The Spiritual Dimension of Moral Injuries

The Interest in Moral Injuries

In certain areas of life where people are confronted with extreme experiences,^[1] a phenomenon occurs that is known as moral injury.^[2] This is a psychological injury caused by inhumane, violent, or cruel acts (a) in which one has participated, or (b) which one could not prevent, or (c) which one has witnessed, or (d) which one has learned about.^[3] The actions that cause these injuries are serious moral transgressions that violate deeply rooted moral convictions and thus cause a form of suffering with a specifically moral quality.^[4]

There are various reasons for the interest in these moral wounds. The most obvious one is certainly that one is affected by moral injury, leading to significant suffering. Or one is confronted by moral injuries in one’s professional capacity as a psychologist or psychiatrist, and develops a scientific interest in the associated phenomena. In fact, the term became established in the 1990s when psychologists and psychiatrists treating Vietnam War veterans in the U.S. were growing increasingly aware that a certain type of psychological disorder – often broadly classified as “post-traumatic stress disorder” (PTSD) – was very inadequately described by this term. In these cases, the suffering at core was not an anxiety disorder resulting from a life-threatening situation, as is usually the case with post-traumatic stress disorders. Rather it was a trauma of a moral nature (i.e. a normative traumatization), accompanied by feelings of guilt and shame, even self-hatred (in some cases also anger and rage)^[5] and which, in a significant number of cases, leads to suicide or attempted suicide.^[6]

There is another reason why the complex of phenomena described as moral injury deserves our attention, namely that in many cases^[7]the whole of morality is at stake. For its impact on a person’s morality is as follows: “[…] rather than being limited to this or that moral principle, [the moral transgression] cuts to the heart or core of one’s very identity as a moral being (one’s sense of morality)”.^[8]

Moral injuries: a specific form of reactive attitude

In order to understand the “comprehensive” dimension of moral injuries just mentioned, it is important to note that – as their name suggests – they belong on the passive-receptive side of human morality: They are suffered! They are psychological events that occur to someone. Thus, they are not the result of a decision, at least not the immediate result. But they are suffered in a very specific way. What is suffered has a cognitive content that is expressed in an implicit moral judgment. That is why moral injuries are classified as  reactive attitudes.^[9] Their implicit evaluative dimension becomes clear in the context of human relationships, both in a person’s relationship with themselves (intrapersonal relationship) and in their relationship with others (interpersonal relationship). These relationships are accompanied by certain expectations and demands. When people do not meet these expectations and demands, we react involuntarily. And the reaction tells us something about the attitude that the person reacting has to the world.^[10]In the specific case of moral injury, it tells us something about the person’s moral attitude, which can generally be described as a strong sense of responsibility.^[11] In contrast to other reactive attitudes (such as resentment, grudges, hurt feelings, gratitude, forgiveness, love, moral praise, moral reproach), with moral injuries – as mentioned – morality as a whole is shattered. Those affected often talk about their moral identity being shaken or lost.

Moral injuries affect the whole of morality

What does it mean to say that moral injuries affect morality as a whole? Fundamentally, moral action is first and foremost about (1.) doing what one has recognized as good and right (the normative dimension). However, it is also important (2.) to muster the necessary ethical motivation in each individual case (the motivational dimension). This second dimension is inseparably linked to the first.^[12]Last but not least – and this dimension often receives too little attention – moral action is also about (3.) believing in the meaningfulness of the moral world.^[13] In order to remain moral beings even in difficult and extreme situations, we must not lose our belief in the meaningfulness of the moral world.^[14]

I would like to elucidate this point by drawing on a few observations by Hannah Arendt.^[15] Although taken from a different context (her discussion of the Holocaust), they are nevertheless relevant because they stem from reflections on morality in the face of extreme human experiences: namely, experiences of extreme injustice.

