MORAL INJURY & PTSD

DOES RELIGION HAVE AN IMPORTANT ROLE IN RECOVERY?

Natalie Aikman

Though the research is limited, through examining the concept of moral injury researchers have come to learn that there is a need for a new approach to tackling moral injury. Some researchers disagree on the definition of moral injury, but the generally agreed-upon definition is the outcome of people that have been exposed to traumatic events that violate their moral values (Griffin et al., 2019). Because the fine line between post-traumatic stress disorder (PTSD) and moral injury comes down to the presence of suicidal ideation, and there is not as vast of an amount of literature about moral injury as PTSD, most of the sources included in this paper focus on PTSD. The difference between PTSD and moral injury, though small, has beckoned the attention of spiritual leaders to aid in recovery for those spiritually affiliated and experiencing moral injury. There is a need for collaboration between mental and physical healthcare providers and theologians or spiritual leaders for people that have sought recovery of moral injury – especially in people that were associated or involved with a religious or spiritual group before experiencing a morally injurious event. This review will mainly focus on moral injury and how it pertains to veterans and active United States military members.

Moral Injury

Moral injury, as defined by Griffin et al. (2019), is the outcome that results from an individual having been exposed to traumatic events that violate their moral values. These traumatic events are referred to as potentially morally injurious events (PMIEs). This may look like giving or taking orders that result in the death of a service comrade or violate the Geneva Convention, failing to report an atrocious act of violence seen committed against you or someone else, or using force to end civilian lives. (Syracuse University). Though, Kinghorn (2012) aims to include any consent or participation, whether explicit or tacit, of a morally injurious event as qualifying someone for potentially experiencing moral injury. Moral injury symptoms may look like losing spiritual beliefs held before exposure to PMIEs, difficulty forgiving a Higher Power or oneself for acts committed, shame, guilt, anger, loss of trust in others or oneself, and/or suicidal ideations (Harris, 2021).

Moral Injury and PTSD

A literature review by Griffin et al. (2019) suggests that, because of the co-morbid symptoms of PTSD and moral injury, moral injury can require, for some people, more specialized recovery practices that include spiritual or religious components. Koenig (2018) suggests that the current therapies for PTSD may not seek to heal moral injury as effectively as they do certain components of PTSD like shame and guilt. To examine the relationship between moral injury symptoms and religiosity in veterans with PTSD symptoms, the authors of this study had the participants complete an assessment. The goal of this study was to create a scale to measure moral injury across 10 dimensions: feelings of betrayal, loss of meaning/ purpose, loss of trust, moral concerns, self-condemnation, guilt, shame, religious struggles, loss of religious faith/ hope, and difficulty forgiving. This scale had high internal reliability and a high test-retest reliability. Their results found a small nonsignificant relationship between moral injury and religiosity when the participant had low PTSD severity, but when the participant had high PTSD severity, the relationship between moral injury and religiosity was strong and positive. They also found that among veterans with severe PTSD, moral injury was inversely related to religiosity, but this relationship did not exist among participants with lower PTSD severity. On the other hand, the results of Park et al., (2017) found that positive religious/spirituality was associated with perceived posttraumatic growth, but not PTSD symptoms. A study by Wisco et al. (2017) sought to understand three types of potential moral injury events (transgressions by others, transgressions by self, and betrayal), to evaluate characteristics of moral injury in U.S. combat veterans, and examine the relationships between mental disorders, suicidality, and PMIEs. The results found that transgressions by others had the highest average score on the Moral Injury Event Scale (MIES) followed by betrayal (which was significantly lower than transgressions by others) and transgression by self (Nash et al., 2013). This means that the severity of moral injury is experienced depends on the type of PMIE endured. The researchers suggested that, because of the moderate association, the Moral Injury Event Scale scores are related to but separate from combat severity. MIES scores were able to predict higher odds of mental disorders and suicidal ideation at the time of measurement. Higher betrayal was associated with higher odds of suicide attempts post-deployment

