Guilt and Shame As a Result of Violating Beliefs: “Moral Injury”

Year 2023, , 387 - 404, 01.10.2023

Erhan Tunç , Gülşah Candemir

https://doi.org/10.37898/spiritualpc.1319074

Abstract

This study on moral injury, which has a content as old as the history of humanity, is believed to contribute significantly to the relevant literature. Despite the limited number of sources in the literature on the subject, which are mostly related to veterans with war experience or limited to the field of religious psychology, this study is expected to fill the gap and provide valuable insights. The study attempted to clarify the distinction between moral injury, which involves a psychological injury caused by a dilemma, and post-traumatic stress disorder, which shares similar features with moral injury and arises after experiencing a traumatic event. As part of this study, psychotherapy approaches within the scope of interventions for the symptoms of moral injury were also included and the issue was tried to be addressed from a mental health perspective. In this context, “mindfulness-oriented meditation”, “self- compassion”, “spiritually-oriented counseling”, and “work focused on forgiving oneself and others”, whose effectiveness has been tested, are included. The issue of moral injury was addressed with psychology- spirituality dimensions; the scope of the study was further expanded with intervention-treatment titles. This study summarizes moral injury’s conceptual framework and focuses on interventions and treatment approaches. As a result, the concept of moral injury was addressed holistically and contributed to the conceptual framework.

