What Is Moral Injury and Why Should Friends Care?

holdingheadIn March 2014, I drove to Durham, North Carolina, to participate in a regional conference on moral injury, co-sponsored by the Soul Repair Center at Brite Divinity School in Fort Worth, Texas, and Quaker House of Fayetteville, North Carolina. I had seen the promotional materials on the Quaker House Facebook page and was intrigued, and admittedly not at all sure what it was about. I had the time, and it seemed like a good opportunity to go find out.

The conference brought together people from different area churches and congregations to hear from Rita Nakashima Brock, the director of the Soul Repair Center, as well as active military, Veterans Administration (VA) personnel, and veterans who are engaged in examining and confronting the damages caused by moral injury among our nation’s veterans. It has been suggested that the long-term, pervasive effects of moral injury may actually cause more harm than post-traumatic stress disorder (PTSD), with which more people are familiar. While it can be hard to disaggregate all of the potential causes, moral injury has been implicated in the rising rates of soldier and veteran suicide.

What is moral injury?

Moral injury comes from the recognition that one has violated one’s core moral beliefs, leading to feelings of shame, grief, meaninglessness, and remorse. Living with these deep scars affects the veterans, their families, and communities. It isn’t just remorse over actions that might be considered unnecessary or avoidable, or failing to prevent abuse; even “justifiable” actions can deeply wound. Moral injury is not limited to those who question the morality of war or the morality of a particular war. Even those who do not question their participation in a military exercise can experience deep moral injury. The consequences include overwhelming depression, guilt, self-medication through drugs and alcohol, feelings of worthlessness, remorse, and despair, and trouble connecting emotionally with others. They feel as though they have “lost their souls in combat,” as described by Rita Nakashima Brock and Gabriella Lettini in their book, Soul Repair: Recovering from Moral Injury after War, and suicide is seen as relief.

How does it differ from post-traumatic stress disorder (PTSD)?

PTSD, on the other hand, is a cognitive disruption to anxiety management as a result of hormonal “conditioning” during extended exposure to trauma. The physical and emotional reaction to danger, or any sensed threat, is effectively short-circuited in the prefrontal cortex and amygdala where intense memories can affect self-control, reasoning, and decision-making. This is why those with PTSD often experience flashbacks, nightmares, hypervigilance, and an exaggerated startle reflex. Their response is being guided unconsciously and automatically by the feelings and experiences of the past rather than the current actual situation. They have lost their sense of the world as a safe place.

PTSD is best managed clinically, and current treatment is grounded in cognitive processing therapy, a type of cognitive behavioral therapy specifically designed for the alleviation of PTSD. With this therapy, sufferers learn to reprocess their experiences so that they can address the “first rank” anxiety issues, including hypervigilance, exaggerated startle reflex, mistrust, memory and concentration issues, anger and violence, and flashbacks. It is less effective on the “second rank” or relational issues of depression, isolation and alienation, substance abuse, despair, and loss of meaning.

The VA tried to get PTSD diagnosed as an injury rather than a disorder, given its biochemical foundation and changes in the brain, but was unsuccessful. They have also accepted a definition of moral injury and, in recognition of the differences, are disaggregating it from PTSD as much as possible.

PTSD and moral injury may be concurrent, or not. The symptoms and intense experience of PTSD may mask moral injury. In those cases, it is only when the PTSD is brought under control that the veteran is able to form a coherent narrative of his or her experience. It is at this point, moral questions begin, along with experiencing a loss of identity or questioning of character. Clinical interventions are less effective with healing these wounds. We develop our moral conscience over time and in community; it is there that any healing must occur, to regain a sense of who we are and what we are.

There are many explanations for why we are seeing increased rates of PTSD and moral injury: changes in training methods (reflexive fire training, dehumanizing the enemy), feelings of betrayal by authorities (violations of military code, sexual assault, failure to prevent abuse). What is agreed upon is that there is a serious problem that must be addressed, and the VA cannot do it alone. Among the hindrances the VA faces is the requirement that it provide only evidence-based treatments, and there is not yet a sufficient evidence base for moral injury interventions.

What is the current response to moral injury?

