Rightin’ wrong: A model for supporting individuals experiencing moral injury

Author: Dr Shannon Hood and Rev Michael George

Publish date: November 23, 2023
Reading Time: 16 minutes

https://doi.org/10.52456/WACJO321

Abstract

This paper proposes a support model for individuals who might be experiencing moral injury. There is no agreed definition for moral injury (Hodgson et al., 2021). For the purposes of this paper, we suggest moral injury is the ongoing negative experience of being exposed to one or more events that are beyond an individual’s moral boundaries. The paper begins with a brief exploration of this definition. Moral injury is not a mental illness (Williamson et al., 2021) and therefore it is inappropriate to speak of ‘treatments’. Instead, moral injury tends to be classified as a syndrome (Koenig & Al Zaben, 2021). In this sense it sits somewhere between a symptom and a formal disease or disorder. As a result, we speak of supporting (not treating) an individual experiencing moral injury. By extension, this support does not require the expertise of a mental health clinician. In fact, the support model suggested in the article should extend beyond mental health professionals to include chaplains, peer support officers and even appropriately trained workplace managers and colleagues.

The support model is made up of six elements, described using the acronym ‘SAF T LOCK R’ (Story, Assess/Analyse, Forgiveness, Test/Try, LOCK in the changes, Review/Refer). These six elements are presented in a somewhat logical sequence although, in practice, the experienced moral injury supporter will adjust the length and sequence of each element to suit the individual. There may even be times where some elements can be omitted altogether. This flexibility and its adaptability to numerous contexts is an advantage over other approaches to support moral injury such as pastoral narrative disclosure (Hodgson & Carey, 2022), which is a rigorous eight-step process designed exclusively for chaplains in a defence context.

Keywords: moral injury, spirituality, forgiveness

The SAF T LOCK R model for supporting individuals experiencing moral injury

Moral injury could be defined as the ongoing negative experience of being exposed to one or more events that are beyond an individual’s moral boundaries. There are some key components of this definition that warrant exploration. One individual’s moral boundaries will differ from the next person and they may change over time. What a person deems morally acceptable when they are 15 years old may be different to when they are 50. The journey of life will expose us to countless events. Some of these we will witness, some will be done to us and some we will do ourselves. Hopefully many of these events are pleasant and enjoyable. However, there will be occasions where these events fall outside of our moral boundaries (what we believe to be right and wrong). In these cases, we may experience some level of temporary discomfort – noting that we may also be completely unaffected by exposure to such events (they will be ‘water off a duck’s back’ so to speak). On some occasions the discomfort will be long lasting. It is in this case that we might find ourselves ‘morally injured’. Simply speaking, there are two ways of resolving this. The first is to choose to shift our moral boundaries. This may sound extreme but is the experience of the authors that in practice it is very common. For example, the seasoned emergency services first responder or long-serving soldier is likely to conclude that somethings they considered unacceptable at the start of their career have somehow become OK and no longer trouble them. They have moved their moral boundaries. The second process of resolution is more complex. The event/s cannot be changed and if the boundaries cannot be moved then our attention is drawn to reducing the ongoing negative impact to an extent that the individual can live a flourishing life in spite of their exposure. To that end, the ‘SAF T LOCK R’ model – a six-element process for working with people who have experienced moral injury – has been developed by the current authors and is  outlined below.

Story

There is healing to be found in simply telling one’s story (Gu, 2018; Rosenthal, 2003). If the story is traumatic, then this can be a form of helpful exposure therapy (Held et al., 2018). Telling and recasting our stories is at the core of narrative therapy (Bryant, 2021). At best, the experience of storytelling can be deeply cathartic, at worst it can be iatrogenic. With respect to moral injury, it is helpful to consider the idea that the person has two stories to tell. The first story relates to the event/s itself, the second story is their personal journey since the event/s transpired. Exploring both stories can be helpful.

