February 28, 2018
Treating Moral and Spiritual Injuries Among Military Combatants (September 16, 2015)
(Editor’s Note: This article was first published September 16, 2015).
Treating Moral and Spiritual Injuries among Military Combatants:
An argument for a synergistic treatment plan for moral and spiritual injuries.
This article argues for a synergistic treatment plan for those who have sustained Post Traumatic Stress Disorder (PTSD) inconjunction with moral and spiritual injuries. This argument is based on the etiological comparisons between PTSD and moral and spiritual injuries. Moral injuries compared to PTSD without moral injuries affect a different part of the brain. While moral and even spiritual injuries appear to contribute to PTSD, moral injuries affect the brain differently compared to those with PTSD without a moral injury. Furthermore, while moral injuries relate to ethics and morality, they also have a symbiotic relationship with spiritual injuries. Healing for both the moral and spiritual injuries must involve a restoration of meaning and purpose. This will enable one to better adjudicate the ethical/moral violations. Additionally, spiritual healing includes forgiveness. The restoration of meaning, purpose and forgiveness in turn can provide a more efficacious healing for those with PTSD.
Trauma, a common causative factor among military personnel who experience combat, affects a person in a variety of ways (Litz et al., 2009; Drescher & Foy, 1995; & Breslau, 2009). A military person may have sustained an injury that affected the physical integrity of his or her body. Yet, sustaining a physical injury is only one dimension of the affect trauma has on an individual. Beyond the physical, one may experience ethical violations which can result in moral and even spiritual injuries. Thus, one may respond to an overwhelming traumatic event psychologically (American Psychiatric Association, 2013), morally (Litz et al., 2009) and spiritually (Drescher & Foy, 1995).
The component of ethics provides a value element to the energy behind psychological injuries (Peters & Whittaker-Johns, 2012; Hare, 1981; & Baier, 1958). One’s sense of justice, fairness, doing good (i.e. beneficence) and doing no harm (i.e. non-maleficence) must be adjudicated in such a way that one can bring back a sense of accepted control (autonomy) (Beauchamp & Childress, 2008). In turn this brings about a new sense of meaning, purpose and self-acceptance as well as bringing about moral healing (Hughes & Handzo, 2009). Closely aligned with ethics is morality and spirituality. Morality addresses a moral code out of which ethics finds its basis. Spirituality addresses meaning and purpose that goes beyond the moral code by including the concept of restored meaning and purpose through forgiveness (Hughes & Handzo, 2009).
When a moral code is violated, moral injuries occur (Litz et al., 2009). Service members can sustain a moral injury when they believe they have transgressed deeply held beliefs that undergird their sense of being human. They can experience such feelings as shame, guilt, brokenness, and even the need for punishment to one’s self (Litz et al., 2009). A moral injury negatively affects one’s sense of meaning, purpose and self-acceptance. This suggests that moral injuries connect in some way to spirituality in that spirituality also relates to meaning, purpose and relationship (e.g. to self and others) (Hughes & Handzo, 2009). Thus, in order to argue for a distinct synergistic treatment plan for moral and spiritual injuries, this paper compares PTSD and moral injuries, ethics and moral injuries, and spirituality with ethics and moral injuries, so as to find etiological similarities and distinctions. These etiological parallels as well as the differences suggest the need for a treatment plan that addresses both the similarities and the distinctions. The final section of this paper presents an integrated treatment approach followed by a summary.
PTSD and Moral Injuries
Not everyone understands PTSD as a strictly psychological injury (Lanius, Brand, Vermetten, Frewen,& Spiegel, 2010). Some point to changes in brain functions among those who have sustained some type of injury, which exhibits symptoms resulting in the diagnosis of PTSD (Lanius et al., 2012). The argument is that the influence of structural irregularities in the brain directly affects some of the exhibited symptoms of PTSD (Lanius et al., 2010; cf. Lanius, et al., 2012). This section will briefly define PTSD by way of its diagnosis and discuss some of the research findings concerning brain functioning. Additionally, this section will discuss moral injuries. Moral injuries will then be compared to PTSD, looking for etiological similarities and differences.
The American Psychiatric Association (APA) in 2000 diagnosed PTSD as an anxiety disorder (Kazdin, 2000). DSM V has moved PTSD from the category of “Anxiety Disorder” to a separate chapter called “Trauma and Stress Related Disorders” (APA, 2013). This category change allows one to understand PTSD as something more than an anxiety disorder. The specification “dissociative subtype” is another change from earlier DSMs (APA, 2013). PTSD can occur after the experience of any type of extreme traumatic stressor. These stressors include exposure to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence (APA, 2013). There are eight criteria that must be met for the diagnosis of PTSD (i.e. stressor, persistent intrusion – nightmares, avoidance, negative changes in cognitions & mood, alterations in arousal and reactivity, duration of symptoms, functional significance, social or work impairment, and exclusion of other causes) (APA, 2013). In addition to these criteria, dissociative symptoms (i.e. depersonalization or derealization) need to be specified in the diagnosis (APA, 2013).
