Abstract
Moral injury, a term coined to represent the potential negative outcomes following transgression of deeply held moral values and beliefs, has recently gained increased recognition as a major concern among military service members exposed to trauma. However, working definitions of moral injury have not yet fully clarified the mechanisms whereby violations of conscience result in these outcomes or their co-occurrence with posttraumatic stress disorder (PTSD). In this paper, advances from the field of moral psychology are used to integrate cognitive, affective, and social dimensions of the emerging moral injury construct, while also pointing to new possibilities for clinical intervention. After reviewing the salience of moral injury for military and veteran populations, the presence of negative moral emotions (e.g., guilt, anger, disgust) are examined within the context of trauma and military-related PTSD. Next, social functionalist accounts of moral emotions are used to explain the development of moral injury and are linked to potential etiologies of PTSD that emphasize both fear and nonfear emotions. Finally, the clinical importance of positive moral emotions for existing and emerging trauma-focused interventions is discussed. Future directions for research and clinical interventions are identified highlighting the importance of utilizing community support.
The tendency to experience thoughts, feelings, behaviors, and decisions through the lens of morality is a distinguishing attribute of human beings that has long intrigued researchers in the social and psychological sciences. However, the empirical study of morality has often been approached in the abstract. One common method for researching moral decision making has used hypothetical vignettes to explore how human beings negotiate and cope with complex moral scenarios. For example, in order to identify developmental stages of moral reasoning, Lawrence Kohlberg asked children to think about whether there are circumstances where stealing is morally acceptable (such as when it is to preserve the life of a loved one, Kohlberg, 1969). More recently, moral psychologists and neuroscientists have used the Footbridge dilemma to examine the role biology might play in moral decision making (Thomson, 1986). In the Footbridge dilemma, participants are asked whether they would give a fatal push to a pedestrian into the path of an oncoming trolley in order to save the lives of five other individuals standing further down the tracks. By design, such vignettes pit human beliefs about what is right and wrong against one another, often causing dissonance and self-doubt for the individual (Greene, 2005).
Unfortunately, for many active duty service members such scenarios are more than hypothetical. Although not constrained to any one era of war, the recent armed conflicts in Iraq and Afghanistan have highlighted anew the difficulties war-zone dilemmas can pose to service members. Examples of representative dilemmas may include a soldier deciding whether to fire on an oncoming unidentified civilian vehicle because of a potential vehicle-borne improvised explosive device or a lead convoy driver choosing between passing by gravely wounded children or stopping and exposing her convoy to insurgent ambushes. Service members confronted with dilemmas like these may anguish about their choices for years following the event. Furthermore, even if Service members do not second-guess the morality of their own wartime actions, upon returning home they may struggle to feel understood and supported by a civilian culture that does not fully recognize the morally challenging decisions frequently presented by war. As such, many of these veterans may go on to face the dilemma of disclosing their wartime experiences and risk social alienation through social judgment on one hand or the alienation of self-imposed silence on the other. Finally, there are other military personnel who navigate these dilemmas without appearing to become caught in them, but the nature of their apparent resiliency is still unclear.
Although difficult moral decisions have always been a part of war, the guerrilla and terror tactics of insurgent forces may be a significant contributor to the occurrence of morally troubling events faced by service members from more recent conflicts. Indicating the frequency of such events, a survey of 1,320 Army soldiers and 447 Marines deployed at the beginning of the Iraq conflict documented that over a quarter of both groups had encountered ethical situations in which they were unsure how to respond (MHAT-V, 2008). To help account for the possible wide-ranging effects of these types of concerns, Litz et al. (2009) presented a model of moral injury to renew attention to the distress and difficulty created for Service members who have faced such situations. Litz et al. provided a working definition of moral injury as, “Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (p. 700). Although empirical work has begun to explore possible causes and consequences of moral injury (Drescher et al., 2011; Vargas, Hanson, Kraus, Drescher, & Foy, 2013), the scientific construct remains in its infancy and is in need of greater theoretical development in order to stimulate and focus research efforts. In particular, Litz et al. (2009) state that there is a recognized need for alternative yet complementary models that can link the cognitive, emotional, and spiritual/existential struggles that arise from morally conflictive events to trauma-related conditions, such as posttraumatic stress disorder (PTSD; Currier, Holland, Jones, & Sheu, 2014; Drescher et al., 2011; Litz et al., 2009; Vargas et al., 2013).
In a partial effort to help meet this need, this review proposes that conceptualizations of moral injury and its relationship to mental health conditions would benefit from recent advances in the areas of moral psychology and moral emotions. Within the last decade and a half, these fields have provided new and innovative perspectives on how individuals make moral judgments and then reason about the judgments they have made. Of equal significance, these perspectives have highlighted the deeply rooted social functions of moral emotions in forming and preserving human bonds. As moral injury is primarily viewed as the violation of personally or socially held moral standards, advances in moral psychology can help illuminate the processes that enable and possibly sustain moral injury in the months and years following a war-zone deployment. Furthermore, because moral psychology focuses on non-fear-based moral emotions such as shame, anger, and disgust, it provides an important resource to explain the significance of these emotions both during morally injurious events and in the wake of war-zone deployments.