Simply allowing space for the person to recount the event/s may cause the person to see the event/s in a new light. Some gentle questioning such as ‘what do you think might have motivated X to do that?’ might cause the individual to think differently about the perpetrator. Carefully timed and crafted questions that actively seek growth such as ‘in the midst of the pain you have described do you feel you have grown in any way?’ might help the person see the event/s in a fuller perspective. When the individual has been the perpetrator of the moral wrongdoing it is very possible their shame has prevented them from telling anyone else the details of the story. Individuals often describe a great sense of relief and release when they can tell their story, which may have been bottled up for many years. Sometimes, simply having a chance to air the story is enough to remove its sting.

The second story relates to how the person has coped since the event/s. What changes in mood and behaviour have they (or their loved ones) noticed? How are they different as a result of the event/s? This second story is important as the details of the event/s may not be able to be changed but one/s reactions as a result may have some room to move as we will explore in the next element.

Assess/analyse

This element of the support process involves assessing the type and extent of the moral injury as well as helping the individual ‘pull-it-apart’ so they understand it better. The assessment can be formal or informal. Formal assessments may involve a validated tool such as the Moral Injury Exposure and Symptom Scale – Civilian (MIESS-C) (Thomas et al., 2023) or the Moral Injury Scale – Youth[1] (MISY) (Chaplo et al., 2019). These formal tools will not only assist in quantifying the extent of moral injury but will also be helpful in defining the type of injury involved. Of course, they will be also invaluable in asking the primary question of whether this person’s experience is in fact moral injury at all.

The three types of moral injury stem from the role the individual played in the event. They may be the perpetrator of the moral injury. In this case, it was something they did (or failed to do) that is causing the moral injury and the symptoms are likely to be described using words such as guilt or shame. Alternatively, the individual may be the victim of a moral injury – something that has been done to them, in which case they are likely to describe their symptoms as betrayal or abuse. The third type of moral injury occurs when an individual is a witness to one or more events, usually resulting in symptoms such as disbelief, shock or disappointment. The assessment/analysis element is designed to assist the individual in better understanding what is happening for them by giving some language and categories to describe their situation.

The more advanced moral injury supporter may use their analysis of the story to incorporate some basic cognitive behavioural therapy (CBT) techniques where appropriate. A common example that emerges when working with moral injury is an individual’s experience of false guilt. False guilt (sometimes known as toxic guilt or harmful guilt) is experienced when an individual is ‘quick to accept that everything is their fault even though it isn’t’ (Cikanavicius, 2018, para. 8). Basic CBT techniques can be very helpful in helping the individual adjust their thoughts or behaviours following the event and as a result diminish the level of negative experience.

Forgiveness

There are times in life when humans conduct themselves in immoral ways toward one another. No amount of storytelling nor cognitive reframing can escape the fact that someone has exposed another individual to a moral offense that causes ongoing negative impact. In these cases, the only constructive option is forgiveness. Of course, forgiveness is a two-sided affair and supporting an individual through forgiveness varies according to which side of the offense they find themselves.

When the individual is the victim of the offense

Let us first consider the situation where the individual has been offended against. According to Tripp et al. (2007) there are four possible pathways toward justice: revenge, reconciliation, forgiveness and avoidance. These show surprising alignment with Augsburger’s Offender-Offended grid, which suggests four possible outcomes: revenge, authentic reconciliation, forgiveness and denial (1996:93) especially when one considers Enright’s view that denial is one type of avoidance – along with suppression, repression, displacement, regression and identification (2001:95–101). Enright later asserts: ‘One may forgive and not reconcile, but one never truly reconciles without some form of forgiveness taking place’ (2001:31). We, along with Watson et al. (2016), would therefore suggest that in the short term, the person who has been offended against has three immediate options: revenge, avoidance or forgiveness, with reconciliation being a medium-term possibility after some level of forgiveness has occurred.

