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How Moral Injury Can Impact Anyone Of Us




Moral Identity and Meaning:

There is increasing evidence from neuroscience and psychology that human beings are born moral and that moral conscience is necessary for empathy, pattern making, language, and relationship maintenance.


Assumptions about moral injury:

  1. The human condition is to be born moral.

  2. Moral injury is a devastating and ordinary human experience of moral failure, not a disorder.

  3. Moral injury is related to trauma and can be experienced alongside it and PTSD, but is not the same as either.

  4. Every society, religion, and culture has to address moral injury, but not all approaches alleviate it. Some can make it worse.

What is Morality?

Moral systems and personal identity have at least five dimensions (See Seligman, A., R. P. Weller, et al. (2012) Rethinking Pluralism: Ritual, Experience, and Ambiguity. Oxford.


Habits

· Learned from birth by mimicry, repetition, practice, and coaching. Largely subconscious behavior that determines daily human interactions. Habitual behaviors carry moral content.

· Difficult to change and constitute most moral behavior on a daily basis.


Meaning-Orienting Systems

· Overarching philosophical, mythical, and/or religious-theological value system that defines crucial aspects of relationships and life purpose.

· Assumed with language acquisition, rather than explicitly examined, unless challenged.

· Questions of meaning emerge when ambiguous or devastating situations arise.


Rules

· Hard moral cultural/social boundaries that cannot be crossed without penalty.

· In complex, pluralistic societies, where oral traditions are too limited, laws are the boundaries.

· How rigidly persons, societies, or leaders relate to rules varies greatly and involves judgments about what is customary, legal, and moral.


Rituals

· Deliver meaning system by enacting important values in symbolic ways with stories so that they become body-memory as well as conscious memory.

· Teach meaning and values through repeated behavior that includes stories or other forms of delivering meaning.

· Often bodily re-enactment of a ritual can evoke the emotions of the meaning system without words or thoughts.

· Provide opportunities to enact aspirational aspects of meaning—performing ideal self v. real self. “as if” subjunctive quality

· Used to integrate ambiguity or threats (death, strangers, sickness, birth, violence) into meaning via story, myth, and connection to ideal self.


Experience

· Can maintain, reinforce, or challenge all of the above.

· Trauma=Experience of Suffering (Keefe-Perry, L. C. & Moon, Z. (2018)

· Overwhelms beliefs, values, behaviors, boundaries, and/or relationships;

· Can be an event, a harmful social structure, or life circumstance

(poverty, gender oppression, incarceration);

· Must be assimilated into identity and meaning;

· Requires new, functional coping strategies that facilitate survival and meaningful relationships.


Devastating, traumatic experiences can destabilize meaning and identity at any point in life—this is moral injury, not a psychiatric disorder but a breakdown of meaning due to a working conscience that cannot make moral sense of experiences.


Coherence can only be reestablished in the struggle to create a new meaning system and identity adequate to integrating the memory of what caused the moral injury.


Moral Injury:

Shay (2014) definition: Moral Injury is 1) the violation of what is right by 2) someone in authority 3) in a high stakes situation.

This kind of moral injury correlates to betrayal and rage and to higher rates of co-morbidity with PTSD (Jordan, 2017). Also relevant to people who work in hierarchical systems where leadership failure carries high stakes and to children and adults who experience violence from family members.


Litz, et. al., (2009):

Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations. This may entail participating in or witnessing inhumane or cruel actions, failing to prevent the immoral acts of others, as well as engaging in subtle acts or experiencing reactions that, upon reflection, transgress a moral code… that severely and abruptly contradicts an individual’s personal or shared expectation about the rules or the code of conduct… The individual also must be (or become) aware of the discrepancy between his or her morals and the experience (i.e., moral violation), causing dissonance and inner conflict,


Litz, B. T., et al. (2016) paraphrased:

Moral Injury’ is a syndrome of shame, self-handicapping, anger, and demoralization that occurs when deeply held beliefs and expectations about moral and ethical conduct are transgressed. It is distinct from a life threat as it is also not inherently fear-based; it can arise from killing, perpetration of violence, betrayals of trust in leaders, witnessing depraved behavior, or failing to prevent serious unethical acts. (Litz 2016: p. 21, paraphrased)


Brock Definition 2020):

Moral injury is a change in character of persons or group resulting from 1) harmful experiences or life conditions of degradation, oppression, and extremity that 2) they are unable to justify, process, and integrate 3) into a reliable identity and meaning system that 4) sustains relationships and supports human flourishing. Its consequences are broken trust, alienation, a sense of betrayal or failure, and social withdrawal.