The Soul Repair Center at Brite Divinity School (soulrepair.org) is leading the way on research and public education on the issue of moral injury and how communities can respond. They are working with veterans’ organizations on re-entry programs, a kind of “reverse boot camp” to help vets process their experiences, including an organization that focuses on the particular needs of women veterans.

Recognizing the need for deep listening and mutual support, they are piloting some initiatives in mentorship as well as Soul Repair Meetings (similar to 12 step programs), especially for the large number of veterans who identify as non-religious or spiritual but not religious. They also work with clergy and faith communities on supporting individuals and groups of veterans and becoming “vet-friendly congregations.”

Quaker House (quakerhouse.org), in Fayetteville, is working to raise awareness about moral injury through speaking engagements and public events, and they are incorporating this new lens for understanding veterans’ issues into their other programs, such as domestic violence within the military. Their work on moral injury and their co-sponsoring the 2014 conference on Soul Repair in Durham not only has resulted in the formation of the Carolina Soul Repair Coalition, but also has created an entry point for greater contact and dialogue with Fort Bragg chaplains and other personnel.

Participants at the Soul Repair Conference in Durham, N.C., March 2014.
Participants at the Soul Repair Conference in Durham, N.C., March 2014.

Why should Friends consider getting involved?

American Friends, whether we pay taxes or are tax-refusers, are all part of the society that sends young people to war. Protesting the war, lobbying our legislators, and generally making a joyful nuisance of ourselves does not exempt us from collective responsibility for the human costs of war, for damaged young men and women who struggle to regain a sense of self upon return from war.

One of the greatest needs of those experiencing moral injury is a safe space to tell their stories—and to tell them repeatedly—to help them regain an understanding of their personal narrative and to explore how they might live with their new identities: the forever-changed self incorporating both the pre-service sense of self and the changes brought about by what was done and experienced.

Friends have many tools at their disposal for discernment and for deep, compassionate listening. Perhaps we can offer some of this cool water to those who thirst.

But please, discern before acting

Before getting involved, either individually or collectively, it is important to educate oneself and truly discern whether or not this work is for you. Veterans have strong “BS meters” and don’t like to be patronized.

We need to confront our own issues, understandings, and internal conflicts over war and peace and not rely on platitudes and easy explanations. We have to go deep within ourselves. Simply claiming the moral high ground of being “against war” will create a barrier to real communication.

Some queries for individual and group discernment might include the following:

  • What are our feelings about war and militarism, pacifism, and those who serve in the military, especially in the era of an “all volunteer army”?
  • Can we avoid being “triumphalist” about our antiwar or pacifist stance?
  • Are we prepared to have a challenging and nuanced discussion among ourselves about the moral complexity of war and society’s obligations?
  • What would happen if a veteran appeared at our next meeting for worship? What might he or she experience? Does the physical environment of our meetingroom meet the needs of some particularly vulnerable veterans? What might they think of the ministry typically offered on the issues of war and peace?
  • Are we able to look for and recognize that of God in combatants?
  • Those seeking clearness with a committee might ask themselves the following: Am I ready and able to put aside my own feelings about war and the military to listen deeply to the challenging experiences of veterans (and their families)? Am I open to being transformed by this experience and to letting go of some of my own certainty?



Kristen Richardson

Kristen Richardson is a member of Chatham-Summit Meeting in New York and Friends General Conference’s Quaker Quest travel team. A former international aid worker, she continues to seek opportunities to put her program, strategic, and spiritual skills into the service of those who need them most through a ministry of management.

3 thoughts on “What Is Moral Injury and Why Should Friends Care?

  1. Moral Injury or Soul Injury?

    Many thanks to Kristen Richardson for her August 2015 article on “Moral Injury.” The trauma experienced by thousands of veterans has been responsible for the increase in veterans’ suicides, domestic violence and drug abuse. The Veterans Administration has chosen to label this condition as “moral injury”. However, many authorities refer to it as “soul injury”, and the healing process as “soul repair.” This stems from a belief that moral injury might imply wrongdoing and possibly carry unwelcome religious connotations.

