Based Treatment guidelines, revealing the standing of each approach and its corresponding level of evidence rating.

  4. Moral Foundations Theory: The authors argue for the need to frame morally injurious events against the backdrop of Haidt’s Moral Foundations Theory, which identifies six universal and cross-cultural moral foundations that underpin moral intuitions.

The chapter then explains how Haidt’s moral foundations can be valuable in clinical work with moral injury, and these include:

  1. Identifying the precipitating moral conflict: Clinicians can explore which moral foundations (care/harm, fairness/cheating, loyalty/betrayal, authority/subversion, sanctity/degradation, and liberty/oppression) were most at stake in the events leading to moral injury.

  2. Assessing moral injury symptoms: Moral injury symptoms may be tied to specific violated moral foundations, and clinicians could assess the relative salience of different foundations to predict which symptoms may be most severe or persistent.

  3. Tailoring evidence-based treatments: Different therapeutic approaches may be more effective depending on the moral foundations most impacted. For example, Compassion-Focused Therapy for violations of the care/harm foundation, or group therapies for injuries related to the loyalty/betrayal foundation.

The chapter concludes by summarizing how Haidt’s moral foundations theory provides a conceptual framework for understanding the diverse ways moral conflicts can lead to moral injury. By systematically assessing the most salient foundations for an individual, along with advances in conflict identification/screening and symptom measures, clinicians can develop a clearer picture of the factors, symptoms, and most promising treatment approaches. This foundation-focused assessment has the potential to lead to more targeted, individualized, and effective interventions, even as the field progresses and acknowledges the provisional nature of work and findings.

Chapter 7:

Moral Injury Across Contexts: Case Illustrations and Interventions

Chapter 7 explores moral injury across various contexts, drawing upon case illustrations and research findings to illuminate the unique challenges and themes that emerge in each setting. The chapter presents a comprehensive and interdisciplinary examination of moral injury, aiming to deepen our understanding of this complex phenomenon and provide guidance for those seeking to support affected individuals and communities.

The chapter begins by introducing moral injury as a concept that refers to the lasting psychological, spiritual, and social harm caused by perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations. It highlights the relevance of moral injury across diverse contexts, including military, healthcare, law enforcement, education, and corporate environments.

The chapter then introduces Jonathan Haidt’s Moral Foundations Theory framework, which posits six innate moral foundations that guide human moral reasoning, intuitions, and behavior. This theory is used as a lens to understand why certain experiences are particularly morally distressing or injurious for individuals.

The chapter is divided into several sections, each focusing on moral injury in a specific context:

  1. Corporate and manufacturing sectors: This section explores issues such as ethical decision-making, whistleblowing, and workplace safety, and recommends interventions such as Acceptance and Commitment Therapy (ACT), and Spiritually Integrated Cognitive Therapy, several group therapies.

  2. Military context: This section examines the impact of combat exposure, killing in war, and the betrayal of deeply held values and suggests interventions such as Adaptive Disclosure – Enhanced therapy, Impact of Killing workshops, Moral Injury Appraisal Focused Treatment (MIAPT), and spiritually integrated cognitive processing therapy.

  3. Healthcare and law enforcement: This section focuses on the moral challenges posed by the COVID-19 pandemic and recommends interventions such as values-affirmation exercises, Dignity Therapy, and Cognitive Processing Therapy (CPT).

  4. Education and academia: This section highlights issues such as academic integrity, student well-being, and the erosion of trust in educational institutions and suggests interventions such as individual therapy, peer support groups, and mindfulness-based interventions.

  5. Moral dilemmas, tension, distress, and injury: This section clarifies the distinctions between these related concepts and discusses the importance of preventive interventions.

  6. Religious and spiritual contexts: This section explores moral injury through the lens of various religious and spiritual traditions, drawing upon scriptural narratives and teachings to illuminate the role of faith in understanding and healing from moral wounds.

The chapter concludes by summarizing the essential findings and themes from the preceding sections and offering recommendations for clinicians and future directions for research and practice in the field of moral injury. It emphasizes the need for a context-sensitive approach, evidence-based interventions, collaboration with community resources, and ongoing education and training for clinicians. The chapter also highlights the importance of future research focusing on developing context-specific measures, conducting longitudinal studies, investigating novel interventions, exploring moral injury in diverse populations, and fostering interdisciplinary collaboration.