Keywords

Moral injury, moral resilience, trauma, PTSD, belief

References

• Altınlı Macić, M. (2022). “Gizli yara: Ahlaki yaralanma”. Mizânü’l-Hak: İslami İlimler Dergisi, 15, 519-554. https://doi.org/10.47502/mizan.1198478
• Arruda, C. T. (2017). The varieties of moral improvement or why Metaethical constructivism must explain moral Progress. Ethical Theory and Moral Practice, 20, 17-38. https://doi.org/10.1007/ s10677-016-9738-1
• Bryan, C. J., Morrow, C. E., Anestis, M. D., & Joiner, T. E. (2010). A preliminary test of the interpersonal-psychological theory of suicidal behavior in a military sample. Personality and Individual Differences, 48, 347–350. http://dx.doi.org/10.1016/j.paid.2009.10.023
• Bryan, C. J., Ray-Sannerud, B., Morrow, C. E., & Etienne, N. (2013). Guilt is more strongly associated with suicidal ideation among military personnel with direct combat exposure. Journal of Affective Disorders, 148, 37– 41. http://dx.doi.org/10 .1016/j.jad.2012.11.044
• Bryan, C. J., Bryan, A. O., Roberge, E., Leifker, F. R., & Rozek, D. C. (2018). Moral injury, post- traumatic stress disorder and suicidal behavior among National Guard personnel. Psychological Trauma: Theory, Research, Practice, and Policy, 10(1), 36–45. https://doi.org/10.1037/tra0000290
• Clarke, D. M., & Kissane, D. W. (2002). Demoralization: Its phenomenology and importance. Australian and New Zealand Journal of Psychiatry, 36, 733–742. http://dx.doi. org/10.1046/j.1440- 1614.2002.01086.x
• Currier, J. M., Holland, J. M. & Malott, J. (2014). “Moral injury, meaning-making, and mental health in returning veterans.” Journal of Clinical Psychology 71(3), 229-240. https://doi. org/10.1002/jclp.22134
• Currier, J. M., Holland, J. M., Drescher, K., & Foy, D. (2015). Initial psychometric evaluation of the Moral Injury Questionnaire-Military version. Clinical Psychology & Psychotherapy, 22(1), 54–63. https://doi.org/10.1002/cpp.1866
• Drescher, K. D., Smith, M. W., & Foy, D. W. (2007). Spirituality and readjustment following war- zone experiences. In C. R. Figley & W.P. Nash (Eds.), Combat stress injury: Theory, research, and management, 295−310. Routledge/Taylor & Francis Group.
• Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Shutz, K., & Litz, B. T. (2011). An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology, 17, 8–13. http://doi.org/10.1177/1534765610395615
• Farnsworth, J. K., Drescher, K. D., Nieuwsma, J. A., Walser, R. B., & Currier, J. M. (2014). The role of moral emotions in military trauma: Implications for the study and treatment of moral injury. Review of General Psychology, 18, 249–262. https://doi.org/10.1037/gpr0000018
• Fjorback, L. O., Arendt, M., Ørnbøl, E., Fink, P., & Walach, H. (2011). Mindfulness-based stress reduction and Mindfulness-based cognitive therapy: A systematic review of randomized controlled trials. Acta Psychiatrica Scandinavica, 124(2), 102-119. https://doi.org/10.1111/ j.1600-0447.2011.01704.x
• Frankfurt, S., & Frazier, P. (2016). A review of research on moral injury in combat veterans. Military Psychology, 28(5), 318–330. https://doi.org/10.1037/mil0000132
• Gradus, J. L., Suvak, M. K., Wisco, B. E., Marx, B. P. & Resick, P. A. (2013). Treatment of post- traumatic stress disorder reduces suicidal ideation. Depress Anxiety. 30(10), 1046-53. https:// doi.org/10.1002/da.22117
• Gray, M. J., Schorr, Y., Nash, W., Lebowitz, L., Amidon, A., Lansing, A., ... Litz, B. T. (2012). Adaptive disclosure: An open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behavior Therapy, 43(2), 407-415. https://doi. org/10.1002/da.22117
• Harris, J. I., Park, C. L., Currier, J. M., Usset, T. J., & Voecks, C. D. (2015). Moral injury and psycho-spiritual development: Considering the developmental context. Spirituality in Clinical Practice, 2, 256–266. http://dx.doi.org/10.1037/scp0000045
• Hayes, S. C. (2004). Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behavior Therapy, 35(4), 639-665. https://doi. org/10.1016/S0005-7894(04)80013-3
• Heinze, K., Hanson, G. C., Swoboda, S. M., & Rushton, C. H. (2021). Measuring healthcare interprofessionals’ moral resilience: Validation of the Rushton Moral Resilience Scale. Journal of Palliative Medicine. https://doi.org/10.1089/jpm.2020.0328
• Holtz, H., Heinze, K., & Rushton, C. (2018). Interprofessionals’ definitions of moral resilience. Journal of Clinical Nursing, 27(3-4), 488-494. https://doi.org/10.1111/jocn.13989
• Hölzel, B. K., Lazar, S. W., Gard, T., Schuman-Olivier, Z., Vago, D. R., & Ott, U. (2011). How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspectives on Psychological Science, 6(6), 537-559. https://doi. org/10.1177/1745691611419671