Though PTSD is separate from moral injury, veterans that have PTSD and experience moral injury have a higher risk of suicide (Bryan et al., 2018).Youssef et al. (2018) sought to examine the relationship between religious involvement, moral injury, and PTSD. Results found that moral injury symptoms were positively correlated with PTSD severity and negatively correlated with religious involvement – but religious involvement was weakly correlated with PTSD symptom severity. They also found religiosity helped block the effects of moral injury on PTSD for some veterans but not for all (depending on what theater they served in). Importantly, the authors discuss the difference between PTSD and moral injury: while moral injury and PTSD often are comorbidities, they should be treated as separate entities. Moral injury does not usually involve fear-based stressors, but rather a violation of held moral values. Along with these results, Koenig et al. (2018) found that religiosity was inversely related to moral injury for the participants who were either Christian or unaffiliated/agnostic/atheist, but this was not true for the veterans affiliated with nonChristian religious groups. This raises several questions that the current literature have not examined: What does the relationship between religiosity and moral injury look like for religious folks outside of the Christian faith, and does greater religiosity reduce moral injury symptoms, or do moral injury symptoms reduce religious affiliation?

Religious/Spiritual Recovery

While examining the impact of moral injury on the treatment of PTSD in U.S. combat veterans, Held et al. (2021) found that moral injury was not a significant predictor of changes (both positive and negative) in depression or PTSD symptoms over time. This article suggests that PTSD present in military veterans previously exposed to morally injurious events may be successfully treated with Cognitive Processing Therapy (CPT). This CPT treatment has shown to improve symptoms of moral injury-based PTSD because of the presence of maladaptive cognitions (which is the focus of CPT). However, this review does not seek to answer the question of if moral injury itself can be treated with the same practices used for PTSD recovery.

Hodgson & Carey (2017) reviewed literature associated with moral injury to get a better understanding of the whole definition of moral injury and the need for different therapies. The presence of religiosity among veterans who experience moral injury makes room for using religiosity/ spirituality as a practice for treatment. Fritts (2013, as cited in Hodgson & Carey, 2017) questions the origins and prevalence of moral injury among veterans. They discuss the tough situation that veterans are put in: the military wants members willing and able to kill the opponent while still being moral -- and for religious folks, this is often difficult. The authors reveal that, among moral injury scholars, there is a desire for a more holistic recovery approach to treating moral injury. This looks like going beyond the depths of the originally accepted medical model to include disciplines, like religion and spirituality, that seeks to understand morality on a different level than psychology has. Fritts (2013, as cited in Hodgson & Carey, 2017) discusses that therapists are not usually priests, and priests are not usually behavioral scientists – and morally injured soldiers deserve the scientific and spiritual communities (as wholes) to work together. Cenker et al. (2021) completed a study to examine the role of spiritual/religious recovery patterns of those in the group categorized by those who have moral injury — intending to reduce types of distress from experiences stemming from military service. The results found increases in self-compassion and psychological health along with decreases in depression symptoms. They also found a decrease in religious/ spiritual struggles and an increase in post-traumatic growth after therapies were facilitated with both a chaplain and a psychologist. Other studies have shown that religious comfort was not related to measures of moral injury, but appraisals of religious struggles predicted other and selforiented facets of moral injury, (Lancaster & Miller, 2018). A study done examining healthcare professionals in China found that the importance of religion to the participants was positively correlated with moral injury symptoms and poor mental health. In the concluding remarks, the authors claim these findings as reasoning enough to begin the integration of religion/spirituality in treating mental health issues (Wang et al., 2020).

Conclusion

Though this literature review was limited by the amount of current research about PTSD and moral injury being treated with therapies including religious/spiritual practices, there have been several interesting findings. At its core, moral injury is still largely exploratory because there is a lack of research on moral injury separate from PTSD. This review did not seek to answer the question of if religion and spirituality have an important role in the recovery of moral injury, but it did review the current literature and begs the question of using religion/spirituality as a means of reducing effects of moral injury. Based on the literature that does pertain to the question, there is plenty of room for more research for a better understanding of how religion and spirituality can aid in the recovery of moral injury with particular attention to United States military members (specifically this population because this is the population of most of the moral injury research). Though this field is largely untouched by empirical research, Cognitive Processing Therapy has been found to aid in the reduction of moral injury-based PTSD. Research would benefit from conducting studies to examine other differences between PTSD and moral injury (other than suicidal ideation) as to make more clear distinctions between them for the purposes of reducing effects of moral injury.