Chapter 8:

Clinical Decision-Making in the Face of Limited Evidence: A Military Case Study

Chapter 8 discusses moral injury and clinical decision-making in the context of a military case illustration involving the Rwandan Peacekeeping force and Commander Dallaire’s report of his team’s experiences. The case illustrates how being unable to prevent harm can be morally troubling for service members, even when following protocol. The chapter explores the moral foundations proposed by Jonathan Haidt that were relevant in this case, including Care/Harm, Fairness/Cheating, Authority/Subversion, and Sanctity/Degradation.

The chapter then discusses the challenges faced by practicing clinicians when responding to the question of evidence-based interventions for treating moral injury. It explains the concept of Evidence-Based Practice (EBP) and the levels of evidence considered in this framework, from strongest to weakest: Randomized Controlled Trials (RCTs), Systematic Reviews and Meta-Analyses, Observational Studies, Qualitative Research, Clinical Expertise, and Patient Values and Preferences.

The chapter contrasts EBP with the Practice Guidelines used by the VA/DOD, which rely on Empirically Supported Therapies (EST). It notes that moral injury is not yet among the listed targeted conditions for treatment in the VA/DOD Clinical Practice Guidelines.

The chapter then provides examples of case series and uncontrolled trials that have explored the effectiveness of various interventions for moral injury, such as Cognitive Processing Therapy (CPT), Resilience Strength Training, Moral Injury Group Psychotherapy, Adaptive Disclosure Therapy, Moral Resilience Training, and Moral Injury Group Psychotherapy. It emphasizes that while these studies provide valuable insights and preliminary evidence, further research using more robust study designs, such as replicated randomized controlled trials, is needed to establish the efficacy of interventions for moral injury.

The chapter concludes by outlining steps that clinicians can take when faced with a newly emerging clinical problem like moral injury, for which no RCTs or systematic reviews are available. These steps include evaluating the quality of available evidence, considering treatment feasibility and safety, consulting expert opinions, monitoring and documenting outcomes, engaging in shared decision-making with the patient, and staying updated on emerging research.

Chapter 9:

The Societal Impact of Unresolved and Resolved Moral Injury

Chapter 9 reviews various contemporary sources that discuss the societal impact of unresolved and resolved moral injury. The main points covered are:

  1. Moral distress and injury affect not only individuals but also the broader society, leading to subpar occupational performance, institutional distrust, and societal outrage.

  2. Negative societal impacts of unresolved moral injury include strained relationships, healthcare staffing shortages, erosion of social cohesion, intergenerational trauma, abuse of power, and health disparities.

  3. Positive societal impacts of preventing and healing moral injury include restored civic pride, expanded capacity for empathy, social justice advocacy, intergroup reconciliation, institutional integrity, and trust in healthcare and educational systems.

  4. Summaries of key sources include analyses of Canada’s Truth and Reconciliation Commission on Indian Residential Schools, the mental health consequences of racism and discrimination among veterans, the intergenerational impacts of clergy-perpetrated sexual abuse, and a race-informed therapeutic approach to racial trauma recovery.

  5. The chapter also discusses the potential risks of cognitive behavioral therapy (CBT) in invalidating real trauma experiences and suggests mitigation strategies to adapt CBT for addressing moral injuries related to racism, abuse, and historical injustices.

Overall, Chapter 9 emphasizes the far-reaching societal consequences of moral injury and the importance of addressing these issues through various means, including truth-telling, reconciliation, culturally informed interventions, and therapeutic approaches that validate victims’ experiences.

Chapter 10:

Cultural Moral Injury: Collective Trauma and the Path to Healing

Chapter 10 explores the concept of cultural moral injury, its consequences, and the process of healing. The main points covered in the chapter are as follows:

  1. Cultural moral injury refers to the collective psychological harm experienced by a culture, society, or group due to actions or events associated with its history. Examples include Germany post-World War II, the United States and slavery/racial discrimination, Australia and Canada’s treatment of Indigenous peoples, and Japan’s conduct during World War II.

