Help for Moral Injury: Strategies and Interventions, by Cecelia Yocum, PhD (Quaker House: 2016)

Cecilia Yocum’s Help for Moral Injury has as its central theme the clinical experience with counseling services for persons dealing with Moral Injury. Drawn from the work of psychologist Yocum and Quaker House – Fayetteville, NC colleagues, the book is compilation of various documents, gathered together to provide strategies and interventions for helping those who are dealing with moral injury.

As we wrote in our blog post “Moral Injury” in July of 2016,

The phenomenon of moral injury is currently being explored seriously in the areas of military service and torture experience, and it has been recognized as a genuine challenge by leaders of the U.S. Armed Forces branches and the Department of Veterans Affairs.1 It is also becoming the object of broader serious discussion in areas of human experience relating to sexuality, abortion, child abuse and poverty.

Yocum’s premise, supported by observations and experience of clinicians, is that Moral Injury is different from Post-traumatic Stress Disorder (PTSD), and should be recognized as a separate and serious health challenge.

PTSD is characterized by a physical response to fear, danger, hyper alertness, and a rise in adrenaline, all of which are necessary for survival in objectively physically dangerous situations. When these reactions become involuntary reactions to remembered life-threatening fear in circumstances that are not objectively physically dangerous situations, tis condition is PTSD.

PTSD treatments do not work for persons dealing with Moral Injury, and remedies for the latter go deeper and are more complex that those for more general stress-related suffering. Common treatments suggested for Moral Injury include lifestyle improvements through exercise, journal writing, identifying/engaging/enhancing personal spiritual/moral resources, a listening presence, acceptance, forgiveness, and amends (direct and indirect).

Here is a summary of current knowledge of Moral Injury as outlined in this book:

• Moral Injury is the personal experience of perpetrating, witnessing, failing to prevent, or learning about acts that violate deeply held, personal moral beliefs.
• Moral Injury results in feelings of shame, guilt, grief, meaninglessness, and remorse.
• Resolution of Moral Injury requires acceptance of the wrong done, forgiveness through rituals, and atonement (through amends).
• Resolution of Moral Injury should be understood as a long-term process.
• Moral Injury has a lasting impact on the person’s life and their community.
• Observing and failing to prevent an event resulting in moral injury includes situations involving actions or obedience to authority orders.
• The currently most well-known Moral Injury circumstance involves obedience to military authority in war.

Implicitly, the author recognizes moral injury as a universal reality in all cultures and militaries, though her own experience is primarily with the moral injuries presented by U.S. military personnel in this book. However, the author recognizes that moral injuries can be the result of traumatic events outside the current military context.

PTSD and Moral Injury share characteristics of anger, depression, anxiety, insomnia, nightmares, and self-medication behaviors. However, Moral Injury does not share the startle reflex, memory loss, fear, and flashbacks of persons with PTSD. PTSD persons do not share sorrow, grief, regret, shame, and alienation of persons with Moral Injury.

The author recognizes that a person may be dealing with a combination of PTSD and Moral Injury. This combination is more difficult to address. It is important to separate assessment of PTSD and Moral Injury for effective resolutions.

The discernment process necessary in managing Moral Injury includes:

• Acknowledging the reality of Moral Injury;
• Assessing culpability;
• Recognizing internal spiritual resources;
• Accepting forgiveness; and
• Making amends

Moral Injury is not an injury to a moral code. Moral codes are not injured. Moral injury is injury to a person.

As stated above, identifying, recognizing, and strengthening the spiritual resources of the person from their past is essential. Journal writing is a private, life-stabilizing exercise and a source of insight for discernment. A listening presence of another person or counselor is a gift of respect in itself to another person and a confirmation of the Moral Injury reality for the person.

Forgiveness can be a one-time liturgical event or a series of events in a life-long process. Amends are various for each person. Amends can be both direct and indirect to the person harmed, their community, other communities, or the world.

The author assumes the reality of Moral Injury. Not addressed in the book is the current controversy among U.S. military leaders and global military leaders regarding the reality of Moral Injury and its treatment. The arguments against the recognition of Moral Injury include:

1. Moral injury (MI) is not universal in the military experience in all cultures.
2. Moral injury in U.S. military experience is rare.
3. Moral injury is not observed in U.S. military experience, except in rare circumstances.
4. Moral injury did not occur for U.S. military personnel in World War I, World War II, Korean War, or Vietnam War.
5. Moral injury is not a result of personal actions in U.S. military experience, except in rare circumstances.
6. Moral injury is not a result of observing actions of others in U.S. military experience, except in rare circumstances.
7. Moral injury does not appear in later life of U.S military personnel.
8. Moral injury has no significant effect on later life of U.S. military personnel.
9. Moral injury is not related to PTSD in U.S. military personnel in any significant way.
10. Any Moral Injury is easily and permanently resolved for U.S. military personnel with medication and counseling.

Quakers: Moral Injury provides an opportunity for all religious traditions to engage in healing ministries, and it is an important reality particularly for Quaker understanding. Moral Injury will impact Quaker advocacy, discernment, and counseling. Moral Injury will also impact treatment of law enforcement personnel. Finally, Moral Injury raises additional concerns for the parenting of youth.

Questions:

• How can Quakers contribute to the clarification and mitigation of Moral Injury?
• What can Quakers point to in the Quaker testimonies to address Moral Injury?
• How can Quaker practice and procedure be applied to addressing Moral Injury?

 

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Note & Image Source

1 “Moral Injury in the Context of War,” by Shira Maguen, PhD and Brett Litz, PhD, PTSD: National Center for PTSD, U.S. Dept of Veterans Affairs (2016).