The symptoms in these criteria as well as the dissociative symptoms appear to have an etiology relating to neurobiology (Wang et al., 2010). The hippocampus may be one of the brain structures that correlates to one or more of the symptoms of PTSD (Bremner et al., 1995). Positron emission tomography (PET) scans have shown among PTSD patients a decrease in the size of the hippocampus (Gilbertson et al., 2002; & Bremner et al., 1995). Other research has compared those re-experiencing traumatic memories and psycho-physiological hyperarousal with those who sustained dissociative symptoms of PTSD (Lanius et al., 2014). Those re-experiencing traumatic memory with psychophysiological hyperarousal “exhibited reduced activation in the medial prefront-and the rostral anterior cingulated cortex and increased amygdala reactivity” (Lanius et al., 2014; cf. Lanius et al., 2012; Lanius et al., 2010; & Blair, 2007). Re-experiencing traumatic memory suggests a failure of prefrontal inhibition (i.e. top-down control of limbic regions) (Lanius et al, 2014; cf. Blair, 2007). The contrasted group (i.e. those who exhibited symptoms of depersonalization and derealization) displayed increased “activation in the rostral anterior cingulated cortex and medial prefrontal cortex” (Lanius et al, 2014; cf. Lanius et al., 2012). This suggests that the dissociative symptoms of PTSD are “mediated by midline prefrontal inhibition of the limbic regions” (Lanius et al, 2014; cf. Blair, 2007).
Accordingly, present research suggests that PTSD involves more than emotions and behaviors (Lanius et al, 2014; cf. Lanius et al., 2012). The interconnection between the functioning of the brain and the exhibited symptoms of PTSD, suggest that as the external and internal sensory information comes into the brain for processing, there is some type of correlation between how the brain processes the information and the level of threat that generates the data imputed into the brain for processing (Lanius et al, 2014; cf. Blair, 2007). If this is correct, it could mean that structures like the cingulated cortex, the hypothalamus, the prefrontal cortex and the amygdala are affected prior to the behavior being exhibited (Lanius et al., 2014; cf. Lanius et al., 2012). Thus, one could argue that PTSD is more than the psychological symptoms displayed (Lanius et al., 2014; cf. Lanius et al., 2012). Rather, PTSD could be understood to be the result of overwhelming trauma damaging the brain structures (Lanius et al., 2014; cf. Blair, 2007).
In order to understand moral injuries, one needs to consider some basic concepts of morality. Morality addresses the moral code that people use to navigate through their lives (Litz et al., 2009). Morals are the personal and shared beliefs of a family, community and society that often have legal rules of behavior (Litz et al., 2009). Morals are deeply held assumptions as to how things should work in their world (Litz et al., 2009). Violating accepted morals has, through experiences growing up, consequences that bring about such expectations as punishment, withdrawal of love, and self-censure (Litz et al., 2009). These learned consequences cause what some call “moral emotions” (Tangney, Stuewig, & Mashek, 2007). Moral emotions help maintain the moral code by expectations of others’ responses to perceived violations of the code (Tangney et al., 2007). These emotions include embarrassment and shame/guilt on the negative (Keltner, 1995) and self-pride on the positive (Tangney et al., 2007). While self-pride generates a desire to continue to stay in compliance, guilt generates a sense of shame that compels compliance (Keltner & Harker, 1998). Shame, which tends to lead toward avoidance and withdraw, is individualistically toxic (Keltner & Harker, 1998). It can generate anger as a defense mechanism to defend one’s vulnerability as something re-triggers his/her sense of shame (Tangney et al., 2007). For this reason (i.e. one’s inability to defend one’s vulnerability toward shame), some suggest that shame is at the core of moral injury (Litz et al., 2009).