  2. Cultural Moral injury can lead to learned helplessness, where individuals feel powerless and unable to change their circumstances. This can manifest differently depending on which of Haidt’s moral foundations (care, fairness, loyalty, authority, sanctity, and liberty) has been violated.

  3. The negative societal impacts of collective helplessness include erosion of community bonds, increased social isolation, decline in civic engagement, mental health crises, social unrest, marginalization, economic decline, cultural pessimism, diminished human potential, and stagnation of progress.

  4. Successful redress of collective moral injury can lead to positive outcomes such as healing, empowerment, social cohesion, justice, preventive measures, cultural shifts, resilience, international support, improved mental health, and positive role modeling.

  5. Rehabilitation programs for the collectively morally injured must be carefully composed, acknowledging suffering, promoting autonomy, conveying empathy, inspiring hope, building community, and offering resources.

  6. The tipping point at which the collectively morally injured might abandon rehabilitation in favor of revolutionary action often occurs due to perceived inefficacy of rehabilitation, lack of authentic representation, heightened awareness of injustices, escalation of suffering, solidarity and organization, external catalysts, diminished fear of repercussions, and lack of alternative solutions.

  7. Historical examples of resistance to change after collective moral injury include post-Civil War Reconstruction in the United States, de-Nazification in post-WWII Germany, South Africa’s Truth and Reconciliation Commission, and land reform and redistribution efforts.

  8. Successful systemic interventions that have precluded the collapse or decay of societies include the New Deal in the United States, Scandinavian social democracy, the Marshall Plan post-World War II, Singapore’s public housing and anti-corruption policies, Rwanda’s post-genocide reconciliation, and Chile’s economic reforms in the 1980s.

  9. Animal models of learned helplessness provide insights into the behavioral conditions that can lead to a sense of powerlessness, and principles drawn from this research can help reestablish the ability to respond after learned helplessness has occurred.

  10. In revolutionary scenarios, established regimes and revolutionaries often emphasize different sets of moral foundations, with their respective moral values appearing to be violated from each other’s perspective. Examples include the American Revolution, the Chinese Revolution leading to Taiwan, the Arab Spring, South African Apartheid, United States Civil Rights, Women’s Suffrage, and the “One Percent Movement” (Occupy Wall Street).

The chapter concludes by suggesting that infusing Haidt’s moral foundations theory into the discourse on moral injury at the cultural level can help bring greater clarity and open the path towards seeking common understanding and ground in bringing about constructive change. The Epilogue will illustrate how such common ground fostered positive cultural change through the activities of Dr. Martin Luther King Jr., Joan of Arc, Trung Sisters, Mahatma Gandhi, Malala Yousafzai, and Martin Luther.

Chapter 11:

Conundrums in Continuing Moral Injury Work

This chapter discusses the many unanswered questions and challenges facing the field of moral injury research and treatment. The main points covered in the chapter are as follows:

  1. The concept of moral injury, as introduced by Jonathan Shay, refers to the psychological, emotional, and spiritual harm resulting from participating in, witnessing, or failing to prevent acts that violate one’s deeply held moral beliefs and expectations.

  2. While moral injury shares similarities with concepts like “moral distress,” “moral pain,” and “soul wound,” Shay’s work provided a more specific framework for understanding the impact of moral transgressions in the context of war and military service.

  3. The field of moral injury faces several challenges, including:
    1. Lack of consensus on a clear definition and the boundaries of moral injury.
    2. Difficulties in accurately measuring moral injury and differentiating it from PTSD symptoms.
    3. Ethical concerns in researching sensitive topics related to moral injury.
    4. Developing treatments before solid construct development and validation.
    5. Limited empirical support for current treatments.
    6. The need for individualized interventions based on personal experiences and cultural contexts.

  4. Distinguishing moral violation from human fallibility is crucial in defining moral injury, and the most heuristic models of moral development in relation to moral injury need to be identified.

  5. Moral injury is distinct from simply getting one’s feelings hurt, as it involves a violation of one’s core moral values and can cause lasting inner conflict and emotional suffering.

  6. The goal of realigning victims with their initial moral values or foundations in moral injury treatment may be problematic, as it can reinforce harmful biases, miss opportunities for growth, invalidate moral insights, and impose dominant cultural values.