In the subsequent sections, the prior research on moral emotions in military populations will be reviewed to demonstrate its clinical relevance to trauma and moral injury in particular. Next, to explain their significance for psychological and social functioning, these moral emotions and their role in moral injury will be discussed within the context of social-functional models of morality and complementary models of PTSD. Finally, we briefly explore the possible relevance of positive moral emotions for recovery following moral injury and conclude by outlining several important considerations for clinical practice and future research.
Moral Emotions in Moral Injury
In advancing a working definition of moral injury, Litz et al. (2009) and other proponents of this emerging construct are not advocating for a new disorder or descriptive diagnosis. Instead, Litz et al.'s definition affirms the existence of traumatic events that extend beyond the realm of fear and imminent threat to one's physical safety. Initial exploration of the potential causes and consequences associated with moral injury suggest that the construct is distinct from the classic threat-based conception of trauma. In a qualitative study of 23 clinical professionals with extensive backgrounds working with service members (Drescher et al., 2011), the most commonly identified stressors that might precipitate a moral injury included betrayals (e.g., leadership failures, failure to act in accordance with one's personal values), incidents involving injury or harm to civilians (e.g., killing, unnecessary destruction of property), within-rank violence (e.g., friendly fire incidents, sexual assault), inability to prevent death/suffering, and ethical dilemmas/moral conflicts. Vargas et al. (2013) also found that betrayals, civilian deaths, and within-rank violence were among the commonly discussed morally injurious stressors in a nationally representative sample of Vietnam veterans. Reviewing this list of potential causes reveals that although threat to life and safety may also be present, morally injurious stressors are characterized by additional features, such as the violation of social trust and distress over involvement in inflicting harm on others.
Likewise, just as potential causes of moral injury extend beyond threat to life, the potential indicators of moral injury also extend beyond anxiety and fear-based emotional responding. In addition to PTSD and mental health disorders that are routinely assessed in military populations, possible indications of moral injury that have been identified thus far include inappropriate guilt and shame, social or relational issues (e.g., avoiding intimacy, anger and aggression, reduced trust in other people and cultural contracts), spiritual/existential problems (e.g., loss of spirituality or weakened religious faith, negative attributions toward God or higher power, lack of forgiveness, crisis in meaning), substance abuse and other attempts at self-handicapping, and suicide and other self-harm behaviors (Drescher et al., 2011; Vargas et al., 2013; Litz et al., 2009). Although individual presentations will manifest different combinations of these indicators, they are all likely to be imbued with deep emotional distress or conflict. It is important then that theoretical models adequately address how various emotions are evoked and embedded in the experience of moral injury.
Research has distinguished negative and positive emotional states based on their elicitors, action tendencies, and particular nervous system responses. With some notable exceptions, many negative emotions are elicited under conditions of immediate threat and engage the sympathetic nervous system (e.g., fight-flight). In so doing, negative emotion generally serves a protective function by narrowing immediate thought-action repertoires, so as to minimize, escape or neutralize threat. In contrast, positive emotions are less likely to emerge in dangerous or life-threatening conditions and tend to engage the parasympathetic nervous system, broaden momentary thought-action repertoires, and build enduring resources on all levels of human functioning (Fredrickson, 2001).
Moral emotions fall on both sides of this continuum and share aspects of these elicitors and action tendencies. Lists of negatively valenced moral emotions commonly include guilt, shame, anger, disgust, and contempt; whereas positive moral emotions include states like compassion, elevation, gratitude, and pride. In keeping with other categories of emotion, moral emotions are experienced and regulated within a context of social connection (Rimé, 2009). However, moral emotions can be functionally distinguished from nonmoral emotions in that they are concerned primarily with the preservation of social relationships (Haidt, 2003). Moral injury, which is characterized by the violation of deeply held personal and societal moral standards, is thus likely to be accompanied by strong moral emotions related to the perceived characteristics and contingencies of the morally injurious event. The following section therefore summarizes the major categories of moral emotion and reviews available findings regarding military-related PTSD and moral injury.
Painful Self-Conscious Emotions
One critical function of moral emotions is assisting in the navigation of complex and varying social relationships by helping individuals avoid the disdain and hostility of other group members (Haidt, 2003). To this end, the painful self-conscious emotions of guilt and shame notify individuals of personal moral infractions and provoke action tendencies aimed at reducing conflict or social damage (e.g., reparation, hiding, submission). As the betrayal of personal moral standards by self/others is a central theme within current conceptions of moral injury (Drescher et al., 2011; Litz et al., 2009; Vargas et al., 2013), these emotions would be expected to have a strong connection to morally injurious experiences (e.g., harming civilians or noncombatants, inability to prevent suffering and death, engagement in killing or extreme acts of violence) and related symptom patterns over time.
Guilt
The emotion of guilt centers on a negative evaluation of a specific behavior and is associated with tension, remorse, and regret over the perceived infraction (Tangney, Stuewig, & Mashek, 2007). Research suggests that guilt is primarily elicited by real or imagined violations that are perceived to threaten one's personal or communal relationship with the harmed party (Clark & Mills, 1979; Fiske, 1991). Accordingly, guilt has historically been considered a prosocial emotion, as the tension created by damage to one's valued relationships will ideally be associated with accepting responsibility and initiating reparative actions in response to transgression (Tangney et al., 2007). Although meta-analytic research has found that generalized, context-insensitive guilt is associated with depression (Kim, Thibodeau, & Jorgensen, 2011), other work has documented that when guilt is contextually limited to a specific transgression and adequately distinguished from other negative emotions it has virtually no association with psychopathology (Tangney et al., 2007).