Like PTSD, shame and guilt in moral injuries have a neurological origin (Michl et al., 2012). A functional magnetic resonance imaging (fMRI) found that shame and guilt correlated with temporal lobe activating (Michl et al., 2012). For shame, the portions that were more active included: anterior cingulated cortex and parahippocampal gyrus (Michl et al., 2012). For guilt, the fusiform gyrus and middle temporal gyrus were more active (Michl et al., 2012). Noticeably absent were the pre-frontal areas of the brain, the hippocampus and the amygdala (cf. Blair, 2007 & Lanius et al., 2014).1,2 This would suggest that moral injuries in terms of shame and guilt are generated in the brain in a different way than such symptoms like re-experiencing traumatic memory (Lanius et al., 2014) and depersonalization or derealization (Lanius et al., 2014; cf. Lanius et al., 2012). This further suggests that as the brain takes the sensory data from the experiences of the trauma of war, it will in some way place meaning on the sensory data and process the data in accordance to that meaning (Lanius et al., 2012 & Michl et al., 2012).
The idea of moral injuries coming out of experiences in war is not new. In the Ancient Greek tragedies, moral pollution resulted from one’s actions in war (Nash & Litz, 2013; cf. Meagher, 2006). Shay defines a moral injury as the result of a betrayal (Shay, 2002; cf. Shay, 2011). Litz et al. (2009) view a moral injury as a violation of one’s own moral code (cf. Shay, 1994). This violation comes by way of her/his own action or inaction (Litz et al., 2009). The central concept of moral injury involves an event inconsistent with one’s moral expectations and has the ability to destroy one’s moral rightness (Nash & Litz, 2013). This involves one’s broken trust in the efficaciousness of previously held core beliefs about one’s own ability as well as the ability of others to always experience a shared moral expected agreement (Nash & Litz, 2013).
PTSD and Moral injury
PTSD occurs as a result of the brain processing overwhelming traumatic information that is interpreted by the brain as life threatening to self, a friend, or as a witnessed event (APA, 2013; cf. Lanius et al., 2010). This in some way affects the prefrontal lobes and limbic system of the brain and thereby affects one psychologically in terms of emotions and behavior. The traumatic information can be perpetrated by an external event and an action or lack of action by oneself (Michl et al., 2012 & Lanius et al., 2010).
A moral injury is also processed through the brain (Michl et al., 2012). However, the brain is processing the meaning of the event in terms of values and beliefs that have been violated (Michl et al., 2012). A moral injury may or may not involve death or the fear of death, but it will involve a violation of a moral code (Nash & Litz, 2013). This may be a reason why different areas of the brain are activated in respect to a moral injury compared to PTSD. However, PTSD can include the effect of moral injuries as a driving force (Nash & Litz, 2013).
Two scenarios 3 may help to understand the distinctions. A sergeant (SGT) in Iraq was caught in an open area during an enemy mortar attack. Knowing his vulnerability, he reacted as he was trained, but, in an open unprotected area, he knew he could be killed. After the event, he began to experience dreams of the event and had several other symptoms that lead to his diagnosis of PTSD. Another SGT in Iraq was in door-to-door combat. As he came around the corner of one house, an Iraqi soldier was coming towards him. The SGT was able to fire his weapon before the Iraqi could fire his. For the SGT, seeing the eyes of the Iraqi as he (i.e. the Iraqi) was shot continues to haunt this American soldier. In both situations, death was impending. In both situations, memory and dreams of the events were invasive. However, the sergeant who was in the mortar attack had virtually no issues with guilt or shame over the event, while the second sergeant did. Both sustained PTSD, but only the second soldier also sustained a moral injury.
Ethics and Moral Injuries
This section presents the differences and common ground between ethics and moral injuries. The differences help define both concepts; however, the common ground allows one to better understand the synergistic relationship between ethics and moral injuries.
Actually ethics and morality have significant common concepts (Hare, 1981). Ethics is a system of moral principles, affecting how people make decisions (Baier, 1958). Ethics refers to values, standards, and rules on which the community, society and to a degree the world has agreed (Hare, 1981). Thus, it is a rubric about what is considered ideally possible in terms of human behavior and understood consequences of the violations of life standards (Hare, 1981). Ethics systematically reflects on morality and seeks to apply morals. When values, standards, etc. are in conflict, ethicists systematically analyze the issues to discern the best “ethical options” (Hare, 1981). Ethics is considered a branch of philosophy and has three major areas of study: meta-ethics, normative ethics, and applied ethics (Hare, 1981). While normative ethics relates to how one is to act, applied ethics covers such disciplines as medical ethics, bioethics, and military ethics (Hare, 1981). The latter, military ethics, addresses how a combatant is to fight, which is called Rules of Engagement (aka ROE) (Department of Defense, 2011). One can follow the ROE and yet still encounter perceived ethical violations, which challenges their deeply held sense of right and wrong (i.e. normative ethics) (Litz et al., 2009). It is interesting to note that even the best ethical options can be in conflict and thus can lead to a moral injury as seen in the above scenario where the SGT shot the enemy soldier.