  7. To mitigate these risks, moral injury interventions should incorporate:
    1. Explicit examination and questioning of moral assumptions.
    2. Exploration of alternative moral frameworks.
    3. Critical examination of dominant cultural assumptions.
    4. Reframing moral injury as a potential catalyst for growth.
    5. Allowing space for moral complexity and uncertainty.

  8. Cultural humility and self-reflection are crucial in moral injury work, as interveners must examine their own moral assumptions and biases and approach individuals from diverse moral backgrounds with curiosity, openness, and respect.

The chapter concludes by emphasizing the need for greater integration of moral philosophy and cultural awareness into intervention frameworks for moral injury, highlighting the importance of making moral assumptions explicit and subjecting them to respectful questioning and debate to facilitate healing and growth.

Chapter 12:

Considerations for New Treatment Development for Moral Injury

This chapter explores new approaches to developing treatments for moral injury, focusing on integrating the Intervention Optimization Approach and Moral Foundations Theory (MFT). The main points covered in the chapter are as follows:

  1. Moral injury results from events that violate an individual’s deeply held moral beliefs or ethical codes. Current treatments lack consensus and have not undergone rigorous component analyses.

  2. The classical treatment package approach has limitations, including: a. Evaluating interventions as indivisible packages. b. Failing to identify effective individual components. c. Difficulty in adapting to different contexts or populations. d. Contributing less to cumulative science of behavior change.

  3. The Intervention Optimization Approach, exemplified by the Multiphase Optimization Strategy (MOST), offers advantages: a. Prioritizes empirical testing of individual components and their interactions. b. Uses efficient experimentation to identify active ingredients. c. Tests component interactions. d. Focuses on mechanisms of change.

  4. Moral Foundations Theory (MFT) proposes innate, universal moral intuitions guiding behavior. Its relevance to moral injury includes: a. Providing a framework for understanding morally injurious events. b. Informing assessment and diagnosis. c. Guiding development of targeted intervention components.

  5. Integrating MFT and the Intervention Optimization Approach involves: a. Preparation Phase: Developing conceptual models, identifying components, adapting measures. b. Optimization Phase: Conducting factorial experiments, using MFT-based criteria, testing adaptive strategies. c. Evaluation Phase: Comparing optimized interventions in RCTs, assessing MFT-related outcomes.

  6. Challenges and future directions in this field include: a. Validating MFT constructs in clinical populations. b. Designing MFT-targeted intervention components. c. Optimizing interventions with complex designs and analyses. d. Evaluating interventions in real-world settings. e. Ensuring long-term sustainability and scalability.

  7. The integration of MFT and the Intervention Optimization Approach offers a promising framework for developing more targeted, efficient, and scalable moral injury treatments.

  8. Realizing the potential of this approach will require significant research and development efforts, including further validation of MFT constructs and measures in clinical populations.

The chapter concludes by emphasizing the potential of this integrative approach to advance the field of moral injury treatment and improve the lives of those affected by moral injury. It calls for a collaborative, empirical, and innovative approach to treatment development that promotes healing, resilience, and posttraumatic growth in the face of moral adversity.

Chapter 13:

Synthesis and Future Directions: Advancing the Understanding and Treatment of Moral Injury

Chapter 13 is the concluding chapter that synthesizes the key insights and findings from the preceding chapters of a book on moral injury. The main points covered are as follows:

  1. The chapter revisits the definition of moral injury as the profound emotional and psychological pain experienced when one’s actions or witnessed actions deeply violate one’s moral or ethical code.

  2. It traces the historical roots of moral injury, originating from the observations of Jonathan Shay and the experiences of Vietnam War veterans, and explores how the concept has evolved and gained relevance beyond the military context.

  3. The chapter delves into specific domains where moral injury manifests, including the military, healthcare, higher education, academia, and law enforcement, highlighting the importance of context in understanding and addressing moral injury.

  4. It integrates Jonathan Haidt’s moral foundations theory as a basis for understanding the concept of “injury” in the moral injury landscape, allowing for a more nuanced understanding of the psychological processes involved.

  5. The role of psychological pre-moral injury status and parenting style as formative forces leading to or serving as risk factors for moral injury is explored, emphasizing the importance of individual differences in moral development and vulnerability to moral injury.