• Joireman, J. (2004). Empathy and the self-absorption paradox II: Self-rumination and self-reflection as mediators between shame, guilt and empathy. Self and Identity, 3(3), 225–238. https://doi. org/10.1080/13576500444000038
• Kabat-Zinn, J., & Hanh, T. N. (2009). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. Delta.
• Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clin Psychol-Sci Pr, 10(2), 144–156. https://doi.org/10.1093/clipsy.bpg016
• Kearney, D. J., McDermott, K., Malte, C., Martinez, M., & Simpson, T. L. (2012). Association of participation in a mindfulness program with measures of PTSD, depression and quality of life in a veteran sample. Journal of Clinical Psychology, 68(1), 101-116. https://doi.org/10.1002/jclp.20853
• King, A. P., Erickson, T. M., Giardino, N. D., Favorite, T., Rauch, S. A., Robinson, E., ... Liberzon, I. (2013). A pilot study of group mindfulness-based cognitive therapy (MBCT) for combat veterans with post-traumatic stress disorder (PTSD). Depression and Anxiety, 30(7), 638-645. https://doi.org/10.1002/da.22104
• Koenig, H. G., ..., & Al Zaben, F. (2021). Moral injury: An increasingly recognized and widespread syndrome. Journal of Religion and Health 60(5), 2989-3011. https://doi.org/10.1007/s10943- 021-01328-0.
• Kopacz, M. S., Connery, A. L., Bishop, T. M., Bryan, C. J., Drescher, K. D., Currier, J. M., & Pigeon, W. R. (2016). Moral injury: A new challenge for complementary and alternative medicine. Complementary Therapies in Medicine, 24, 29-33. https://doi.org/10.1016/j. ctim.2015.11.003
• Kopacz, M. S., O’Reilly, L. M., Van Inwagen, C. C., Bleck-Doran, T. L., Smith, W. D., & Cornell, N. (2014). Understanding the role of chaplains in veteran suicide prevention efforts: A discussion paper. Sage Open, 4(4), 1-10. https://doi.org/10.1177/2158244014553589
• Kuo, W. H., Gallo, J. J., & Eaton, W. W. (2004). Hopelessness, depression, substance disorder, and suicidality: A 13-year community-based study. Social Psychiatry and Psychiatric Epidemiology, 39, 497–501. https://doi.org/10.1007/s00127-004-0775-z
• Leary, M. R., Tate, E. B., Adams, C. E., Batts Allen, A., & Hancock, J. (2007). Self-compassion and reactions to unpleasant self-relevant events: The implications of treating oneself kindly. Journal of Personality and Social Psychology, 92, 887–904. https://doi.org/10.1037/0022-3514.92.5.887
• Litz B. T., & Kerig P. K. (2019). Introduction to the special issue on moral injury: Conceptual challenges, methodological issues, and clinical applications. Journal of Traumatic Stress, 32, 341–349. https://doi.org/10.1002/jts.22405
• Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706. https://doi.org/10.1016/j.cpr.2009.07.003
• Luoma, J. B., Kohlenberg, B. S., Hayes, S. C., & Fletcher, L. (2012). Slow and steady wins the race: A randomized clinical trial of acceptance and commitment therapy targeting shame in substance use disorders. Journal of Consulting and Clinical Psychology, 80(1), 43-53. https:// doi.org/10.1037/a0026070
• Mantri, S., Lawson, J. M., Wang, Z., & Koenig, H. G. (2021). Prevalence and predictors of moral injury symptoms in health care professionals. The Journal of Nervous and Mental Disease, 209(3) 174-180. https://doi.org/10.1097/NMD.0000000000001277
• Morgan, D. (2003). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. Psychother Res.,13(1), 123–125. https://doi.org/10.1093/ptr/kpg004
• Nash, W. P., Marino Carper, T. L., Mills, M. A., Au, T., Goldsmith, A., & Litz, B. T. (2013). Psychometric evaluation of the Moral Injury Events Scale. Military Medicine, 178, 646–652. https://doi.org/10.7205/MILMED-D-13-00017
• Nieuwsma, J. A., D Walser, R., K Farnsworth, J., D Drescher, K., G Meador, K., & Nash, W. (2015). Possibilities within acceptance and commitment therapy for approaching moral injury. Current Psychiatry Reviews, 11(3), 193-206. https://doi.org/10.2174/1573400511666150629105234
• Niles, B. L., Klunk-Gillis, J., Ryngala, D. J., Silberbogen, A. K., Paysnick, A., & Wolf, E. J. (2012). Comparing mindfulness and psychoeducation treatments for combat-related PTSD using a telehealth approach. Psychological Trauma: Theory, Research, Practice and Policy, 4(5), 538- 547. https://doi.org/10.1037/a0026161
• Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of post-traumatic stress disorder. Behavior modification, 29(1), 95-129. https://doi. org/10.1177/0145445504270876
• Purcell, N., Koenig, C. J., Bosch, J., & Maguen, S. (2016). Veterans’ perspectives on the psychosocial impact of killing in war. The Counseling Psychologist, 44, 1062–1099. https://doi. org/10.1177/00110000166 66156
• Raes, F., & Williams, J. M. G. (2010). The relationship between mindfulness and uncontrollability of ruminative thinking. Mindfulness, 1(4), 199-203. https://doi.org/10.1007/s12671-010-0021-6