Diagram by Dr. William Nash (USN psychiatrist, ret.), Greater Los Angeles VA

Some Moral Emotions:

• Guilt

• Shame

• Embarrassment

• Alienation

• Sorrow

• Remorse

• Outrage/Anger

• Disgust

• Frustration

• Humiliation

• Contempt

• Desire for Revenge

Grief as a Dimension of Moral Injury

· Loss of closest friends;

· Loss of innocence or sense of goodness

· Loss of profession

· Loss of mission

· Loss of role / purpose for others

· Loss of family or capacity for intimacy– conflict / divorce

· Loss of faith and meaning community

· Loss of self—forever changed • Living with broken heart

Aspects of Moral Injury

  • Close correlation of betrayal, in particular, with PTSD. (Jordan, 2017)

  • Can emerge long after events or experiences or immediately after an event.

  • Is found in every war or extremity.

  • Can also result from devastations such as natural disasters, sexual assault, and oppressive

  • contexts such as poverty etc.

  • Creates mistrust and isolation.

  • Alienation is hard to overcome.

  • Can be found in many professions and circumstances, each with its own distinctive features.

Relation of PTSD to Moral Injury



WHO IS SUSEPTIBLE TO MORAL INJURY?

Do the feelings you indicated below cause you significant distress or impair your ability to function in relationships, at work, or other areas of life important to you? In other words, if you indicated any problems below, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?”


Response options include “not at all,” “mild,” “moderate,” “very much,” and “extremely.” Symptoms causing functional disability were categorized as either causing (1) none or only mild disability (not clinically significant) or (2) moderate, very much, or extreme disability (clinically significant).


Child Protective Services People

Moral Injury Event Scale (MIES)– Child Protective Services Version Using Military MIES (Haight, 2017, Everyday)

1) I saw things that were morally wrong

2) I am troubled by having witnessed others’ immoral acts

3) I acted in ways that violated my own moral code or values

4) I am troubled by having acted in ways that violated my own morals or values

5) I violated my own morals by failing to do something that I felt I should have done

6) I am troubled because I violated my morals by failing to do something that I felt I should have done

7) I feel betrayed by leaders who I once trusted*

8) I feel betrayed by fellow service members who I once trusted*

9) I feel betrayed by others outside the U.S. military who I once trusted*

10) I trust my leaders and fellow service members to always live up to their core values

11) I trust myself to always live up to my own moral code

*Omitted for CPS study.


Frontline Workers

Moral Injury Symptoms Scale – Healthcare Professionals Version (MISS-HP), (Manri, et. al., 2020)

1) I feel betrayed by other health professionals whom I once trusted. I feel guilt over failing to save someone from being seriously injured or dying.

2) I feel ashamed about what I’ve done or not done when providing care to my patients.

3) I am troubled by having acted in ways that violated my own morals or values.

4) Most people with whom I work as a health professional are trustworthy.

5) I have a good sense of what makes my life meaningful as a health professional.

6) I have forgiven myself for what’s happened to me or to others whom I have cared for.

7) All in all, I am inclined to feel that I’m a failure in my work as a health professional.

8) I sometimes feel God is punishing me for what I’ve done or not done while caring for patients.

9) Compared to before you went through these experiences, has your religious/spiritual faith strengthened?

10) Do the feelings you indicated above cause you significant distress or impair your ability to function in relationships, at work, or other areas of life important to you? In other words, if you indicated any problems above, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?