  6. The chapter summarizes the role of faith as both a formative force in the development of morals, a setting event for the development of moral injury, and a mechanism for healing, highlighting the complex interplay between faith, moral values, and psychological well-being.

  7. Evidence-based psychological interventions for moral injury are reviewed, drawing on selective case illustrations to demonstrate the clinical decision-making process regarding treatment selection and emphasizing the importance of tailoring interventions to individual needs and preferences.

  8. The chapter critically evaluates the degree and level of construct validation research on moral injury and critiques the existing treatment outcome research, acknowledging the limitations and the need for further empirical investigation.

  9. A broad summary of existing treatment models for moral injury is provided, using an evidence-based framework for analysis, including the Adaptive Disclosure Model, the Trauma Resiliency Model, and the Integrative Trauma Recovery Model.

The chapter reminds the reader of the broader societal effects of moral injury and the institutional responses necessary to prevent and mitigate its impacts, advocating for systemic changes and strategies to address the societal implications of moral injury.

  1. Finally, the chapter highlights the remaining conundrums in the field of moral injury, emphasizing the need for further work on sharpening the construct, addressing construct reification, considering the dimensional nature of moral conflicts, examining the role of Adverse Childhood Experiences and Authoritarian Parenting Style as risk factors, and being aware of moral narcissism among professionals.

The chapter concludes by reiterating the importance of a comprehensive understanding of moral injury, its relevance in various domains, and the need for evidence-based interventions in clinical practice. It emphasizes the role of clinicians in contributing to the ongoing development of the field and in preventing and mitigating the impact of moral injury on individuals and society.

Epilogue: Beyond the Clinical Consultation Room: Institutional and Cultural Moral Injury and Responsive Interventions

The Epilogue explores the concept of cultural moral injury, its consequences, and potential interventions beyond the clinical consultation room. The main points covered in the epilogue are as follows:

  1. Cultural moral injury refers to the collective psychological harm experienced by a culture, society, or group due to actions or events associated with its history. Examples include Germany post-World War II, the United States and slavery/racial discrimination, Australia and Canada’s treatment of Indigenous peoples, and Japan’s conduct during World War II.

  2. Martin Luther King Jr.’s approach to addressing racism and discrimination aligns with addressing moral injury by seeking justice, equality, and dignity for those affected. His advocacy aimed to confront and transform systemic injustices that have historically led to moral injuries among marginalized communities.

  3. King’s appeal to religious concepts and doctrines played a role in leveraging the transformative power of moral conflict and ethical transformation among both perpetrators and observers of racism, facilitating the internalization of moral conflict and galvanizing broader anti-racism activism.

  4. Moral conflict, particularly in the context of addressing societal issues such as racism, should be constructively guided and shaped toward motivated growth, personal healing, and positive societal evolution rather than being pathologized or treated solely as an individual psychological condition.

  5. The emphasis on symptom reduction and improved daily functioning in moral injury literature may overlook the opportunity for individuals to engage in a meaningful reconstruction of their moral framework and values, which is crucial for addressing the underlying sources of distress and potential risk factors within existing moral frameworks.

  6. Introducing “self-compassion” as a principal or sole component of intervention for morally injured individuals could preserve defective moral frameworks and judgments in the limited service of “feeling better,” neglecting the deeper ethical reflection and moral reconceptualization needed to address the root causes of moral injury.

  7. The “just world hypothesis” moral framework and breached social justice frameworks illustrate the limitations of standard Counseling and CBT in addressing moral injury, highlighting the need for a more comprehensive and adaptive therapeutic approach that integrates critical ethical reflection, moral reconceptualization, and adaptive moral development.

  8. An innovative alternative approach to addressing moral injury could integrate elements of narrative exposure therapy, contextual listening, relational healing, community engagement, ethical reflection, moral reconstruction, intersectional and contextual frameworks, and collaborative and transformative advocacy.

  9. Individuals who rigidly adhere to a fixed moral framework and exhibit closedness to alternative moral realities may be more susceptible to moral injury, while those who demonstrate openness to diverse moral perspectives, engage in ethical growth, and embrace ethical pluralism are better positioned to navigate moral challenges with greater resilience and adaptability.