However, in contrast to the generally prosocial features of transgression-specific guilt in civilian samples, “combat-related guilt” (as it has been termed in the literature) has been associated with lower psychological well-being in military populations, consistently emerging as a risk factor for PTSD (e.g., Henning & Frueh, 1997). Even more pertinent to understanding moral injury, a number of studies found that even when controlling for severity of combat exposure, involvement in acts of abusive violence (e.g., mistreating civilians, torturing prisoners) was related to PTSD symptom severity and other problems (e.g., Beckham, Feldman, & Kirby, 1998; Currier et al., 2014; Hiley-Young, Blake, Abueg, Rozynko, & Gusman, 1995). Drawing on a large sample of Vietnam veterans, this relation has recently been elaborated by Marx et al. (2010), who found that guilt mediated the associations between abusive violence and both PTSD and depressive symptomatology. In addition, several other recent studies demonstrated that killing in combat and guilt were each associated with service member suicidal ideation (Bryan, Ray-Sannerud, Morrow, & Etienne, 2013a; Maguen et al., 2012). As will be discussed shortly, discrepancies between guilt in nonmilitary samples and guilt related to military experiences suggest that researchers could be assessing different moral emotions. Rather than isolating guilt as defined more narrowly in the moral emotions literature, studies assessing military-related guilt may also be tapping into the more psychologically damaging emotion of shame.
Shame
In contrast to the innocuous effects of context-specific guilt observed in research with nonmilitary samples, shame has been consistently associated with a wide variety of psychological symptoms across populations and measurement methods (e.g., Tangney et al., 2007). Whereas guilt focuses outwardly on a specific behavior, shame involves a negative global evaluation of the core self that is accompanied by feelings of worthlessness, powerlessness, and feeling vulnerable and exposed (Lewis, 1971; Tangney et al., 2007). Accordingly, whereas guilt can promote greater empathy and socially reparative actions, shame typically activates social hiding behaviors and decreases empathy due to increased preoccupation with one's own distress and emotional discomfort (Joireman, 2004). Furthermore, shame has been robustly associated with substance abuse, anger, and aggression (e.g., Tangney & Dearing, 2002), whereas guilt often discourages these types of problematic behaviors (e.g., Tangney, Miller, Flicker, & Barlow, 1996).
Tempering conclusions regarding shame and moral injury is that relatively few studies have explicitly examined the effects of this emotion in military populations. Consistent with studies of guilt and shame in nonmilitary populations, Leskela, Dieperink, and Thuras (2002) found that for former prisoners of war (N = 107), PTSD was associated with shame-proneness but not guilt-proneness. Even more interesting, when Leskela et al. removed effects of shame-proneness, guilt-proneness was inversely correlated with PTSD symptoms. Focusing on a sample of World War II and Korea War Veterans with PTSD, a more extensive examination of shame found lower urinary cortisol levels to be associated with emotional numbing and “shame-laden depression” (Mason et al., 2001, p. 397). Although combat experiences were not specifically assessed in this study, Mason and colleagues’ findings suggest that emotional numbing reflected an avoidance-based coping strategy in the face of preoccupying and overwhelming shame. More recently, several studies have specifically found that shame is associated with higher risk for suicide in service members (Bryan, Ray-Sannerud, Morrow, & Etienne, 2013b), even when controlling for concurrent depression and PTSD symptoms (Bryan, Morrow, Etienne, & Ray-Sannerud, 2013). Although no studies to date have directly explored shame in the context of moral injury, numerous clinical descriptions of combat-related symptomatology specify shame and self-condemnation as a central source of dysfunction and an obstacle to recovery (e.g., Clewell, 1987; Haley, 1974; Singer, 2004), and recent empirical findings have linked shame to PTSD in a trauma-exposed civilian sample (Harman & Lee, 2010).
Research on painful self-conscious emotions indicates an important clarification in terminology may be necessary with regard to military-related trauma. To date, the vast majority of research on moral emotions in military populations has used the term combat guilt or combat-related guilt to refer to a variety of painful emotional reactions stemming from involvement in warfare. However, the use of these terms may obscure crucial distinctions within and between the moral emotions of guilt and shame. When service members violate personal standards in war but partition these violations apart from their broader self-concept, an instance-specific form of guilt should result. This guilt, with its external focus on behavior, should avoid the more damaging global, internal, and stable negative appraisals that often typify shame. Equally as damaging as shame, however, may also be trait-like, context-insensitive guilt, which Kim et al. (2011) found to be similarly linked with depression.
It would therefore be expected that service members with specific, contextual guilt regarding combat events should be less symptomatic, whereas those who experience shame or generalized guilt in connection with combat events should instead encounter a greater number of trauma-related mental health symptoms that may be indicative of a moral injury (e.g., PTSD, suicidal ideation). This distinction between specific guilt, generalized guilt, and shame may help to explain the more positive effects of specific guilt in civilian samples and the negative effects of combat-related guilt in military populations. Future research should be careful in maintaining this distinction in order to assess the differential effects of guilt and shame in military-related moral injury. Investigators are encouraged to select instruments that clearly differentiate shame from contextual guilt, as well as the generalized, trait-like tendencies to experience these emotions (for a review of such instruments see Kim et al., 2011).