Moral injuries occur when an ethical standard, which is deeply held to be inviolable, is broken (Litz et al., 2009). As mentioned earlier in this paper this may occur from direct participation in acts of combat (killing or harming others – enemy combatants or non-combatants) (Litz et al., 2009). It also can occur indirectly from such acts as witnessing death or dying, failing to prevent immoral acts of others, or even giving or receiving orders perceived as gross moral violations (Litz et al., 2009).
The Common Ground
A common ground between ethics and moral injury is the moral code. For the ethicist and the moralist, the moral code defines the values, standards, etc. by which one must live in order to be accepted by self and community (Hare, 1981). Ethics not only addresses the values, standards, etc., but it also recognizes the consequences of ethical violations (Hare, 1981). Morality and moral injuries also address the values and standards and recognize the consequences when these deeply held beliefs (i.e. common held values and standards) are violated (Litz et al., 2009).
Ethics does not inflict consequences (note: neither does morality). It recognizes what the community believes should be (Hare, 1981). If an ethical violation occurs, ethics “recognizes” it. However, moral injuries arise not only from the recognition of what should be and what has been violated, but it also addresses the meaning behind this violation and thereby judges one’s self (note: in part he/she believes the community has or will condemn him/her) (Litz et al., 2009).
In a sense, the one sustaining the moral injury can be understood as both the prosecutor and judge. The evidence would be not only the perceived ethical violations but also one’s view of him/herself and one’s belief of community condemnation (Litz et al., 2009). This self-view not only focuses on direct actions and indirect actions as discussed above, but also reviews the internal emotional dynamics at the time of the event (Litz et al., 2009). The verdict leaves one without hope, condemned and deserving rejection of self and community (Litz et al., 2009).
Spirituality Compared to Ethics and Moral Injuries
Spirituality, while not ethics, also addresses values and standards of the community (Hughes & Handzo, 2009). In this way, it has similarities to ethics. Spirituality also deals with issues like forgiveness and therefore, connects with moral injuries. This section will define spirituality and discuss similarities and distinctions it has with ethics and morality. Also, this writer will discuss similarities and distinctions between spiritual injuries and moral injuries.
Definition of Spirituality and Relationship with Ethics and Morality
Spirituality is that which gives a person meaning and purpose (Hughes & Handzo, 2009). Hughes and Handzo define it as “a person’s pursuit to connect to something or someone beyond him or herself as a means of making meaning or significance” (Hughes & Handzo, 2009). Meaning and significance in life correspond to how one relationally connects with self, others, ideas, nature, higher power, art, etc. (Hughes & Handzo, 2009). Each person will prioritize these relationships in accordance to the meaning she/he ascribes to that relationship (Hughes & Handzo, 2009).
Some define spirituality in more specific terms of spiritual beliefs. Spiritual beliefs contain a tenet about the course of human life and existence beyond life, but are not necessarily associated with religious practice (Walsh, 2006). In this way, some may have discovered some type of meaning even in the chaos of life. Accordingly, therapists like Walsh have found that individuals who have strong beliefs typically have better adjustments and experience less psychological distress (Walsh, 2007; cf. King, Speck, & Thomas et al., 1999). Nelson-Pechota (2004) had similar findings. She found that Veterans who had fewer and less severe PTSD symptoms or no PTSD symptoms also had reported being satisfied with the meaning and purpose of their lives (Nelson-Pechota, 2004). However, she found that those who felt alienated from God were having difficulty in reconciling their understanding of God with their combat experiences (Nelson-Pechota, 2004). This seemed to correlate with their experience of a higher number of PTSD symptoms (Nelson-Pechota, 2004).
Both ethics and morality are concerned over the values and standards of the community and society (Baier, 1958). Spirituality is also connected to values and standards. However, there appears to be at least two differences on how spirituality approaches these (e.g. values and standards) compared to ethics and morality. First, spirituality connects with the meaning and purpose associated with these principles. However, since it could be argued that ethics and morality also connect with meaning and purpose of values and standards (Litz et al., 2009), one can suggest a synergy rather than a division. Thus, ethics and morality are spiritual as they focus on meaning and purpose. Yet, even though this dynamic is present, ethics and morality focus more on the rightness rather than the meaning ascribed to the wrongness. Spirituality seeks to find meaning and purpose even in chaos (Walsh, 2007).
A second difference between spirituality and ethics/morality relates to the consequences. For ethics/morality, the consequences tend to be static. A violation deserves appropriate consequences (Litz et al., 2009). However, with spirituality and its focus on meaning, purpose and relationship, forgiveness stands out. Self-acceptance for the ethics/moral violator is to endure the consequences. Self-acceptance for the same violator from a spiritual dynamic is forgiveness (Hughes & Handzo, 2009).