This chapter concludes by emphasizing the need for a constructive paradigm shift towards more adaptive, culturally sensitive, and empowering approaches that promote ethical well-being and address the complexity of moral injury in a meaningful and comprehensive manner. The proposed model, based on expert opinion, is presented as a starting point for further research and development in the field of moral injury intervention.

Appendix A

This Appendix provides an annotated bibliography of books and reports related to the atrocities committed during the breakup of the former Yugoslavia in the 1990s, particularly focusing on the systematic use of rape and sexual violence as weapons of war and ethnic cleansing. The works summarized include:

  1. “Rape Warfare: The Hidden Genocide in Bosnia-Herzegovina and Croatia” by Beverly Allen (1996), which examines the use of rape as a deliberate tool of genocide, primarily by Serb forces against Bosniak and Croatian women.

  2. “Sexual Violence: An Invisible Weapon of War in the Former Yugoslavia” by M. Cherif Bassiouni and Marcia McCormick (1996), a report documenting various forms of sexual violence and their consequences, arguing that these acts were part of a campaign of “ethnic cleansing” and genocide.

  3. “Genocide in Bosnia: The Policy of ‘Ethnic Cleansing'” by Norman Cigar (1995), which contends that the atrocities committed by Serb forces were the result of a deliberate policy of genocide aimed at creating an ethnically homogeneous Greater Serbia.

  4. “Sarajevo: A Biography” by Robert J. Donia (2006), a comprehensive history of Sarajevo, with a central focus on the city’s siege during the Bosnian War and its impact on the city’s multi-ethnic and multi-religious heritage.

  5. “Endgame: The Betrayal and Fall of Srebrenica, Europe’s Worst Massacre Since World War II” by David Rohde (2012), providing a detailed account of the events leading to the Srebrenica massacre and the failure of the international community to prevent it.
  6. “A Witness to Genocide: The 1993 Pulitzer Prize-Winning Dispatches on the ‘Ethnic Cleansing’ of Bosnia” by Roy Gutman (1993), a collection of news dispatches exposing the systematic campaign of ethnic cleansing carried out by Serb forces.

  7. “‘A Problem from Hell’: America and the Age of Genocide” by Samantha Power (2013), examining the United States’ response to genocide in the 20th century, including the ethnic cleansing in Bosnia and Kosovo.

  8. “Mass Rape: The War Against Women in Bosnia-Herzegovina” by Alexandra Stiglmayer (1994) presents a comprehensive account of the systematic use of rape as a weapon of war and ethnic cleansing during the Bosnian War.

  9. “When History is a Nightmare: Lives and Memories of Ethnic Cleansing in Bosnia-Herzegovina” by Stevan M. Weine (1999) explores the long-term psychological, social, and cultural consequences of the war through the experiences and memories of Bosnian refugees.

These works collectively provide insight into the atrocities committed during the Yugoslav Wars and the challenges faced by Australian Torture Treatment Therapists working with immigrants from the former Yugoslavia who had experienced or witnessed these events, leading to significant moral injury on a grand scale.

Appendix B

This appendix provides a brief description of novels that illustrate the theme of moral injury. The list includes ten novels from various authors and time periods, each exploring the psychological struggle resulting from actions that go against one’s moral beliefs. These novels tackle various aspects of moral injury, such as guilt, redemption, betrayal, the psychological effects of war, moral responsibility towards the environment, moral corruption, and the impact of one’s actions on their conscience. The list provides a diverse set of perspectives on the struggles individuals face when dealing with moral beliefs and the consequences of their actions. The novels include:

  1. “Crime and Punishment” by Fyodor Dostoevsky
  2. “The Road” by Cormac McCarthy
  3. “Atonement” by Ian McEwan
  4. “The Kite Runner” by Khaled Hosseini
  5. “Regeneration” by Pat Barker
  6. “Silent Spring” by Rachel Carson (non-fiction)
  7. “All Quiet on the Western Front” by Erich Maria Remarque
  8. “Lord Jim” by Joseph Conrad
  9. “The Picture of Dorian Gray” by Oscar Wilde
  10. “The Man Within” by Graham Greene

References:

The authors provide an extensive set of references to sources cited in the text throughout the book for those who wish to review original sources relied upon.