Other-Condemning Emotions
In contrast to painful self-conscious emotions, Haidt (2003) identifies another subset of censuring emotions that can occur in response to others’ violations of sociomoral codes. This second subset primarily includes the negative emotions of anger, disgust, and contempt, which are believed to function primarily as a means of discouraging others’ selfish conduct or actions that might threaten the cohesiveness of the social group (Hutcherson & Gross, 2011).
Anger
Of these three other-condemning moral emotions, anger is the most widely researched in military populations and involves a tendency to aggressively approach others in order to discourage or end acts that are perceived as immediate threats to the self or desired goals and rewards (Hutcherson & Gross, 2011). In particular, evidence suggests that anger can be provoked by the perceived intentional violation of one's personal rights and freedoms (Rozin, Lowery, Imada, & Haidt, 1999; Russell & Giner-Sorolla, 2011). Albeit limited, recent research has implicated the role of combat-related traumas in the development of anger in military samples. Meta-analytic studies have found a robust and large effect size of anger in predicting PTSD symptomatology (Orth & Wieland, 2006), which exceeds the magnitude of effect sizes for other anxiety-related disorders (Olatunji, Ciesielski, & Tolin, 2010). This association was also particularly pronounced for military traumas in Orth and Wieland's (2006) review. Other reports suggest that up to half of all returning service members experience problems with anger (e.g., Taft, Creech, & Kachadourian, 2012). Although it is unclear to what degree selection factors may account for these types of findings, a recent study using a sample of combat-deployed service members found that anger increased significantly from pre- to postdeployment, suggesting the importance of war-zone stressors in rates of postdeployment anger and aggression (Koffel, Polusny, Arbisi, & Erbes, 2012).
More specific to moral injury, even when controlling for combat exposure, killing in war has emerged as being a significant predictor of postdeployment anger (Maguen et al., 2010) and those service members who have reported killing noncombatants or killing in anger have been found to be particularly symptomatic (Maguen et al., 2013). These findings suggest that taking human life or engagement in other potentially morally injurious stressors may produce anger independent from the hyperarousal accompanying exposure to safety-threatening traumas. In line with this interpretation, Adler, Britt, Castro, McGurk, and Bliese (2011) found that the number of combat events was positively correlated with both anger and social alienation at 4 months postdeployment, even after controlling for PTSD symptoms. In interviews with a sample of Iraq and Afghanistan veterans, Worthen and Ahern (2014) identified three primary causes of anger: (a) lack of postdeployment structure, (b) PTSD, and (c) morally injurious experiences (e.g., violation of conscience, betrayal of trust). Although anger related to a lack of structure abated in less than a year, anger over PTSD and moral injury had persisted for years after returning from deployment. Altogether, these studies provide support for the prominence of anger in combat-related PTSD and preliminary indications for its importance for moral injury as well.
Disgust
Whereas anger is provoked in response to violations of personal rights and/or freedoms, evidence has increasingly suggested that moral disgust is an elaboration of the body's natural disgust response to contaminated objects (i.e., rotten food, feces; Chapman & Anderson, 2013). Bodily disgust is typically associated with feelings of revulsion and offense and its core action tendency is rejection and expelling of the toxic substance. Moral disgust is likewise evoked by acts that are perceived to contaminate one's sense of moral purity, such as sexual taboos, and has been positively associated with the severity of moral judgments (Haidt, Rozin, McCauley, & Imada, 1997). Furthermore, research has found moral disgust reactions tend to be highly resistant to change (e.g., Hutcherson & Gross, 2011; Haidt et al., 1997).
In comparison to anger, less research has examined the role of disgust in posttraumatic functioning. However, it appears that elevated sensitivity to disgust could be a risk factor for PTSD in some cases (Badour, Feldner, Blumenthal, & Bujarski, 2013), and experimental research has similarly shown that the disposition to experience disgust can increase intrusive thoughts following exposure to disturbing stimuli (Bomyea & Amir, 2012). Demonstrating its role in PTSD, Badour, Feldner, Blumenthal, and Knapp (2013) found that disgust reactivity accounted for nearly 70% of the relation between peritraumatic disgust and posttraumatic symptoms in a sample of female sexual assault survivors. Likewise, service members with PTSD reported more disgust than non-PTSD service members in response to a trauma imagery script (Pitman et al., 1990). In addition, Foy, Sipprelle, Rueger, and Carroll (1984) found that a combination of military-related disgust and anxiety correctly classified 90% of veterans as either positive or negative for PTSD. More recently, Engelhard, Olatunji, and de Jong (2011) found that peritraumatic disgust predicted military-related PTSD independently of peritraumatic fear, further supporting a unique role for disgust in this condition. Finally, service members with PTSD were found to have higher disgust sensitivity than those without PTSD, although they did not differ from healthy nonveteran counterparts in this trait (Olatunji, Armstrong, Fan, & Zhao, 2014).