    Clearwater Monthly Meeting’s experience with the topic of moral/soul injury started in April of this year when we set up a booth in the theatre lobby of a performance called “Telling:Tampa Bay,” which was part of an ongoing series sponsored by the Florida Humanities Council for veterans to tell their stories to their local communities. Our booth had printed literature on moral injury provided by Quaker House and a sign up-sheet for anyone seeking an opportunity to learn more. Even those who had never heard the term recognized what it meant to them and their loved ones. Because of this response, our meeting felt led to raise public awareness of moral injury and reach out to our veterans at the same time.

    To prepare ourselves with more information we sought guidance from Quaker sources. The first source was from two Florida monthly meetings, Tampa and Jacksonville, who had already conducted public gatherings on this topic and, of course, Lynn and Steve Newsom from Quaker House. We decided to organize a public forum, called it “An Open Conversation on Moral Injury” and invited Lynn and Steve to Clearwater to give the opening presentation and guide the discussion.

    We visualized a safe place where people could learn more about moral injury and share their thoughts and feelings. The conversation needed to include not just veterans, families and friends but also health care professionals, veterans’ service organizations, members of the faith community and concerned citizens. To this end we advertised in local papers and radio stations, posted fliers, called all referrals, emailed, snail mailed and engaged face to face with anyone who would listen.

    The result of this effort is still having its effects on our meeting. To our surprise, a comfortable 70 participants filled the seats. Not only did Lynn and Steve give a deeply moving, effective and informative presentation, one of the attenders, Deborah Grassman, spontaneously became part of their presentation. Deborah, co-founder of an organization called “Opus Peace” (www.opuspeace.org), has personally worked with over 10,000 dying veterans as a hospice nurse for the VA and brought the perspective of how unresolved trauma resurfaces at the end of life.

    The open discussion portion of the program brought participants to tears while listening to stories of pain and grief. Also, there was laughter. Everyone was touched by the open sharing. Although the conversation could have gone longer, it felt important to keep the 90 minute schedule as promised. Nevertheless, attenders lingered afterwards to seek each other out, crying on shoulders, offering support and help all the while expressing their gratitude for this opportunity to be together.

    Our mission to create greater awareness about moral injury was now presenting a new challenge as the meeting began questioning what is the next step. How can we bring people together? Where can the soul healing start ? Who is doing this work? In response we decided to try networking with attenders from our conversation who were committed to helping veterans and determine if there were common concerns on the topic.

    Our first call was to Deborah Grassman at Opus Peace which is conveniently based in nearby St. Petersburg, Florida. She and co-founder Pat McGuire have gathered a group of dedicated, informed individuals who help veterans and their families with the healing process. Their audience is far reaching as they travel around the United States giving workshops and presentations on soul injury and soul repair. We are encouraged by what they are doing and shall continue following our leading to help bring peace to veterans and their families. We acknowledge the “soul” in moral injury and hope to do more to aid those seeking repair.

    Eileen Zingaro
    Clearwater Friends Monthly Meeting

  2. Thank you for this thoughtful and meaningful piece, Kristen, and for the work you do. This is a really important topic.

    I am a Clinical Social Worker at a VA clinic, and I just wanted to clarify a misstatement about the VA. I have to preface this by saying that I am NOT speaking for the VA in any official capacity, but just sharing my own experience as a therapist here.

    You said, “Among the hindrances the VA faces is the requirement that it provide only evidence based treatments…” In fact, the VA encourages, develops, and promotes the use of evidence based treatments, but does NOT require using ONLY those treatments. There is ample room for a clinician’s discretion, and a veteran’s preference of treatment modality. We would never force a certain treatment modality on any given individual, if they did not want to undergo that particular treatment, and not all EBTs are appropriate for all individuals. So, despite there being no EBT specific to moral injury, we treat it every day, in a variety of ways. Acceptance and Commitment Therapy (an EBT) is one approach that is often a good fit for addressing moral injury. As is “regular” therapy, where one processes and comes into contact with their own internal experience in the supportive environment and safety of therapy.

    So, thank you for the above article and the work that you and others are doing re moral injury. I just wanted to clarify that small point, which will, I hope, bring more understanding about what we do at the VA.

    Respectfully yours,
    Julie Ainslie

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