Spiritual Injury and Moral Injury
Moral injury. Moral injuries closely correspond to spiritual injuries. Both focus on meaning and purpose. The cause for the injury is also similar. However, one strategic difference is the view of relationship. For spirituality, relationship not only includes self and others, but it also includes the “wholly other” (Hughes & Handzo, 2009). This connectedness appears to be absent in ethics and morality and thus is not considered part of a moral injury. Yet, in a spiritual injury, a broken relationship with the “wholly other” brings profound spiritual disequilibrium (Hughes & Handzo, 2009).
Integrated Treatment Approach
This paper has discussed the integrated and synergistic dynamics of PTSD and moral and spiritual injuries. These types of injuries (i.e. injuries caused by overwhelming trauma and moral and spiritual violations) occur to different areas of the brain in connection to the level of trauma and/or the degree of one’s sense of spiritual and/or moral and ethical violations. Consequently, effective treatments need to address the synergistic dynamics not only in terms of the damage caused by the brain processing extreme traumatic events (e.g. death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence) (APA, 2013), but also in terms of the damage caused by the brain processing overwhelming ethical, moral and spiritual conflicts. This section examines treatment options for PTSD and moral and spiritual injuries followed by an integrated treatment analysis. The intent is not to validate a specific treatment option, but rather provide examples of treatment options that can lead to a synergistic approach.
Treatment for PTSD
There are a number of treatment approaches for the patients diagnosed with PTSD (U.S. Department of Health and Human Services, 2015). These approaches fall under two avenues of interventions: psychotherapy and/or pharmacotherapy (National Institute of Mental Health, 2010). Psychotherapy has several different treatment modalities (Schurr, 2008; cf. National Institute of Mental Health, 2010), for example, Cognitive Behavioral,4 Interpersonal (Bleiberg, 2005), Group (Foa, Keane, Friedman, & Cohen, 2010), and Psychodynamic (Possemato, 2011; cf. National Institute of Mental Health, 2010). While pharmacotherapy targets brain chemistry issues (Schurr, 2008; cf. National Institute of Mental Health, 2010), psychotherapy addresses ways to deal with the frightening events that trigger PTSD symptoms (Foa et al., 2010).
In reviewing the etiology of PTSD (see section above under PTSD and Moral Injuries), the two treatment avenues (i.e. pharmacotherapy and/or psychotherapy) for PTSD patients address both the brain function issues and the emotionally triggered reactions evidenced by such issues as psycho-social encounters, etc. (Foa et al., 2010; cf. Possemato, 2011). A typical pharmacotherapy approach would address such problems as depression/anxiety/ sadness (e.g. sertraline, paroxetine, or fluoxetine), sleep issues (e.g. benzodiazepines), and mental health issues (antipsychotics) (National Institute of Mental Health, 2010; cf. Foa et al., 2010 & Possemato, 2011). Psychotherapy would seek to reduce the psycho-social symptoms by psycho-education (e.g. teaching about trauma, using relaxation and anger control skills, learning better habits – sleep, diet, exercise, and identifying and dealing with guilt and shame arising from the traumatic event(s)) (National Institute of Mental Health, 2010; cf. Foa et al., 2010 & Possemato, 2011).
Treatment for Moral Injuries
Litz et al. (2009) present what appears to be one of the present accepted treatment protocols for moral injuries (cf. Steenkamp et al., 2011). This protocol starts with three assumptions about the service member who has sustained a moral injury: 1) Has an intact moral belief system; 2).Two routes to moral healing – processing the memory and exposure to corrective life experience; 3) Patient will need an intense encounter with countervailing experience (Litz et al., 2009). Based on these assumptions, Litz et al. (2009) recommends an eight step protocol in which the therapist builds the veterans’ trust, educates them on the plan of action, enables them to express the experiences in a safe and accepting environment, sets the stage for self-forgiveness, followed by reconnecting with family and friends and then setting realistic future goals.
Treatment for Spiritual Injuries
Healing of spiritual injuries involves a reaffirmation of meaning, purpose and relationship (Koenig, 2002; cf. Witvliet, Phipps, Feldman, & Beckham, 2004). This includes addressing one’s core needs (e.g. significance, security, forgiveness, etc.) leading to a new and different perspective of meaning, purpose, and relationship (Hughes & Handzo, 2009). The spiritual care provider will need to be eclectic as she/he follows the patient’s agenda (Witvliet et al., 2004). This agenda is found by assessing the level of spiritual injury and developing a treatment plan. This plan will normally start with basic interventions (i.e. Intentional Ministry of Presence, Meaning Making, and Grief work) (Hughes & Handzo, 2009). Depending on the needs of the patient, the spiritual care provider will use certain specific interventions (e.g. prayer, healing rituals, confession, guilt discussion, life review, scripture paralleling, reframing God assumptions, & encouraging connection with community) (Hughes & Handzo, 2009). For the patients who enjoy mantras, a spiritual mantra is available (Hughes & Handzo, 2009). Even creative-writing techniques can help the patient who expresses her/himself better in writing (Hughes & Handzo, 2009).