Cenkner, D.P., Yeomans, P.D., Antal, C.J., & Scott, J.C. (2021). A pilot study of a moral injury group intervention co-facilitated by a chaplain and psychologist. Journal of Traumatic Stress, 34(2), 367-374. doi:10.1002/ jts.22642

Griffin, B. J., Purcell, N., Burkman, K., Litz, B.T., Bryan, C.J., Schmitzm, M., Willierme, C., Walsh, J., & Maguen, S. (2019). Moral injury: An intergrative review. Journal of Traumatic Stress, 1(1), 1-13. https://doi. org/10.1002/jts.22362

Harris, J. I., Chamberlin, E. S., Engdahl, B., Ayre, A., Usset, T., & Mendez, D. (2021). Spiritually integrated interventions for PTSD and moral injury: A review. Current Treatment Options in Psychiatry, 8(4), 196-212. DOI 10.1007/s40501-021-00248-w

Held, P., Klassen, B. J., Steigerwald, V. L., Smith, D. L., Bravo, K., Rozek, D. C., Van Horn, R., & Zalta, A. (2021). Do morally injurious experiences and index events negatively impact intensive PTSD treatment outcomes among combat veterans? European Journal of Psychotraumatology, 12(1). DOI: 10.1080/20008198.2021.1877026

Hodgson, T. J. & Carey, L. B. (2017). Moral injury and definitional clarity: Betrayal, spirituality and the role of chaplains. Journal of Religious Health, 56(4), 1212-1228. doi:10.1007/s10943-017-0407-z

Kinghorn, W. (2012). Combat trauma and moral fragmentation: A theological account of moral injury. Journal of the Society of Christian Ethics, 32(2), 57-74. doi:10.1353/sce.2012.0041.

Koenig, H. G., Ames, D., Youssef, N. A., Oliver, J. P., Volk, F., Teng, E. J., Haynes, K., Erickson, Z. D., Arnold, I., O’Garo, K., & Pearce, M. (2018). The moral injury symptom scale–military version. Journal of Religion and Health, 57(1), 249–265. https://doi.org/10.1007/s10943-017-0531-9

Koenig, H.G., Youssef, N.A., Ames, D., Oliver, J.P., Teng, E.J., Haynes, K., Erickson, Z.D., Arnold, I., Currier, J.M., O’Garo, K., & Pearce, M. (2018). Moral injury and religiosity in US veterans with posttraumatic stress disorder symptoms. The Journal of Nervous and Mental Disease, 206(5), 325-331. doi: 10.1097/NMD.0000000000000798

Lancaster, S. & Miller, M. (2018). Moral decision making, religious strain, and the experience of moral injury. 1-29. DOI:10.31234/osf.io/dz7ev

Nash, W. P., Marino Caper, T. L., Mills, M. A., Au, T., Goldsmith, A., Litz, B. T. (2013). Psychometric evaluation of the moral injury events scale. Military Medicine, 178(1), 646- 652. DOI: 10.7205/MILMED-D-13-00017

Park, C.L., Smith, P.H., Lee, S.Y., Mazure, C.M., McKee, S.A., & Hoff, R. (2017). Positive and negative religious/spiritual coping and combat exposure as predictors of posstraumatic stress and perceived growth in Iraq and Afghanistan veterans. Psychology of Religion and Spirituality, 9(1), 13-20. https://doi.org/10.1037/rel0000086

Syracuse University. (n.d.). What is moral injury. The Moral Injury Project What is Moral Injury Comments. Retrieved April 17, 2022, from https:// moralinjuryproject.syr.edu/about-moral-injury/

Youssef, N. A., Boswell, E., Fiedler, S., Jump, R., Lee, E., Yassa, M., ... & O’Garo, K. (2018). Moral injury, posttraumatic stress disorder, and religious involvement among US veterans. Annals of Clinical Psychiatry, 30(2), 113121. https://www.researchgate.net/publication/324867389

Wang, Z., Al Zaben, F., & Koenig, H. G. (2020). Religion/spirituality, moral injury, and mental health among health professionals in China. Research Square, 1(1), 1-14. https://doi.org/10.21203/rs.3.rs-77800/v1

References

Bryan, A. O., Bryan, C. J., Morrow, C. E., Etienne, N., & Ray-Sannerud, B. (2014). Moral injury, suicidal ideation, and suicide attempts in a military sample. Traumatology, 20(3), 154-160. http://dx.doi.org/10.1037/ h0099852

Wisco, B.E., Marx, B.P., May, C.L., Martini, B., Krystal, J.H., Southwick, S.M., & Pietrzak, R.H. (2017). Moral injury in U.S. combat veterans: Results from the national health and resilience in veterans study. Depression & Anxiety, 34(4), 340-347. doi:10.1002/da.22614