Moral Injury
The International Centre for Moral Injury describes moral injury as an experience of “sustained and enduring negative moral emotions – guilt, shame, contempt and anger – resulting from betrayal, violation, or suppression of deeply held or shared moral values” and “a profound sense of broken trust in ourselves, our leaders, governments and institutions to act in just and morally ‘good’ ways.”
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In March 2022, the Veterans Collaborative had our first virtual community summit on Moral Injury Related to Military Service to educate veterans, mental health care providers, and veteran service organizations about moral injury and the challenges veterans face when their military service required them to act against their values or beliefs, facilitated by Cliff Coy. We heard from:
Dr. Brett Litz, a clinical psychologist and professor in the Departments of Psychiatry and Psychological & Brain Sciences at Boston University, Director of the Mental Health Core of VA Boston’s Massachusetts Veterans Epidemiology Research & Information Center (MAVERIC), and creator of Adaptive Disclosure, a flexible psychotherapy employing strategies targeting threat-based, loss-related, and moral injury-related trauma.
Dr. Mary Ellis, a clinical psychologist with the Boston Vet Center specializing in the treatment of Veterans, Active Duty service members, and first responders, specifically focused on PTSD and moral injury. She earned her MBA from Cleveland State University and PsyD from Wright State University’s School of Professional Psychology. Dr. Ellis completed her pre-doctoral internship at the VA Memphis and her post-doctoral fellowship at VA Boston.
Dr. Wesley Sanders, a clinical psychologist and Marine Corps Reserve veteran with the Home Base Program and the founder of Frost Call, a veterans gaming community. Dr. Sanders specializes in the treatment of PTSD and readjustment issues, including family and parenting difficulties. He received his MA from the College of William & Mary and his PhD from the University of Vermont, completing his internship at VA Boston and his post-doctoral fellowship in the Women’s Health Sciences Division of the VA’s National Center for PTSD.
The summit also included a roundtable discussion with veterans who have experienced moral injury and sharing of information and resources. The list is provided below––this is a living document, so please feel free to add resources to it.
Links to additional resources and information generated during our community summit and since are compiled in the document below. You can add additional resources directly or download the document as a PDF if you are unable to view the embedded document.
Veterans Perspectives & Projects
Betrayal Trauma
Researchers have generally distinguished two types of morally injurious situations based on whether an individual is personally responsible for perpetrating harm (including by failing to prevent harm) or if an individual personally experiences or witnesses harm perpetrated by others.
Research suggests both types are associated with spiritual/existential issues and that these internal conflicts exacerbate social problems (isolation, aggression, legal issues), mental health symptoms (anxiety, depression, PTSD), substance abuse, and suicide risk, however:
personal responsibility was associated with more negative self-directed emotions and cognitions (involving guilt, shame, and self-blame); and
experiencing/witnessing perpetration of harm by others was associated with more negative other-directed emotions and cognitions (involving anger, trust, and other-blame).
The concept of “institutional betrayal” was first described by Jennifer Freyd in 2008. Institutional betrayal involves public health failures, corruption, sexism, racism, and a range of other issues that transpire in the context of a healthcare, military, religious, educational, or other trusted institution. Betrayal Trauma may be experienced by individuals in situations involving institutions.
Wrongdoings are perpetrated by institutions against individuals when individuals responsible for preventing or responding supportively to wrongdoings within an institution fail to do so, such as when an individual reports sexual assault. Victims, perpetrators, and witnesses may all display blindness “to preserve relationships, institutions, and social systems upon which they depend.”
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After wrongdoing is reported, responsible individuals within an institution may fail to respond or take the report seriously, or even attempt to cover up the alleged wrongdoing or investigate and punish the reporter or victim.
Institutional DARVO is described as a “particularly aggressive” form of institutional betrayal, signaling that an institution is either not committed to all of its members or to those it is responsible to protect.