Integrated Treatment: An Analysis
In reviewing the above three treatment groupings, one finds common characteristics in all three groups. Each treatment group can affect depression, anxiety, and to some extent a calming of the brain (Litz et al., 2009; cf. National Institute of Mental Health, 2010; Possemato, 2011; & Hughes & Handzo, 2009). Each treatment modality can affect a degree of moral reconciliation as well as meaning and purpose (Litz et al., 2009; cf. National Institute of Mental Health, 2010; Possemato, 2011; & Hughes & Handzo, 2009). Nonetheless, each treatment group has its own target area wherein one might experience the greatest effectiveness. For example, pharmacotherapy (under the PTSD grouping) would typically provide the best treatment approach for brain functioning issues (e.g. depression, anxiety, sleep disorders, etc.) (National Institute of Mental Health, 2010; cf. Foa et al., 2010; & Possemato, 2011). While each treatment approach can build trust, psychotherapy and treatments specializing in moral and spiritual injuries will typically be more effective (Litz et al., 2009; cf. National Institute of Mental Health, 2010; Possemato, 2011; & Hughes & Handzo, 2009). Also, talk therapies (i.e. psychotherapy and therapy specializing in moral and spiritual injuries) can focus on developing and restoring relationships, while addressing issues with self-acceptance and forgiveness (Litz et al., 2009; cf. National Institute of Mental Health, 2010; Possemato, 2011; & Hughes & Handzo, 2009). These goals will help in the restoration of meaning and purpose (Hughes & Handzo, 2009). However, therapy for moral injuries focuses on the restoration of meaning and purpose and thereby may be more effective in helping the client adjudicate ethical and moral wrongs (Hare, 1981).
It is important to realize that the different therapeutic approaches that are designed to restore relationships, meaning and purpose are compatibly different and may affect brain functioning in different ways (Litz et al., 2009; cf. National Institute of Mental Health, 2010; Possemato, 2011; & Hughes & Handzo, 2009). For example, with moral injuries, the therapist (i.e. both psychotherapist and the “moral therapist”) seeks to establish self-acceptance by coaching the patient to do benevolent acts so as to establish a history of “goodness” (Litz et al., 2009). This is intended to enable the patient to find self-goodness and thus to forgive and accept him/herself (Litz et al., 2009). At the same time, the spiritual care provider will seek to enable the patient to find meaning even in chaos (Hughes & Handzo, n.d.). By accepting the imperfections of life, one can better find self-forgiveness. These two goals (i.e. finding self-goodness and learning to accept meaning in chaos) have a reciprocating effect on each other, thereby intensifying the quality and effectiveness of the approaches. Accordingly, when moral and spiritual injuries therapies are combined with PTSD therapy, one can best experience a synergistic dynamic for holistic healing. Thus, when one sustains PTSD with moral and spiritual injuries (e.g. the above story of the SGT who saw the eyes of the enemy soldier when the SGT shot his enemy), he/she might have residual complications with one’s sense of ‘rightness’, forgiveness, connectedness (e.g. to self and high power), etc., if the PTSD treatment protocol does not include the treatment for moral and spiritual injuries.
Moral injuries align with spiritual injuries and PTSD. There are etiological differences between moral injuries and PTSD in respect to brain functioning. Ethics and morality are similar at least in respect to the moral code. Moral injuries arise from a violation of the moral code and the expected consequences of the violation. Spirituality connects with ethics and morality in terms of values and standards, but reflects a “wholly other” relational connection that is not found in ethics and the moral code. Yet there is a synergism connecting moral injuries with spiritual injuries that can be utilized in providing a connected treatment plan. This treatment plan includes: unconditional acceptance, restoring relationships with self and others, finding renewed meaning and purpose along with self-forgiveness and acceptance. The reciprocal relationship treatment plan for moral and spiritual injuries will intensify the quality and effectiveness of the individual treatment approaches. Since PTSD has a different etiology from moral and spiritual injuries, treatment for PTSD (i.e. Pharmacotherapy and psychotherapy) cannot effectively address the issues involved with moral and spiritual injuries. Accordingly, when one sustains PTSD with moral and spiritual injuries, a distinct synergistic treatment plan needs to include a holistic approach. This approach needs to integrate the treatment of moral and spiritual injuries with the treatment of PTSD.