In practice, the person seeking support following a moral injury may well have explored revenge and experimented with a variety of avoidance strategies, yet continues to live with negative experience often characterised by a sense of betrayal or abuse. The supporter has at their disposal countless tools to assist in the process of forgiveness, and the SAF T LOCK R model recommends a collaborative approach in selecting the forgiveness tool that will best suit the individual. While many forgiveness tools take a psychological approach (Elliott, 2011; Enright, 2001; Worthington et al., 2010), SAF T LOCK R encourages the supporter to consider applying a tool that aligns with the individual’s spirituality. While The discipline of psychology is less than 200 years old, but the major world religions have been engaging in practices of forgiveness for thousands of years.

The ten-day period known as the ‘Days of Awe’ – Rosh Hashana, Yom Kippur and the days between – is a popular time for forgiveness. Observant Jews reach out to friends and family they have wronged over the past year so that they can enter Yom Kippur services with a clean conscience and hope they have done all they can to mitigate God’s judgment. (Cohen, 2022, para. 7).

For the Muslim, the Qur’an promises: ‘If any one does evil or wrongs his own soul but afterwards seeks God’s forgiveness, he will find God Oft-forgiving, Most Merciful’ (Surah 4, v. 110). Encouraging forgiveness, the Buddha said: ‘Hate never yet dispelled hate. Only love dispels hate’ (Dhammapada 1:5). Those following the Buddhist faith are exhorted to forgive as a way of reducing suffering.

Perhaps the Christian faith places the greatest emphasis on forgiveness, with Jesus exhorting: ‘For if you forgive other people when they sin against you, your heavenly Father will also forgive you” (Matt. 6:14), teaching echoed by St Paul in his letter to the church in Colossae: ‘Bear with each other and forgive one another if any of you has a grievance against someone. Forgive as the Lord forgave you’ (Col. 3:13).

Forgiving is never easy. While some psychological approaches may be helpful, many individuals find forgiveness impossible by sheer force of will, yet are able to extend forgiveness in ways they might describe as supernatural when their spirituality is involved.

When the individual is the perpetrator of the offense

When the individual has offended another by something they have done or something they failed to do, they may be left with emotions of shame and guilt. While psychological models (Elliott, 2011; Enright, 2001; Worthington et al., 2010) should not be discounted and may be the only alternative for the individual who claims no spirituality or does not want their spirituality included in the support process, SAF T LOCK R again advocates for the inclusion of a perpetrator’s spirituality when seeking forgiveness. This will take the form of apology, confession or repentance.

In Islam, sincere repentance is known as taubah. This requires the follower to:

  • recognise and admit they have made a mistake;
  • ask forgiveness from Allah and if the sin was against a person, they have to ask forgiveness from that person also;
  • try to atone for the sin if possible by, for example, returning money if it was stolen;
  • make the intention never to do the sin again (Matthews, 2023, para. 6).

Ken Sande (2004) approaches forgiveness from a Christian worldview and advocates for a similar list of what he describes as ‘The seven As of confession’:

  1. Address everyone involved;
  2. Avoid ifs, buts and maybes;
  3. Admit specifically;
  4. Acknowledge the hurt;
  5. Accept the consequences;
  6. Alter your behaviour;
  7. Ask for forgiveness;

The forgiveness element of SAF T LOCK R can vary radically from individual to individual. Some may want to include some form of facilitated ritual, some may prefer to engage in a practice of solitude. Some may wish to include the people involved, others may seek a rite of private confession and absolution. Some may prefer the services of a mental health professional and many may prefer the involvement of a chaplain or faith leader.

Additionally, forgiveness is a process (Enright, 2001; Sande, 2004). Worthington et al. helpfully distinguish between decisional forgiveness and emotional forgiveness, observing: ‘A person could make a decision to forgive an offender yet still not feel a sense of emotional peace toward the offender’ (2011:172). For the individual experiencing moral injury there can be a lag between the choice to forgive and the alleviation of the negative experience. There is no ‘one-size-fits-all’.