Though no research has specifically investigated the role of moral disgust in moral injury, Schnall, Haidt, Clore, and Jordan (2008) found that inducing bodily disgust led participants to make more severe moral judgments. This suggests that bodily disgust evoked in the context of military-related trauma and/or subsequent recollections/reflections might increase moral disgust related to service members’ negative attributions regarding these events. For example, disgust evoked by sensory exposure to bodies that have been mutilated from powerful modern weapons may intensify moral emotions and judgments related to culpability and condemnation for the casualties sustained. Alternatively, moral disgust may be evoked in combatants in foreign wars by exposure to severe poverty and/or novel and personally disturbing cultural practices and beliefs that conflict with service members’ own backgrounds, values/beliefs, and cultural expectations. Accordingly, future research should examine both bodily and moral disgust in morally injurious events and their potential interaction in influencing posttraumatic functioning.
Contempt
Contempt, the third other-condemning moral emotion, is arguably the least understood at present, although evidence has supported it as a distinct moral emotion that pertains to judgments of others as incompetent or morally lax (Hutcherson & Gross, 2011). Prior research with nonmilitary samples has also implicated contempt in response to violations of communal relationships (i.e., respect for hierarchies and social obligations; Rozin et al., 1999; Laham, Chopra, Lalljee, & Parkinson, 2010). The distinction between contempt and disgust, however, has been difficult to assess as these two emotions are strongly associated with each other (Hutcherson & Gross, 2011), and the development of reliable measurements of contempt has been elusive (Matsumoto & Ekman, 2004). It has even been suggested that contempt reflects a blend of anger and disgust (Prinz, 2007). To date, there are no studies regarding contempt and military-related trauma, but there are strong theoretical and clinical reasons to suggest that contempt may play a role in moral injury and PTSD in military populations. For example, dehumanization of enemy combatants and their perceived ethnic groups, perceptions of superior officers as incompetent or indifferent to service member safety, or betrayal by trusted civilians have each been proposed as causes of moral injury (Drescher et al., 2011) and would very likely entail some degree of contempt.
Summary of Negative Moral Emotions
The above empirical review highlights the relevance of moral emotions for military-related PTSD generally and provides preliminary evidence for their role in moral injury. It also points out, as in the case of shame and guilt, the importance of examining unique variance accounted for by specific moral emotions in addition to their overall predictive effects on variables related to moral injury. However, the limited research on moral emotions in general and in military populations specifically hinders any definitive conclusions at this time. Expanding this line of research would be facilitated by a theoretical approach that can explain the role of moral emotions in moral injury and military-related PTSD.
Moral Injury and Social-Functional Models of Morality
Litz et al. (2009) define morality as “personal and shared familial, cultural, societal, and legal rules for social behavior,” emphasizing that “morals are fundamental assumptions about how things should work and how one should behave” (p. 699). In focusing on moral rules, Litz et al.'s (2009) model emphasizes that when rules are violated, the attributions made about those violations will influence what moral emotions are evoked. We agree that this is an important factor in determining responses to a potentially morally injurious event. However, we believe that it is also important to recognize the influence of affect on shaping cognitions (Boden & Berenbaum, 2010). Evolutionary and neuroscientific approaches to morality suggest that intuitive affective processes are major contributors to moral judgments in particular, such that they would exert significant influence on attributions following a potentially morally injurious event (Greene, 2005; Haidt, 2001). Thus, the scientific study of moral injury would be well served by incorporating such automatic affective influences in understanding Service member's reactions to morally challenging war-zone events.
One approach to moral emotions that has gained prominence within the last two decades is social-functionalism (Hutcherson & Gross, 2011; Keltner, Haidt, & Shiota, 2006). In contrast to normative approaches to morality, which seek to determine the morally correct response to a situation (e.g., determining if guilt is appropriate or inappropriate reaction to a behavior), social-functionalism takes a descriptive approach by evaluating the pragmatic value of morality for the survival of a social group as a whole. In this view, specific moral emotions are conjoint products of biological development and human culture, which operate within larger, more complex “moral systems” that Haidt (2012) defines as “interlocking sets of values, virtues, norms, practices, identities, institutions, technologies, and evolved psychological mechanisms that work together to suppress or regulate selfishness and make cooperative social life possible” (p. 800). That is, from a social-functionalist perspective, moral systems (including moral emotions) exist because they have promoted group survival over time by selectively encouraging and/or discouraging individual actions in order to reinforce overall collaboration and cohesion among group members.
Cross-cultural research has identified that moral emotions are evoked in relation to a number of core social issues such as caring, fairness, loyalty, authority and sanctity (Graham, Haidt, & Nosek, 2009). As an illustration, group survival is generally facilitated when group members adhere to common standards of reciprocity. This standard requires that group members restrict their own consumption of resources in order to maintain fairness, although they would individually benefit from taking more than their share. Moral systems encourage such selflessness in part by utilizing other-condemning emotions such as anger, contempt, and disgust to discourage overconsumption. In response to or in anticipation of these other-condemning emotions, self-condemning emotions (i.e., guilt, shame) encourage repair or mitigation of damage done to the offending party's social reputation. If their attempts at reconciliation fail, offending parties may be expelled from the group entirely in order to ensure that their selfish behavior is not repeated. As this example illustrates, a moral system's prioritization of the group's wellbeing may sometimes be at odds with the wellbeing of the individual.
