Tag: moral injury

My professor set me up for success in the clinical world when I was tasked read Unspeakable Truths and Happy Endings: Human Cruelty and the New Trauma Therapy, by Rebecca Coffey.  The purpose, was to prepare us as students to sit in the pocket of the client’s story- no matter how tragic or graphic.  It was a challenging task as the book was filled with gruesome stories, including one of a veteran, introducing me to the impact of combat trauma.  It was a wake-up call to the high honor and power of listening to someone’s story, especially those of military families.

In addition to the symptoms of post-traumatic stress, many of us have likely seen some form of soul injury in our office. The term “moral injury” has gained attention over the last decade as an additional area of focus in the treatment of veterans.  Coined by Jonathan Shay, but further defined by the U.S. Department of Veteran Affairs, moral injury refers to an “act of transgression, which shatters moral and ethical expectations.”[i]  The act of “transgression” being the center and key to whether or not there has been a personal value or moral injured.

But I have wrestled lately with something else going on in my clients, something in addition to moral injury.  I have seen it occur in my life as a military spouse as well as in my husband’s experience as a chaplain, one who is not regulated to carry a weapon or engage in battle. This particular type of soul injury involves a shattering of values or beliefs not just due to actions in combat, but when one experiences the deep hurt and disappointment of those they are supposed to trust.  As it relates to moral injury, this can definitely occur when someone in authority commands them to perform an action that goes against their values, but it doesn’t account for the soul injury that occurs when they come home and reintegrate into society.

Joshua Mantz, a service member who tells his vulnerable story in his TED talk “Overcoming Moral Injuries” states that veterans who struggle with moral injury do so because they have experienced the “worst of what humanity can do”.[ii]  Many that struggle with suicide are often those who painfully witness the “worst of humanity” in their own actions, breaking a sort of self-trust.  Witnessing the atrocities of war, evil, death, and destruction breaks the long held hope that good triumphs evil.  Instead, around any corner there-after lies the danger of being surprised by the wounding or disappointment in life and humanity.

Chaplain (Colonel) Timothy Mallard also experienced this “missing piece” and defined it as “spiritual injury”, the “intra and inter-personal damage to souls brought on by significant trauma, including the rupture to foundational religious values, beliefs, and attitudes, the inability to healthfully participate in an immanent human faith community, and the temporary or permanent loss of a transcendent relationship to God (manifested particularly in questions about forgiveness, doubt, truth, meaning, and hope).”[iii]  Different, although connected to moral injury, spiritual injury speaks of the impact trauma has on one’s relationship with family, community, and God. Left untreated, these two injuries to the soul have devastating effects on a person and family.  According to Mallard, veterans returning home find themselves not only reintegrating into the family, but attempting to assimilate back into community. These two, then, become the testing ground for whether or not the veteran will attempt reintegration in his or her spiritual life.

As a mental health clinician and military spouse, I contend that we must accept the impact our personal response has in either validating or disproving the new construct that arrests the injured soul, or as Mallard calls it “spiritual injury”. If it is true that we are the testing ground or gate-keepers in restoring the hope that humanity is still good, we have a high calling indeed.  When they enter our office, these families bring with them the hope, albeit a fading spark, that good can win.  There, in the vulnerable, exposed and naked attempt to tell their story, as Rebecca Coffey taught me, is our chance.  However, if they instead receive apathy or worse- a cold, sterile clinical approach, we risk a crisis of the moral human experience leading many to the divorce of humanity all together.

Far too often in my attempts to advocate mental health within the military community, I hear accounts of re-injury in the clinical office.  I am weary of stories, even if they are in the minority, of clinicians falling asleep in session, not understanding the culture, or worse treating the diagnosis rather than the person. If we aim to be part of breaking the stigma that mental health truly makes a difference, then cultural competency must extend past traditional cultural awareness and count the military culture as worth our time to study.

After doing life with the military community, there are some key points that are not commonly addressed, but are crucial to treating the expanding needs of military families.  While the basics of understanding acronyms and branch specifics goes a long way, it will not go so far as our response to their moral and spiritual injury.