When confronted with such experiences, it is important to maintain faith in a moral world, or rather, in the meaningfulness of a moral world, so that one can at least in some measure feel that one inhabits a world that supports moral action. In extreme situations, the question arises whether the world (as it is experienced) is even fit for humans.^[16] Against this background, it is illuminating to describe the struggle with moral injuries, which are often experienced as a threat to moral identity, as a struggle to re-establish a sense of belonging in the world. One could call this the spiritual dimension of ethics.^[17]

For the purposes of this discussion, the “spiritual dimension” refers to the dimension of human life that gives meaning to the idea of a moral world. This can be a theistic belief, or it can also be a spirituality without reference to a transcendent reality in this sense. The key point is that it provides a person with an existential answer to the question of the meaning of their morality, which today is often expressed as: Why be moral? The concept of the spiritual, as used by many authors, is broader and also vaguer than the concept of the religious.^[18]Because of this openness to broad interpretation, the term “the spiritual dimension of ethics” is used here. It refers to a personal reality that extends beyond a person’s immediate reality (e.g. their immediate needs) and is experienced as providing meaning.^[19]

Arendt’s writings repeatedly address the question of how we can be at home in the world, particularly as moral beings. For those suffering from moral injuries, this question arises with existential urgency.

Loss of trust and alienation from what gives life meaning

When people who suffer from moral injury describe the phenomenon, various concepts stand out. For example, they talk about experiencing a betrayal of what is right,^[20] or about experiences of serious moral transgressions and the resulting inner conflicts and moral distress.^[21] But they also mention a loss of trust and declining confidence in their own and others’ ability and motivation to act morally.^[22]This shows that there is a deeper “spiritual wound” with concomitant emotional effects.^[23] Those affected by moral injury struggle with a shaking of the moral foundations of their personal identity, which can lead to its collapse and is experienced as a moral downfall. In his book Achilles in Vietnam: Combat Trauma and the Undoing of Character,^[24]Jonathan Shay relates what a soldier who had completed three combat tours in the tank force in Vietnam says about himself in retrospect:

“[…] I look back today and I’m horrified at what I turned into. What I was. What I did. I just look at it like it was somebody else. […] War changes you […] strips you of all your beliefs, your religion, takes your dignity away. […] You know, it’s unbelievable what humans can do to each other. I never in a million years thought I would be capable of doing that. Never, never, never.”^[25]

The inner processes of which such statements give a small impression have a massive impact on the relationship that individuals with moral injury have with themselves, with other people, and, for people of faith, also with God.^[26] As a result, they feel alienated from what gives their life meaning.

Isolation, helplessness, and hopelessness are common side effects of moral injuries

This alienation is reinforced by a tendency to withdraw, as individuals with moral injuries develop a negative self-image based on their perception of moral failure which sometimes leads them to believe that they are unworthy of forgiveness. By distancing themselves from others, they also deprive others of the opportunity to counteract what they are experiencing – for example in the form of completely different interpersonal experiences such as unconditional love or unconditional trust. Isolation, helplessness, and hopelessness are common side effects of moral injuries.^[27]

Reconciliation with reality

Against the backdrop of the preceding considerations, if one asks what the source is for the implicit moral judgment that characterizes the reaction in cases of moral injuries, I believe the answer must be:^[28]the inner (= subjective) court of conscience.^[29] And the starting point for a possible reconciliation with reality, which Arendt discusses in the context of extreme experiences of injustice, for example, would be the public court of practical reason. The moral philosopher Nancy Sherman also works as a psychologist with individuals suffering from moral injury. She has written about the phenomenon of harsh self-accusation that is characteristic of many cases of moral injury:

“The right therapy in these cases involves redrawing the lines around agency and accountability. It’s a case where letting go is understanding the limits of control. It’s also a case where compassion and mercy may have to come from others so you can learn to show it toward yourself.”^[30]

She is sketching the outlines of a psychological approach that can help people who suffer from moral injury. Moral and religious concepts play a central role here because this is fundamentally  about the possibilities and limitations of one’s own capacity to act, and the attribution of responsibility for one’s own actions. What matters is the intersubjective view characteristic of the standpoint of reason, in which compassion and mercy may come into play.

Furthermore, the attempt at reconciliation with reality in the case of moral injury begins with the perception of a violation of deeply rooted moral convictions and values, and the resulting feelings of self-condemnation, shame, guilt and rage. Starting from this point, a deeper understanding should help to regain the lost trust in reality with its moral dimension.