Some social-functional models emphasize that the context of a particular social relationship will determine whether a given action will be perceived as moral or immoral (Rai & Fiske, 2011), and thereby evoke positive or negative moral emotions, respectively. For example, common moral concerns, such as autonomy or reciprocity, may have less relevance in relationships whose morality is defined by dimensions of rank or hierarchy. In the context of military basic training, it may be morally acceptable for a drill instructor to exercise authoritative control and harsh punishments over recruits and give less regard to perceived disrespect regarding the recruits’ capacities for independent decision making. Recruits in turn might more readily accept these conditions due to their desire to identify with their fellow trainees and cultural norms of the larger military service branch. Contextual cues become even more complex when multiple social relationships elicit moral emotions with conflicting behavioral responses, such as when recently returned service members simultaneously experience loyalty and a desire to be with both their deployed comrades and their civilian family members. Moral emotions are hence likely to be highly attuned to the goals and values of the individual's perceived social community such that what evokes moral emotions in one context may not evoke them in another.
Military service that includes a war-zone deployment presents unique implications for moral emotions in part because of the stark contrasts that confront service members when transitioning between military and nonmilitary social contexts. It is precisely because of these contrasts that a comprehensive understanding of moral injury requires viewing associated emotions not only as reactions to the violation of moral rules, but also as a result of service members’ shifts between radically different moral contexts. We argue that social-functional perspectives of moral emotions are critical to understanding service members’ experience during these transitions. In particular, we suggest that moral emotions not only serve as indicators that a moral injury has occurred, but also help to explain the occurrence of morally injurious behaviors themselves and the subsequent attributions and behaviors that service member's employ in response to them.
Prior to entering the armed forces, most to-be-recruits exist within moral systems that are largely oriented toward civilian concerns and goals. However, the different experiences of individuals within civilian culture are likely to influence their transitions into the military's moral system. For example, a recruit without prior connections to the military may differ significantly from a recruit with a long family history of military service in the extent to which their social network and moral education reflect the moral systems they will encounter in the military. In addition, individual differences in traits such as the proneness to feel specific moral emotions such as guilt and shame, along with differences in emotional awareness and clarity, are also likely to influence how individuals integrate into the moral system of their military branch. In fact, these individual and demographic factors serve as the foundation upon which military identities are built. Furthermore, this foundation will also provide service members with a moral backdrop against which to compare and contrast future morally injurious experiences that might occur in the context of war-zone service.
Upon entering basic training, recruits are immersed into a new moral system. This assimilation usually involves intensive socialization and indoctrination for the purpose of reorienting a recruit's moral emotions and judgments to the social context of their military branch (Soeters, Winslow, & Weibull, 2006). Training drills, rituals and ideologies (e.g., semper fi) form individual and collective military identities, which are calculated to enhance both small and large group cohesion, and ultimately survival in the theater of combat (Manning, 1994). This training capitalizes on moral emotions such as pride in order to generate an espirit de corps that will bind recruits’ sense of self and obligation to their respective military branches and comrades in arms. A recruit's successful completion of basic training therefore involves not only competence in fundamental professional skills but a sense of moral identification with the military culture as well.
This selfless commitment to the larger group is critical for survival in the context of a war-zone deployment. Here, where concern for the welfare of one's comrades is the preeminent determiner of morality, sharp distinctions are created between friendly and enemy forces. Moral emotions and judgments become likewise calibrated to the immediate social context of combat, wherein morality is defined as the suppression of (oftentimes lethal) external threats to ensure the success and survival of one's unit members. In such a moral system, the greatest shame for a service member would be to forsake his or her unit in the face of danger, and the greatest moral anger is typically reserved for those who put group members at risk. However, it is also this tight moral system and its constituent moral emotions that may also enable members of a fighting unit to engage in potentially morally injurious behaviors in certain cases.
Threats to or losses sustained within the fighting unit may prompt strong other-condemning moral emotions (i.e., anger, disgust, contempt) that increase the probability of abusive violence. Despite the strong moral guidance provided by military rules of engagement and ethical training and leadership, it has been recognized that various social influences can nevertheless contribute to moral disengagement wherein opposing forces are dehumanized and excluded from moral consideration (Bandura, 1999). Within the highly cohesive moral system of a combat unit, other-condemning moral emotions toward the enemy have the potential to engender such dehumanization and thereby increase the likelihood that combatants (or civilians perceived as being associated with enemy combatants) would be the target of abusive violence (e.g., Sherman & Haidt, 2011). This likelihood may be further strengthened if service members’ loyalty and respect for authority are tested through pressure from within the fighting unit (e.g., being ordered to fire on civilians). It would be expected that this dehumanization of enemy combatants would persist so long as the service member perceived the enemy to exist outside their moral group. Thus, morally injurious behaviors may be made more likely when the threats to group safety inherent in war-zone deployments trigger strong other-condemning moral emotions directed at those perceived as the enemy.
Even in the absence of a strongly polarized moral system that could sanction abusive violence, moral emotions also help to explain the positive association between potentially morally injurious experiences (i.e., killing, failing to prevent harm) and psychological symptoms that are indicative of a moral injury. Evidence suggests that without intensive behavioral conditioning, humans display strong resistance to intentionally harming others, even in the socially sanctioned context of war (Grossman, 1996)—an aversion that some neuroscientific commentaries suggest may have developed in order to reduce in-group aggression (Greene, 2005). However, notwithstanding a dispositional aversion toward lethally harming other humans, Service members in combat situations are often left with few alternatives. The reality of combat is that even service members who would otherwise be hesitant to inflict harm are often required to do so in order to protect themselves or prevent harm to others.