1. The military is an elite space and access is earned.

Being invited into this community is not something to take lightly.  It is a reverent “club” where trauma is both a stigma and an intense connective agent. Wearing the uniform alone does not earn you access.  Deployment does not even deem you worthy.  It is a raw, gritty, and real group of individuals and family members that have learned to push through adversity and personal pain.  Both service members and spouses have been pushed to their limits and back again and although they present a tough exterior, it is quite vulnerable.  Gaining rapport with this community requires that you also are vulnerable and real, and that you can meet them there quickly.  Although this may not require full transparency, they need to know that you are authentic as well.

Respect is earned by showing you can push through, are loyal, and will give your all when it matters most. Military life requires us to build relationships quickly if we want community, but that means we also assess others quickly.  We never know when our life will change and call us away. There is no time for 10 sessions of “getting to know each other” so they will determine within the first session whether you are safe, authentic, and whether you can be trusted with their most sacred stories.

2.  You will never reach a place where real healing can happen without regarding the sacred spaces as sacred.

When Matt returned from his first deployment, I knew he was different.  We both were.  He had experienced death and grief on a level I had not.  He had lost friends, memorialized his soldiers, and counseled his brothers through the darkest moments of their life.  I had experienced my own version of survival parenting on my own, overcoming loneliness, and navigating the life on my own.  Matt came home with a “carpe diem” mentality- of live life to the fullest while I had wrestled life to the ground into full submission.  In our reintegration, we clashed in our efforts to feel simultaneously understood and seen.  Both experiences were life changing, both had experienced moral and/or spiritual injuries now a part of our narrative. We discovered that our response to each other’s injury could either heal or further injure the other.

As I reflected on how memories of joy and trauma are secured by the sensory parts of the brain, my husband and I both experience flashbacks of our separate experiences in a sensory way.  When my husband looks off into the distance remembering his friend’s body, I know his past is invading his present.  In similar ways, recounting intense community with fellow spouses during a difficult deployment brings up sensory memories for me.  In our attempt to find a new way to communicate, we coined the phrase “Sacred Spaces”.  Sacred Spaces are multi-sensory, life-changing events set apart from the normal day to day experiences that now take up significant space in our story, individually and together.  It has become a way for us to say, “I’ve been through something so big that I’m different because of it.  I can’t change that, but I need you to tread lightly when I talk about it.  You can’t fix it, and we definitely can’t ignore it.”[iv] In essence, we became healing agents in our response to each other’s most sacred moments by treating them as sacred.

Most military members will never have the right verbiage to describe their most significant moments as a Sacred Space but will viscerally experience it as sacred.  Much like walking into a cathedral, so is the honor of listening to the vulnerable stories of military families.  In order to succeed, we must learn how to not only walk into a sacred space, but through it.  In a culture where a service member must become a god whose actions decide on the life or death of another, it requires another deity that can give them permission to be human again.   Your capacity to sit with them in their pain, courage, grief, insecurity, ego, and humility all at once gives them that permission.  This very moment between the two of you will then become its own Sacred Space where acceptance, forgiveness, and mercy is a glimpse into the deeper question of whether God will respond the same. You then symbolize the community’s role in reintegrating the veteran while also modeling that for the family member.  It is one of the most sacred things we can do for another.

3.  Evidence based is effective, but it is your human connection that will change a life. 

My favorite part of Mantz’s talk (spoiler alert) was that he, at his lowest point considering suicide, discovered a clinician who showed up.  This act of humanity changed the trajectory of his life by modeling that good existed and was in direct contrast to the evil he saw on the battle field.  That moment revealed that the only way to heal the visceral soul tear from experiencing the worst of humanity, is to prove that humanity’s best is far more powerful.  If we wish to model the best of what humanity has to offer to the military community, it must include the human connection.