Hannah Arendt’s characterization of understanding in her essay Understanding and Politics (originally titled The Difficulties of Understanding) fits very well with the attempt to understand in the case of moral injury. She writes that understanding is “an unending activity by which, in constant change and variation, we come to terms with and reconcile ourselves to reality, that is, try to be at home in the world.”^[31] Up to a certain extent, the attempt to reach a deeper understanding can be healing. But as with all attempts at reconciliation, the process depends on factors beyond our control.

The spiritual dimension in therapy

Since the spiritual dimension plays a key role in moral injury, it seems obvious to ask whether it also offers starting points for therapy. When attempting to answer this question, one should first remind oneself of what experienced clinical psychologists generally say about treatment options, so as not to have any illusions. The U.S. American trauma expert Brett T. Litz is an internationally recognized authority in this field. In a conversation with colleagues, he said “[…] that there is no cure, that suffering cannot be eradicated, that on an individual, communal, cultural, and societal level we did this, and this is the aftermath^[32] […] We can’t make this person what he or she was before this happened. It is just not possible.”^[33]

So, if there is anything healing to be found when dealing with moral injuries, it is not a return to the status quo ante – the state before the injury. But the spiritual dimension can potentially be very helpful when it comes to finding a way forward in dealing with the injury.^[34]

If there is anything healing to be found when dealing with moral injuries, it is not a return to the status quo ante – the state before the injury

Fundamentally, the spiritual dimension – like almost everything in human life – is extremely ambivalent. It can make a person even more vulnerable than they already are. But it can also have a crucial role in dealing with injuries. This is because it brings into play dimensions of experience that, like moral injuries, relate to the whole of human existence. An example would be the experience of guilt or sin as a primordial human experience, and ways of dealing with it such as in the form of mercy and forgiveness. This can be a fruitful approach to dealing with the scary, painful and sad reality of moral wounds^[35] in a way that opens up a path to the future.

It makes sense to include the spiritual dimension when dealing with moral injuries, simply because, for many people, different forms of value orientation (non-moral, moral, and religious forms of value orientation) are closely intertwined. When successful, this allows access to “deeper sources of life”, which in many cases can have a healing effect, because religion is often experienced as promoting a sense of meaning in life, and religious feelings are a powerful motivating force.^[36]

Regardless of what special religious connotations terms such as guilt and forgiveness may have in any given case, the perception and judgment of a benevolent and compassionate friend plays a vital role in therapy for moral injury. This is part of a therapy called adaptive disclosure, which was devised by Brett Litz and others for the treatment of active soldiers and war veterans.^[37] At a critical point in the therapy, patients are asked to imagine an empty chair in the room. It is supposed to be a seat for a trusted and benevolent friend with moral authority who may be able to help them regain their lost confidence in their own goodness. The hope is that the morally injured person will gradually be able to see lovable aspects of their personality again, through the eyes of this imaginal person. Alternatively, patients are sometimes asked to imagine themselves as a compassionate friend offering support to a fellow soldier. This soldier, mirroring the patient’s own experience, is plagued by and trapped in feelings of guilt and is, as is often the case, engaging in self-harming behaviors. Would you mercilessly level accusations of guilt at them?^[38] The imagined change of perspective gives rise to empathy based on shared humanity.

Our shared humanity demands that we create a moral culture which bestows meaning

When dealing with experiences of extreme injustice and the mental suffering that this causes – as in the case of moral injuries – we are reminded of an important aspect of our shared humanity that we often forget if we are not confronted with such experiences. The shared humanity of all people, of which their moral disposition is a fundamental part, also demands that we shape the shared political world in such a way that people feel at home in it as moral beings, and that people who have suffered moral injuries can feel at home in it again, because they can trust in the meaningfulness of the moral world. Taking responsibility for our actions, including our moral failures, is an essential step in this direction. But a meaningful moral culture requires much more, such as dealing with the experience of guilt, for example in the form of the possibility of forgiveness and mercy.

DOI: 10.48701/opus4-822