Without the influence of other-condemning emotions like anger and contempt during combat, some service members may alternatively experience moral emotions that are attuned to the suffering of enemy combatants, such as compassion. Responding with compassion for the enemy may indicate that service members still implicitly perceive opposing combatants as legitimate members of their larger moral group (i.e., humanity). The cost of such compassion during or in the wake combat may be in making service members more prone to painful self-conscious moral emotions in the wake of inflicting lethal harm on other humans. Indeed, it has been observed that combat veterans’ descriptions of their own morally injurious experiences often emphasize distress following the recognition of a shared humanity with the deceased combatants (Farnsworth, 2013). Thus, positive moral emotions during deployment may in some instances make moral injury more likely if they also increase the likelihood that service members experience self-censuring moral emotions in response to the violations of their implicit moral code.
Another source of moral injury that has received more attention from researchers and clinicians is witnessing moral violations of others (e.g., Litz et al., 2009; Shay, 2011). Although Litz et al. (2009) acknowledge witnessing moral violations in their working definition, they do not elaborate on the distinct effects of other-directed versus self-directed moral injury. Social-functionalist accounts fill this role by citing the ability of other-condemning moral emotions, such as anger, to be activated in behalf of others or the group as a whole. Military moral systems, like other organizations, utilize hierarchies and positions of authority as ways to structure social interactions. These types of hierarchies often possess a moral quality in that reverence and respect for authority figures can be a sustaining moral virtue in its own right (Graham et al., 2009; Rozin et al., 1999).
In such a context, commanding officers can be particularly endowed with noble characteristics or viewed as the epitomes of their branch's chosen values, including a commitment to the men and women under their command (Manning, 1994). When leaders violate these values, it may spur intense feelings of betrayal and strong condemnatory moral emotions from within their ranks. This process may also occur when individuals assumed to be friendly or neutral within the moral system betray the trust of a service member (e.g., civilians who conduct covert insurgent activity, children delivering explosive devices, sexual assault by another service member). In all of these cases, individuals who were once perceived within the service member's moral system as being safe have become unreliable and active threats to both their survival and that of the larger group. Accordingly, service members experiencing such betrayals may perceive a shrinking of their viable social collaborators to include a few select individuals, or in extreme cases, just themselves. In this increasingly narrowed moral system, strong self- and other-condemning emotions may predominate along with a social disillusionment and unwillingness to invest trust in future relationships or social contracts (Shay, 2011).
Finally, another critical event in considering the moral emotions of service members is the return home after deployment. Whereas some service members may experience moral injury in the context of deployment, for others the onset of negative moral emotions may not occur until after transitioning back into a civilian context—a possibility that has received some support by recent qualitative studies with veterans from the wars in Iraq and Afghanistan (Burnell, Boyce, & Hunt, 2010; Usoof, 2011). For many service members, the transition from a context of life-threatening combat to relatively innocuous civilian life constitutes a massive shift in moral systems and related moral emotions. Whereas morality during deployment may be defined in large part with respect to the survival of the unit, civilian morality is comprised of a larger number of comparatively trivial moral issues, virtually none of which condones lethal violence or aggression. Yet, notwithstanding their return to a civilian moral system, Service members retain all the conditioned behaviors, moral emotions, and social affiliations that they developed during their training and deployment.
The postdeployment period may therefore present a time of high risk and estrangement from others, as memories of combat or acts of abusive violence can trigger painful self-conscious emotions in some service members. Although these emotions function to avoid the contempt, anger, and moral disgust of one's social network (Haidt, 2003), they may lose their adaptive value for the individual if self-destructive loops form in which negative moral emotions and self-critical thoughts mutually reinforce one another. In such cases, service members may determine that they are no longer worthy of community membership and so abandon attempts at social reintegration. Similar patterns might also be observed if the experience of anger or moral disgust leads service members to ruminate on the violations they have experienced and so abandon attempts at forgiveness or reconciliation with the offending parties. Maladaptive interpretations of negative moral emotions may therefore compound the experience of moral injury for some service members and prevent the potentially beneficial action tendencies from taking effect for adaptive moral emotions.
In summary, social-functionalist models of morality clarify not only the moral emotions experienced by service members following moral injury, but also help to explain how moral emotions may contribute to morally injurious behaviors themselves. Furthermore, whereas Litz et al.'s (2009) model emphasizes dissonance as a crucial element to moral injury, social-functionalist accounts help to clarify how and why variation in the timing of this dissonance may occur. They accomplish this by identifying the importance of social context in shaping moral judgments and emotions of service members as they move into and out of combat settings. In the next section, contemporary models of posttraumatic symptoms that incorporate emotions beyond fear are reviewed in order to examine the link between moral injury and PTSD in more depth.