Evidence based modalities continue to provide some of the best outcomes I have seen to reduce symptoms of post-traumatic stress, however, our delivery and approach must equally include human warmth.  Mantz states that it takes moral courage to ‘“dive deep into the emotional state that they are in, truly and inherently understand what they are going through, walk through the depths of hell with them, grab them by the hand and say ‘You are not alone anymore- we are going to get you out of this’.”[v]

Too often, military families and veterans seek counseling only to be met with an immediate diagnosis or treatment plan.  These play a necessary role in progress, but the military community is too raw to tolerate the cold approach of academic treatment plans that lack the human dimension. Death is cold, and so is evil.  Our approach must show a direct contrast to that experience.  When avoidance is already high, many military families fear therapy will feel transactional and assume it will be one more place they feel misunderstood.

4.  You will miss the mark if you forget the family.  Everyone forgets the family.

The military spouse community holds a secret, even amongst themselves, that they have accepted a life of being unseen.  While America is making huge progress in tending to the challenges of careers and deployment readiness, military spouses have an unspoken commitment to put the military and service member first.  The cost to themselves, is an incredible amount of repression and anger that subconsciously destroys families.  It is undeniable to them that their service member’s visible and invisible wounds of war pale in comparison to their own personal suffering.  The comparison is quite real within military marriages with the spouse usually accepting the submissive role as secondary in her desire to see her spouse well and whole from these injuries.  While spouses may present themselves as strong and willing to go “second”, clinicians must not play in to the pattern that exists.

Military spouses are often unaware of the underlying resentment that exists, much less what needs to change in order to be authentic within counseling or their marriage.  It is their patriotic duty to serve their serving spouse rather than take care of self.  In my own life, I saw this to be true when I had the opportunity to travel overseas with the Secretary of Defense and visit deployment conditions.  In my visit to warring countries I never thought I would see, I came face-to-face with my own reflection.  I saw my own resentment of the difficulty that war brought into my life and marriage.

Over the mountains of Afghanistan, I ultimately came to terms with my role as a military spouse  and wife.  I had the greatest healing power of all to show my husband that good could triumph evil. I, even in my imperfection, could be the most consistent experience of the best of what humanity could offer. My ability to embrace the messiness that military life had handed us, could rebalance the scales.  In order for me to do this though, I had to first process through the moral and spiritual injury I had also experienced, the death of my expectations of an easier life. (For more, read my story, Sacred Spaces: My Journey to the Heart of Military Marriage).

In Coffey’s book, she quotes Bessel Van der Kolk, one of the leading researchers of post-traumatic stress.  He tells a survivor, “Pay more attention to the therapist’s intellectual and emotional equipment than theoretical system… Pay attention to whether the therapist really wants to hear the troubles you have to tell. Ask yourself, ‘Do I feel validated?  Is the therapist really listening to my story?’”[vi]  Listening to someone’s story, not just for the story itself, but because someone has a story to tell is one of the highest honors of being a clinician.  As you seek to serve the military community and become culturally competent, think back to what ignited the spark within you to become a healer. There is an entire community waiting for someone to truly listen.


[i] Shira Maguen and Brett Litz, “Moral Injury in the Context of War,” U.S. Department of Veteran Affairs National Center for PTSD, accessed online at http:www.ptsd.va.gov/professional/co-occurring/moral_injury_at_war.asp on March 3, 2017

[ii] Joshua Mantz, “Overcoming Moral Injuries”, Tedx Santo Domingo, accessed online at https://www.youtube.com/watch?v=ORBf73HiJns, (2016)

[iii] Timothy Mallard, “Spiritual Injury: Toward a Definition, Criteria, and Treatment Response for Wounded Warriors and Families, “ D.D. Eisenhower Army Medical Center Department of Behavioral Health and U.S. Army Cyber Center of Excellence Unit Ministry Team Interdisciplinary Moral and Spiritual Injury Symposium, Fort Gordon, GA (26 May 2016)

[iv] Weathers, Corie, Sacred Spaces: My Journey to the Heart of Military Marriage (St. Paul, MN: Elva Resa Publishers, 2016), 18.

[v]Mantz (2016).

[vi] Coffey, Rebecca. Unspeakable Truths and Happy Endings: Human Cruelty and the New Trauma Therapy. (Baltimore, MD: Sidran Institute Press, 1998) 85.

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