RECOVERY STRATEGIES

Individual Recovery Strategies

  • MEMORY PROCESSING: Writing/drawing/enacting personal narratives. Need ways to externalize inner struggle and express story many times. As they are retold, the older layers of the self and new perspectives can emerge in the retellings.

  • HOLISTIC HEALTH PRACTICES: Sleep hygiene, mindful eating, time outdoors.

  • TRUSTWORTHY, BENEVOLENT CONVERSATION PARTNERS: Talking to benevolent moral authority to process moral and theological struggles.

  • SITTING IN THE FIRE: Processing trauma pain by going into and through, so it no longer controls a life narrative and dominates behavior.

  • INTEGRATION OF TRAUMA: Integrating memory/story into a larger life narrative— as memory is processed over time, it will change with new experiences.

  • RESTORATION OF EMPATHY: Rehumanization of Enemies, lessen need to hate or fear, perspective-taking, compassion for self.

  • INTIMATE, CARING RELATIONSHIPS: Reconnection with estranged others.

  • COMMUNITY: Long-term community to sustain meaning-orienting system and a provide ways to serve others.

  • ACCEPTANCE: Compassion for self and others, forgiveness, love of beauty and life, or submission to a meaning system adequate to the magnitude of suffering experienced.

Collective Strategies and Rituals

  • LAMENTATION: to process grief for various kinds of losses.

  • LIMINAL SPACES: (sequester outside ordinary time and space—“eternal now”) to transition from military life and identity to civilian community that understands and cares (ex. Navajo Enemy Way Ceremonial, or ancient Christian penance system). This process places an individual story within the context of a larger one to restore meaning and belonging with support from the entire community.

  • USE OF ARTS: such as music, dance, theater, writing groups, visual art, to integrate all three brain areas and process experience, to restore capacities for joy and love of beauty.

  • SPIRITUAL PRACTICES: that calm stress, enable exploration of inner feelings and emotional intelligence, offer ways to experience trauma pain to burn through it (sitting in the fire), and create inner equilibrium.

  • ENACT ASPIRATIONAL VALUES: the re-humanization of enemies and values that restore collective connections to life.

  • PUBLIC RECOGNITION: commissioning for service work, other symbols of belonging to a larger mission and meaning system. Ways to validate individuals matter to others.

Community Support Strategies

WELCOME: Prepare a welcoming context by

- Offering ministries of presence through open-hearted acceptance and opportunities to serve others

- Practicing deep listening (see details below)

- Attending to ways to create safe gathering spaces for those struggling with post- traumatic stress symptoms and moral injury


SUPPORT: Peer Specialists to Mentor and Facilitate Groups helps create trust quickly. (Many people can have moral injury, esp those who work under emergency life or death conditions—medical care givers, EMTs, law enforcement officers, prison guards, gang members, people in natural disasters, etc.).


FOCUS ATTENTION: Use spiritual practices that create inner emotional/bodily awareness.


CREATIVITY: Think creatively about how people can be lifted in spirit:

- Singing groups

- Ministry through animals (equine therapy, service dogs, and pets)

- Festivals that help restore playfulness, relaxation

- Theater or dance

- Outdoor Activities

- Prayer/meditation groups


GROUPS: Organize groups that facilitate telling personal stories (stories need to be told multiple times for a person to process their trauma story)

- Book groups

- Writing groups using writing prompts to create poetry or personal stories

- Art creation groups, visual, kinesthetic, musical, literary, etc.


HOLISTIC HEALTH PRACTICES: Develop ritual practice groups to learn and sustain embodied calming processes, reflection, spiritual disciplines

- Meditation

- Tai Chi

- Prayer

- Yoga

- Labyrinth Walking

Transformation through Deep Listening

Deep listening is based on empathy and respect, and it can be profoundly transformative and healing. It is rare that anyone has a chance to talk about their deepest pain and most difficult struggles and feel deeply heard without the listener trying to fix or soothe away the pain because they are uncomfortable listening. Just the acknowledgment of our pain and struggle by others can be healing because we are no longer alone and lost inside our pain, even as it is honored as real and true. Instead, it is shared by others who accompany us in our struggle. When we listen with our hearts to another, it is hard to forget what we heard because we have felt their pain, not just heard it.