Situations potentiating harm to individuals by institutions may involve or result in illnesses or deaths, increased inequality, or economic ruin, and lead to emotional and physical distress. Institutional DARVO describes specific types of harmful behaviors perpetrators and their defenders may engage in within an institutional context:
Deny the behavior;
Attack the victim confronting them; and
Reverse the roles of Victim and Offender.
DARVO generally involves perpetrators or defenders adopting a victim role, such as by accusing a victim of an offense while portraying themselves as falsely accused. For example:
A victim reports having been sexually assaulted, trusting the institution to investigate their allegation; authorities blame, investigate, or charge the victim with a crime instead.
A nurse reports an issue impacting patient safety, trusting the institution to investigate the allegation; authorities engage in whistleblower retaliation and gaslighting instead.
Freyd introduced the term “betrayal blindness” in 1996 in the context of betrayal trauma as “the unawareness, non-knowing, and forgetting exhibited” towards betrayal, which may involve interpersonal “traumas” (like adultery) and/or institutional betrayal when an institution is expected to support/protect those who trust/depend on it and that trust is violated, resulting in harm.
Freyd founded the Center for Institutional Courage in January 2020, offering a broad knowledge base as an antidote to institutional betrayal. The Center issued The Call to Courage and offers 11 Steps to Promote Institutional Courage for leaders and changemakers within institutions to use as guidance when developing new policies or revising existing ones.
Spiritual Care at the VA
Spiritual Care is available for all VA patients commensurate with their needs, desires, and voluntary consent wherever inpatient or outpatient care is provided. Chaplains are the only authorized subject matter expert within the VA to conduct spiritual assessments, devise spiritual care plans, and provide spiritual care desired by veterans within these settings.
VA Chaplains evaluate veterans’ spiritual needs, resources, and desires, and address their spiritual strengths and injuries in collaboration with other VA providers. VA’s Chaplain Service provides a spectrum of holistic care and enhances spiritual health and wellbeing through worship services, rituals, rites, religious sacraments and ordinances, spiritual care and counseling, and groups.
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VHA Directives articulate the reason for the issue of directives and related issues, in addition to providing key definitions. VHA Directives supersede other national, VISN-level, and facility-level policies or memos issued to the extent they are in conflict.
What is Included in the VA Medical Benefits Package
In general, the entire VA Medical Benefits Package is available to all VA enrolled veterans with specific care provided when it is determined by a VA provider that it aligns with generally accepted practice standards and will promote, preserve, or restore the health of a particular veteran:
Care restores health if it restores quality of life or daily functioning lost due to illness/injury.
Care preserves health if it maintains current quality of life or daily functioning, prevents disease progression, cures disease, or extends the veteran’s life span.
Care promotes health if it enhances quality of life or daily functioning, prevents future disease, or ameliorates an identified predisposition for a condition or early disease onset through monitoring or early diagnosis and treatment.
The Under Secretary for Health has identified improving access to care as a key strategic priority for VHA. VHA Directive 1111 provides policy for ensuring the availability of spiritual care for all persons receiving VHA care. The National VA Chaplain Service is responsible for the content.
Community clergy may provide patient-requested ministry according to their specific faith group’s traditions.
Native American Traditional Practitioners may meet spiritual needs of veterans who desire them. These practitioners are not chaplains and do not have to meet VA’s requirements to qualify as a chaplain. The VA Community Care Network includes several Native American Healing providers in Massachusetts.
Within VHA Directives, you will find background for a policy and related authorities; exemptions; and offices and individuals responsible for implementation, training, and oversight at the national, regional, and local facility levels.
Chaplaincy Innovation Lab
Brandeis University’s Chaplaincy Innovation Lab in Waltham offers Trauma and Moral Injury: A Guiding Framework for Chaplains as a framework to name the realities in which spiritual professional do their work, recognizing an important dimension of trauma as “the difficulty in naming and acknowledging that our worlds have not only been shaken, but, in fact, shattered.”
The eBook explores how trauma and moral injury live in our bodies, our institutions, and our country, questions for chaplains to consider, and resources on trauma and moral injury at no cost.
““Moral injury newly names the consequences of ethical harm that we experience on a personal and collective level.””