• Rende B (2000). Cognitive flexibility: Theory, assessment, and treatment. Seminars in Speech and Language, 21, 121–133. https://doi.org/10.1055/s-2000-7560
• Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic post-traumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70(4), 867-879. https://doi.org/10.1037/0022-006X.70.4.867
• Resick, P. A., Monson, C. M., & Chard, K. M. (2008). Cognitive processing therapy: Veteran/ military version. Washington, DC: Department of Veterans’ Affairs.
• Ross, S. R., Hertenstein, M. J., & Wrobel, T. A. (2007). Maladaptive correlates of the failure to forgive self and others: Further evidence for a two-component model of forgiveness. Journal of Personality Assessment, 88, 158−167. https://doi.org/10.1080/00223890701267985
• Ross, S. R., Kendall, A. C., Matters, K. G., Wrobel, T. A., & Rye, M. S. (2004). A personalogical examination of self- and other-forgiveness in the five-factor model. Journal of Personality Assessment, 82, 207−214. https://doi.org/10.1207/s15327752jpa8202_8
• Rushton, C. H. (Ed.). (2018). Moral resilience: Transforming moral suffering in healthcare. Oxford University Press. Available from: https://oxfordmedicine.com/view/10.1093/ med/9780190619268.001.0001/med- 9780190619268
• Rushton, C. H. (2016). Moral resilience: A capacity for navigating moral distress in critical care. AACN Advanced Critical Care, 27(1), 111-119. https://doi.org/10.4037/aacnacc2016275
• Selby, E. A., Anestis, M. D., Bender, T. W., Ribeiro, J. D., Nock, M. K., Rudd, M. D., . . . Joiner, T. E. (2010). Overcoming the fear of lethal injury: Evaluating suicidal behavior in the military through the lens of the interpersonal–psychological theory of suicide. Clinical Psychology Review, 30, 298–307. https://doi.org/10.1016/j.cpr.2009.12.004
• Spilg, E. G., Rushton, C. H., Phillips, J. L., Kendzerska, T., Saad, M., Gifford, W., ... Robillard, R. (2022). The new frontline: Exploring the links between moral distress, moral resilience and mental health in healthcare workers during the COVID-19 pandemic. BMC Psychiatry, 22, 1-12. https://doi.org/10.1186/s12888-021-03637-w
• Tangney, J. P., & Dearing, R. (2002). Shame and Guilt. Guilford Press.
• Tangney, J. P., Miller, R. S., Flicker, L., & Barlow, D. H. (1996). Are shame, guilt, and embarrassment distinct emotions? Journal of Personality and Social Psychology, 70, 1256–1269. https://doi. org/10.1037/0022-3514.70.6.1256
• Tangney, J. P., Stuewig, J., & Mashek, D. J. (2007). Moral emotions and moral behavior. Annual Review of Psychology, 58, 345–372. https://doi.org/10.1146/annurev.psych.56.091103.070145
• Tunç, M. F., Özdemir, İ., & Ümmet, D. (2022). Adaptation of Moral Injury Scale into Turkish culture. TRC Journal of Humanitarian Action, 1(3), 109-116. https://doi.org/10.55280/ trcjha.2022.1.3.0014
• Vargas, A. F., Hanson, T., Kraus, D., Drescher, K., & Foy, D. (2013). Moral injury themes in combat veterans’ narrative responses from the National Vietnam Veterans’ Readjustment Study. Traumatology, 19, 243–250. https://doi.org/10.1177/1534765613476099
• Walser, R. D., & Westrup, D. (2007). Acceptance and commitment therapy for the treatment of post-traumatic stress disorder and trauma-related problems: A practitioner’s guide to using mindfulness and acceptance strategies. New Harbinger Publications.
• Witvliet, C. V., Phipps, K. A., Feldman, M. E., & Beckham, J. C. (2004). Post-traumatic mental and physical health correlates of forgiveness and religious coping in military veterans. Journal of Traumatic Stress: Official Publication of the International Society for Traumatic Stress Studies, 17(3), 269-273. https://doi.org/10.1023/B:JOTS.0000029270.47848.e5
• Wortmann, J. H., Eisen, E., Hundert, C., Jordan, A. H., Smith, M. W., Nash, W. P., & Litz, B. T. (2017). Spiritual features of the war-related moral injury: A primer for clinicians. Spirituality In Clinical Practice, 4, 249–261. https://doi.org/10.1037/scp0000140
• Yeterian, J. D., Berke, D. S., Carney, J. R., McIntyre–Smith, A., St. Cyr, K., King, L., ... Moral Injury Outcomes Project Consortium. (2019). Defining and measuring moral injury: Rationale, design, and preliminary findings from the moral injury outcome scale consortium. Journal of Traumatic Stress, 32(3), 363-372. https://doi.org/10.1002/jts.22380
• Zalta, A. K., & Held, P. (2020). Commentary on the special issue on moral injury: Leveraging existing constructs to test the heuristic model of moral injury. Journal of Traumatic Stress, 33(4), 598-599. https://doi.org/10.1002/jts.22516
• Zettle, R. D., & Rains, J. C. (1989). Group cognitive and contextual therapies in treatment of depression. Journal of Clinical Psychology, 45(3), 436-445. https://doi.org/10.1002/1097-4679