Test/try

Acceptance and commitment therapy (ACT) has been shown to be effective in supporting people with moral injury (Borges et al., 2022; Evans et al., 2020). According to Corey (2016), when applying ACT:

[clients] learn to identify with thoughts and feeling they have been trying to deny…. Client and therapist work together to identify personal values in areas such as … spirituality…Therapy involves assisting clients to choose values they want to live by, designing specific goals and taking specific steps achieve those goals :256).

Thus, ACT underpins the ‘F T LOCK’ elements of the SAF T LOCK R model.

Discussions of forgiveness will involve identifying and embracing the sense of anger, abuse, betrayal, guilt or shame rather than engaging in practices of avoidance or denial. Where possible, the client’s spiritual understanding and value of forgiveness is identified and explored. The next element will give the client the opportunity to commit to (or LOCK in) a new set of behaviours but for now SAF T LOCK R presents the individual with an opportunity to test (or try on for size) a change they wish to make. This is not an essential element. The enthusiastic individual may have a clear sense of their desired change and commit immediately to LOCK in a change. However, experience suggests many individuals will prefer to adopt a reversable ‘baby step’ (or conduct an ‘experiment’) that they can subsequently discuss with the support person. Test/try can also take the form of ‘homework’ in the more traditional ACT models.

LOCK in the change

Aspects of all four preceding elements (Story, Assessment/analysis, Forgiveness and Test/Try) come together at the LOCK stage. Until this point the individual may have been toying with new perspectives on their story or they may have been considering the adoption of new cognitive beliefs in light of the analysis of their story. Or they may have come to a sense of the need to confess a wrongdoing or possibly extend the gift of forgiveness to an individual or an institution. They may even have undertaken a baby-step in one of these directions. Now is the time to take the plunge; LOCK in a new mindset, LOCK in a date to meet and apologise, LOCK in a time and location for a rite of forgiveness, LOCK in a daily self-care practice. As Corey notes when discussing ACT ‘a commitment to action is essential, and clients are asked to make mindful decisions about what they are willing to do to live a valued and meaningful life’ (2016:256).

Review/refer

For the simplicity of the model, Review/refer is listed as the final element but, in practice, this is a constant throughout the process. Informal review is an intentional activity of checking the process continues to be helpful for the individual. However, it is recommended where possible that a review meeting be organised for some time after the individual has resolved to LOCK in a change to see how it went. This can involve celebrating any identifiable improvements and processing outcomes that didn’t go to plan. Referral may occur at any stage in the SAF T LOCK R process. For example, if the initial telling of the story suggests significant unprocessed trauma, the support person may choose to refer immediately to specialist mental health support. Another example might be the mental health professional who refers to a faith-based chaplain for the forgiveness element.

Summary

First identified amongst veterans by Shay (1994), moral injury came to prominence through the seminal work of Litz et al. (2009). Moral injury has now been seen amongst healthcare workers (Phoenix Australia & Canadian Centre of Excellence, 2020) and emergency services workers (Lentz et al., 2021).

SAF T LOCK R is grounded in the principles of acceptance and commitment therapy, exposure therapy, cognitive behavioural therapy, forgiveness and religious CBT, all of which

have been shown to be effective in the alleviation of moral injury symptoms (Jones et al., 2022; Koenig & Al Zaben, 2021). Future refinements to the SAF T LOCK R model will be possible with ongoing application and further research.

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Author note

Shannon Hood https://orcid.org/0000-0002-1387-8600

Correspondence concerning this article should be addressed to Shannon Hood, Dean of Counselling and Chaplaincy, Asia Pacific School of Pastoral Care and Counselling, 1 College Ct, Karrinyup WA 6018. Email: shood@pbc.wa.edu.au

Copyright

Copyright 2023 Dr Shannon Hood and Rev Michael George

[1] Although this 24 questions scale is designed for youth it is equally applicable for use by adults and is slightly more comprehensive than the MIESSC.

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