1The amygdala’s functional response does not appear to equate a bad action as immoral.
2Several studies seem to suggest that frontotemporal dementia will negatively affect one’s ability to identify social violation. (Cf. Lough et al., 2006; Mendez,2006; &
Nakano et al., 2006).
3Both of these scenarios were told to this writer. Certain specifics (e.g. correct rank, and details of the events) were removed. However, the basic information is as told to this writer.
4There are several different variations of CB. (Cf. Zayfert & Becker, 2008).
Cornell University Press.
10. Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (2010). Effective treatment for PTSD: practice guidelines from the International Society for traumatic stress studies.New York: The Guilford Press.
11. Gilbertson, M.W., Shenton, M.E., Ciszewski, A., Kasai, K., Lasko, N.B., Orr, S.P., & Pitman, R.K. (2002). Smaller hippcampal volume predicts pathologic vulnerability to psychological trauma. Nature Neuroscience, 5, 1242-1247. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2819093/.
12. Hare, R.M. (1981). Moral Thinking. Oxford: Clarendon Press.
13. Hughes, B. & Handzo, G. (2009). Spiritual care handbook on PTSD/TBI. Retrieved fromhttp://www.healthcarechaplaincy.org/docs/publications/landing_page/spiritual_care_ptsd_handbook1.pdf.
14. Kazdin, A.E. (Ed.) (March, 2000). Encyclopedia of Psychology. Washington, DC:American Psychological Association.
15. Keltner, D. (1995). Signs of appeasement: Evidence for the distinct displays of embarrassment, amusement, and shame. Journal of Personality and Social Psychology, 68(3), 441−454.
16. Keltner, D. & Harker, L.A. (1998). The forms and functions of the nonverbal signal of shame. In P. Gilbert & B. Andrews (Eds.), Shame: Interpersonal behavior, psychology, and culture (pp. 78−98). New York: Oxford University Press.
17. King, M., Speck, P., & Thomas, A. (1999). The effect of spiritual beliefs on outcome from illness. Social Science Medicine.,48, 1291n9.
18. Koenig, H. (2002). Spirituality in Patient Care. Philadelphia: Templeton Foundation Press.
19. Lanius, R. A., Brand, B., Vermetten, E., Frewen, P.A., Spiegel, D. (2012). The dissociative subtype of posttraumatic stress disorder: rationale, clinical and neurobiological evidence, and implications. Depression and Anxiety, 29, 1-8. doi:10.1002/da.21889.
20. Lanius, R., Miller, M., Wolf, E., Brand, B., Frewen, P., Vermetten, E., & Spiegel, D., (January 3, 2014). Dissociative subtype of PTSD. PTSD:National Center for PTSD. Retrieved from http://www.ptsd.va.gov/professional/PTSD-overview/Dissociative_Subtype_of_PTSD.asp.
21. Lanius, R. A., Vermetten, E., Loewenstein, R. J., Brand, B., Schmahl, C., Bremner, J.D., & Spiegel, D., (2010). Emotion modulation in PTSD: Clinical and neurobiological evidence for a dissociative subtype. American Journal of Psychiatry, 167, 640-647. doi: 10.1176/appi.ajp.2009.09081168.
22. Litz, B.T., Stein, N., Delaney, E., Lebowitz, L., Nash, W.P., Silva, C., & Maguen, S.,(2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695–706.
23. Lough, S., Kipps, C.M., Treise, C., Watson, P., Blair, J.R., & Hodges, J.R., (2006). Social reasoning, emotion and empathy in frontotemporal dementia. Neuropsychologia 44, 950–958. Retrieved from http://www.ncbi.nlm.nih.gov/ pubmed/16198378.
24. Meagher, R. E. (2006). Herakles gone mad: Rethinking heroism in an age of endless war. New York: Olive Branch Press.
25. Mendez, M.F. (2006). What frontotemporal dementia reveals about the neurobiological basis of morality. Medical Hypotheses, 67(2), 411-8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16540253.
26. Michl. P., Meindl, T., Meister, F., Born, C., Engel, R.R., Reiser, M., & Hennig-Fast, K., (Oct, 9, 2012). Neurobiological underpinnings of shame and guilt: a pilot fMRI study. Social Cognitive and Affective Neuroscience. Retrieved from http://scan. oxfordjournals.orcontent/early/2012/10/29/scan.nss114.full.pdf+html.
