By William P. Nash and Christa Davis Acampora
Most of the themes that have coalesced in recent years around the concept of Moral Injury have been around a long time. The term may be relatively new to this context, but the central ideas are ancient: that there can be dire consequences for wrongdoing, both for the wrongdoer and for the wronged, and that those consequences can endure for lifetimes and even ripple across generations. Some consequences are internal, like the painful and sometimes overpowering emotions of shame, guilt, and anger, or losses of the competency, value, and trustworthiness of our core selves. Other consequences are external, such as losses of resources or social standing, or being expelled from the group, figuratively or literally.
Another enduring theme is that we don't all agree on what's right and what's wrong, even in peacetime. In situations of conflict, it can be daunting to find the least bad option in each situation, and to find it before it's too late. Some moral standards are culturally defined; others are very personal. We are not equally invested in moral rules and their consequences, from person to person and over the course of each of our own lives. Yet we are all experts at denying our own wrongdoing, exactly for fear of its consequences. We can also too easily convince ourselves that consequences don't exist or that they simply don't matter. Thus, Moral Injury is in no way unique to the battlefield, as the contributions to this volume attest.
There are also ancient themes of hope feeding the Moral Injury conversation—hope springing from how tenaciously we can fight to right perceived moral wrongs, to atone for our sins and to seek atonement from those who have wronged us; how we can remain compassionate with ourselves and others in the face of deep shame and anger; how we can find meaning in chaos; how we can forgive ourselves and others, even when it makes no sense at all to do so; and how we can become better people, day by day, given the chance.
These themes appear in the most ancient of writings, including the world's sacred texts. It would be hard to find a great novel, movie, poem, or song that didn't touch on one or more of these themes, comedically or tragically. The imperatives and challenges of living a life of meaning and purpose, and the consequences of perceived failure to live up to moral expectations, are just that central to who we are.
Though we may be familiar with these seemingly universal themes, we haven't yet woven them into a sturdy fabric of actionable understanding when it comes to Moral Injury. The concept has not one definition but many. We can list any number of potentially morally injurious events in various life situations, but we don’t yet have a robust theory to reliably predict what else we haven’t thought of that belongs on this list. We can describe some of the biological, psychological, social, and spiritual characteristics of Moral Injury as a state of being, but we don’t know which of those characteristics might be necessary and sufficient for recognizing Moral Injury in ourselves or others. And though many approaches have been proposed for moral repair as a process of rebuilding after Moral Injury, we don’t yet know what works and what doesn’t, or for whom.
We are still the proverbial blind men and women unwittingly describing the parts of an elephant that are close enough to touch, yet we have no idea how trunk, ears, tusks, and tail might possibly fit together on one beast, or even whether what we perceive are truly aspects of just one entity.
If conversations about Moral Injury are to advance understanding and lead to rational action, they must transcend boundaries of perspective, language, and ideology. We need books like War and Moral Injury: A Reader, to provide a platform for many voices, many perspectives, many experiences, regardless of whether they appear to converge on any common themes. We are way too early in the game to limit ourselves to only one or a few perspectives. Nothing should be excluded until we are much further along in our understanding
That’s one reason we decided to write this foreword together, as the result of our own Moral Injury dialogue, so that our gateway into this important book would also be multidisciplinary.
Here’s a cautionary tale about the potential dangers of prematurely narrowing the conversation about Moral Injury. It comes from the early decades in the life of the concept of post-traumatic stress disorder (PTSD), a psychiatric diagnosis that overlaps with Moral Injury in definite but unclear ways. The diagnostic criteria for PTSD that first appeared in the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980 were drawn from two precursor constructs: post-Vietnam syndrome and rape trauma syndrome. Importantly, the DSM-III criteria for PTSD were formed from the features that appeared to be common to both syndromes, such as nightmares, flashbacks, avoidance of reminders, and overdrive of the sympathetic nervous system. But what happened to the features thought to be characteristic of one or the other syndrome but not both? They were ignored. Among the orphaned features of post-Vietnam syndrome were the following, copied from a 1981 paper by Matt Friedman, the psychiatrist who became the first executive director of the VA’s National Center for PTSD (Friedman, “Post-Vietnam Syndrome,” 933).
Guilt figures strongly in post-Vietnam syndrome and includes not only survivor guilt because close friends were killed in combat, but also guilt about Vietnamese (especially women and children) who were killed in the line of duty. A feeling of betrayal may accompany the guilt as the combat veteran becomes convinced that society and the government have failed to acknowledge or reward his personal military sacrifice. The result is an abiding distrust of the Veterans Administration, the Armed Forces, and other organizations.
And of course, Vietnam was not the first war in which guilt and anger over perceived violations of moral expectations were recognized. WWII aircrew pilots who heaped devastation on civilian cities reported similar experiences lasting for years after they returned. And there were many other instances.
Omitting the gnawing moral aspects of post-Vietnam syndrome from the criteria for PTSD cleared the way for scientific conceptions of psychological trauma to narrow even further and become mostly, if not solely, about fear conditioning. Subsequent editions of DSM required exposure to an event that threatened one’s own life or limbs for the diagnosis of PTSD to apply. And psychological treatments for PTSD were based on learning theory (since conditioning is a form of learning), supported by decades of basic research using rat models of fear conditioning as a proxy for PTSD. Concern is growing that the disappointing performance of talking treatments for PTSD may be traced to the narrow conception of PTSD as a disorder of fear and brain fear circuitry.
It doesn’t seem surprising that guilt never figured as strongly in rape survivors as it did in in combat veterans, but what about anger over perceived betrayals of trust? Tragically, there is evidence that rape survivors who expressed significant anger were criticized by their care providers for what was conceived to be a maladaptive coping response on their part. Anxiety was to be expected; anger was not—despite evidence over many decades that anger, rage, and hatred are common among survivors of serious assault, especially at the hands of someone known and trusted.
There is a palpable note of urgency in much of this book. Urgency for what? Urgency for the authors to act through their writing, perhaps, because moral injuries task the injured to do something about it: to neutralize a recognized moral danger or at least to warn others about it, to comfort others who are morally injured while encouraging their rebuilding work, and to atone, of course, and to seek atonement. There may be urgency to share what has been experienced and learned to expand our store of information about Moral Injury, and urgency to motivate others to act.
We are honored to add our voices to this important work, and to respond to the authors’ call. We are determined. And hopeful.