Kay Lindahl in The Sacred Art of Listening, writes:

There's something beyond technique when two or more people are deeply listening to each other. It is an awareness that not only are we present to each other, we are present to something that is spiritual, holy, sacred.


Such "deep listening" goes against the cultural grain. Lindahl cites research studies by the International Listening Association: we spend about 45 percent of our time listening, but we are distracted, preoccupied, or forgetful about 75 percent of that time. The average attention span for adults is about 22 seconds. Immediately after listening to someone talk, we usually recall only about half of what we've heard; within a few hours, only about 20 percent. (This is probably worse now because of technology devices and their distractions.)

Here are some approaches to deep listening.


l. Start with a ritual. At the beginning, light a candle or sound a gong, for ex., to signify that this is a time for focused attention. The ritual marks the space as special and heightens the feeling of intimacy during a conversation.


2. Listen for understanding, not judgment or evaluation. Give your full attention to the speaker. This is easier to do when you are not distracted by planning what you want to say, your opinion, or how you should to respond. Knowing there will be no questions and asking people to sit in silence after someone speaks allows what is said to settle into our hearts and be received. You are not there to analyze, judge, or try to fix another's experience, just to be fully aware of them and to be present to them. Lindahl writes: "You do not have to agree with or believe anything that is said. Your job is to listen for understanding."


3. Listen and speak from your heart. This means you must be open and vulnerable, willing to describe your yearnings and admit your failings. The listening space is less safe place if we are not hearing with open minds and loving hearts -- and more anxious if listeners respond by evaluating and judging—these are ways of keeping others out of our hearts.


4. Respect the power and difficulty of speaking and allow silences and tears without trying to make the pain go away. Let the full feelings of the speaker be present as a gift of trust.


5. Always ask first if you want to share someone’s story (this agreement of whether or not comments need to be confidential should be decided ahead if a group is closed and private).


Be truly present to the speaker. Don't be distracted by your plans, assumptions, judgments, or need to respond. Experience the deep communion that is possible as you deeply listen to another.


This style of listening without comment is not always appropriate. Obviously, there are occasions when you need to be engaged in dialogue and your responses are expected. But try this approach to listening at least some of the time. (http://www.spiritualityandpractice.com/practices/features.php?id=15570)

From "Slowing Down to the Speed of Love" by Joe Bailey, a licensed psychologist.

Deep listening occurs when your mind is quiet. Your thoughts are flowing rather than crowding your mind with distractions, interpretations, judgments, conclusions, or assumptions. Your mind is open, curious, interested -- as though you were hearing this person for the first time. Deep listening is listening intently and openly, not analyzing or figuring out -- we are simply letting the feelings and sounds affect us. Deep listening is not defensive, argumentative, or intrusive. It is not about struggling to analyze or interpret. It is a purely receptive state of mind. In a state of deep listening, we realize our oneness.


We realize that we are not separate, but truly one spirit -- we are connected. When we listen deeply, we let go of any beliefs we have about the other person. We let go of our prejudices and past memories of him or her.


Preparation via Meditation:

  • Try to sit stable and still, like a mountain. Be relaxed and alert.

  • Listen to what you hear.

  • Do not imagine, name, or analyze what you hear. Just listen with wide-open awareness.

  • As thoughts, emotions, memories, associations arise in your mind, notice them, gently let them go, and return to the speaker.

  • Radar that goes out looking for something and a satellite dish with a wide range just sits in the backyard, waiting. Be a satellite dish. Stay turned on and receive.

  • If there are no sounds, listen, and rest in the silence.

Deep listening applies not only to communication with another, but also to listening to ourselves. The goal is to hear beyond the words to the essence of what the words and feelings are pointing to. When your mind and heart are joined -- you are listening wholeheartedly.


The goal of deep listening is to be touched by the other person, embrace his or her story and truth, and to hear the essence of what he or she is saying.

(http://www.selfgrowth.com/articles/what_is_deep_listening.html)

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