27. Nakano, S., Asada, T., Yamashita, F., Kitamura, N., Matsuda, H., Hirai, S., & Yamada, T. (2006). Relationship between antisocial behavior and regional cerebral blood flow in frontotemporal dementia. Neuroimage,32(1).301-6. Retrieved from http://www. ncbi.nlm.nih.gov/pubmed/ 16624585.
28. Nash, W.P. & Litz, B.T. (Dec 16, 2013). Moral Injury: A Mechanism for War-Related Psychological Trauma in Military Family Members. Clinical Child and Family Psychology Review. DOI10.1007/s10567-013-0146-y. Retrieved from http://www.cstsforum.org/assets/media/documents/general_readings/ptsd/Nash%20%26% 20Litz%20(2013)%20moral%20injury%20war-related%20trauma%20in%20military %20family%20members.pdf.
29. National Institute of Mental Health. (2010). Post-Traumatic Stress Disorder. How Is PTSD Treated? Retrieved from: http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/how-is-ptsd-treated.shtml.
30. Nelson-Pechota, M. (2004). Spirituality and PTSD in Vietnam Combat Veterans. Retrieved from www.warveteranministers.org/spirituality_intro.htm.
31. Peters, K. E. & Whittaker-Johns, B. (Dec, 2012). Scientific & religious perspectives on human behavior: an introduction. Zygon: Journal of Religion & Science. 47 (4), 797-805.
32. Possemato, K. (2011). The current state of intervention research for posttraumatic stress disorder within the primary care setting. Journal of Clinical Psychology in Medical Settings,18, 268-280.
33. Schurr, P.P. (Summer, 2008). Treatments for PTSD: understanding the evidence. National Center for PTSD. PTSD Research Quarterly, 19(3). ISSN: 1050-1835. Retrieved from http://www.ptsd.va.gov/professional/newsletters/ research-quarterly/V19N3.pdf
34. Shay, J. (1994). Achilles in Vietnam: Combat trauma and the undoing of character. New York: Scribner.
35. Shay, J. (2002). Odysseus in America: Combat trauma and the trials of homecoming. New York: Scribner.’Shay, J. (2011). Casualties. Dædalus, the Journal of the American Academy of Arts and Sciences, 140(3), 180–188.
36. Steenkamp, M. M., Litz, B. T., Gray, M. J., Lebowitz, L., Nash, W., Conoscenti, L., Lang, A. (2011). A brief exposure-based intervention for service members with PTSD. Cognitive and Behavioral Practice,18, 98–107. Abstract. Retrieved from http://www.sciencedirect.com/science/article/pii/S1077722910000933
37. Tangney, J. P., Stuewig, J., & Mashek, D. J. (2007). Moral emotions and moral behavior. Annual Review of. Psychology, 58, 345–72.
38. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, National registry of evidence-based programs and practices (2015). 19 Interventions. Retrieved from http://www.nrepp.samhsa.gov/SearchResultsNew.aspx?s=b&q=ptsd
39. Walsh, F. (2006). Strengthening family resilence. (2nd ed.) New York: Guilford, Press.
40. Walsh, F. (2007). Traumatic loss and major disasters: strengthening family and community resilience. Family Process. 46 (2), 207-227.
41. Wang, Z., Neylan, T. C., Mueller, S. G., Lenoci, M., Truran, D., Marmar, … Schuff, N. (March, 2010). Magnetic Resonance Imaging of Hippocampal Subfields in Posttraumatic Stress Disorder. Archives of General Psychiatry, 67(3), 296–303. doi:10.1001/ archgenpsychiatry.2009.205.
42. Witvliet, C. V. O., Phillips, K. A., Feldman, M. E., & Beckham, J. C. (2004). Posttraumatic mental and physical health correlates of forgiveness and religious coping in military veterans. Journal of Traumatic Stress, 17, 269-273.
43. Zayfert, C. & Becker, C.B. (Oct 15, 2008). Cognitive-Behavioral Therapy for PTSD: A Case Formulation Approach. The Guilford Press, New York, New York.
William D. Smith BCC, spent twenty years as an Army Chaplain with three deployments, including four years as a hospital chaplain. He completed his CPE residency at Brooke Army Medical Center in 1994, Bill holds several degrees: MDiv (1974), ThM (1977), MS in Community Counseling (1997), MA in Bioethics (2015), and a PhD in General Psychology (2008). He is a Clinical Member and Approved Supervisor with the American Association for Marriage and Family Therapy (AAMFT), and practices in Virginia and Pennsylvania. He is currently Chief of Chaplains Services at Coatesville VA Medical Center in Coatesville, PA. Bill has been ordained as a Baptist minister since 1982.