Moral Emotions and the Development of PTSD
As early research has found PTSD to be one of the major diagnostic correlates of moral injury and PTSD, another important task is to understand how moral emotions may contribute to the association between these clinical presentations. Although formal research on moral injury is just beginning, there is growing consensus in the field that posttraumatic issues often arise from experiences that may not necessarily threaten service members’ lives and safety (Nash & Litz, 2013). Although trauma has historically been conceptualized as a fear-provoking event, it is evident that many trauma survivors experience prominent trauma-related emotions other than fear (Grey & Holmes, 2008; Hathaway, Boals, & Banks, 2010; Power & Fyvie, 2013) that can be associated with elevations in PTSD symptomatology (Andrews, Brewin, Rose, & Kirk, 2000; La Bash & Papa, 2014; Taft et al., 2012). Pertinent to military populations, some of the most frequently reported peritraumatic emotions aside from fear (e.g., shame, anger) have been proposed to represent key warning signs of combat-related moral injury (Litz et al., 2009; Worthen & Ahern, 2014). Additionally, PTSD has been removed from the anxiety disorders section in the newly published fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5; American Psychiatric Association, 2013), and the revised criteria place greater emphasis on negative enduring changes in cognitions and mood that often occur following exposure to traumatic events (i.e., self-blame, persistent dysphoria). These observations suggest that a broader focus on peritraumatic and posttraumatic emotions in moral injury and military-related PTSD is warranted for meeting the needs of service members.
Although a thorough review is beyond the scope of the current article, several models of PTSD emphasize the interplay between emotions other than fear, the survivor's social network, or meaning-making in the development and maintenance of PTSD symptoms (e.g., Budden, 2009; Charuvastra & Cloitre, 2008; Lee, Scragg, & Turner, 2001; Neimeyer, 2004; Park, 2010). Integrating these domains may help to bridge the current gaps previously noted by Litz et al. (2009) in understanding the association between moral injury and PTSD. The Schematic, Propositional, Analogical, and Associative Representational Systems (SPAARS) model of PTSD presented by Dalgleish and Power (2004) presents an excellent example of how models of posttraumatic reactions that can accommodate moral emotions might help account for PTSD in the context of a moral injury.
Dalgleish and Power's (2004) framework proposes that the diagnostic criteria for PTSD can be divided into emotion-specific and emotion-nonspecific components. On the one hand, emotion-nonspecific components attempt to resolve discrepancies between the survivor's pre- and posttrauma schemas via oscillating reexperiencing (e.g., intrusive thoughts) and avoidance (e.g., psychic numbing) processes. In contrast, emotion-specific components pertain to the specific goals or states threatened by the trauma and will vary depending on the nature of the threatened goal. For example, whereas a traumatic threat to physical safety might include elevated anxiety and physiological arousal, a traumatic threat to one's bodily cleanliness might provoke disgust-related responses such as nausea and vomiting (see Dalgleish & Power, 2004 for a military-related case of the latter).
The breadth of the model proposed by Dalgleish and Power complements the social-functionalist account of moral emotions in that it allows for the social meaning of a particular type of trauma to influence the emotional content of the survivor's posttraumatic reactions. In the case of a morally injurious stressor, the violation of deeply held moral standards creates a discrepancy between the service member's pre- and post-trauma schemas, threatening the goal of social collaboration and reinforcing negative moral emotions, such as shame or anger. In turn, the painful discrepancy created by the morally injurious stressor may elicit oscillations between reexperiencing and avoidance that perpetuate the experience of negative moral emotion over time, similar to the maintenance of fear cues in Pavlovian-inspired conditioning models of PTSD. This model therefore provides one explanation of how morally injurious events can produce PTSD or PTSD-like symptoms.
In addition to Dalgleish and Power (2004), other complementary models of PTSD highlight how negative interactions with social networks also encourage avoidance of trauma cues and maintain PTSD symptoms (Budden, 2009; Lee et al., 2001). These perspectives are important to consider from a social-functionalist perspective because the cultural systems that calibrate moral emotions are constructed and enacted by many individuals regulating one another's behavior in order to sustain mutual collaboration. In such a system, it can easily be seen how the moral emotions of anger, disgust, or contempt may discourage positive interactions following traumatic events, thereby decreasing social processing and perpetuating posttraumatic symptoms. Furthermore, the action tendencies associated with the moral emotions of shame and context insensitive guilt may prompt efforts at avoidance for individuals within the system (e.g., affective numbing, substance use, social isolation), thereby constraining service members from processing their morally injurious traumas and maintaining posttraumatic symptoms (Belsher, Ruzek, Bongar, & Cordova, 2012).
Furthermore, because the meaning attributed to a morally injurious event has been suggested to be the most critical element in determining long-term responses (Litz et al., 2009), meaning-making frameworks may also provide important perspectives on the relation between moral injury, moral emotions, and PTSD. Several behavioral scientists have described how PTSD may develop in the context of stressful life events from a meaning-making standpoint (e.g., Neimeyer, 2004; Park, 2010). Although meaning has been defined in a diversity of ways, Park (2010) has drawn a critical distinction between global and situational meaning. Whereas global meaning captures an individual's main beliefs, goals, and subjective sense of purpose, situational meaning refers to how he or she understands or “makes sense” of a particular event. According to Park, PTSD symptomatology may arise to the degree that the stressor violates key aspects of one's global meaning system. For example, in a study of 130 college students exposed to a range of possible traumas, Park, Mills, and Edmondson (2012) found that violation of global values and goals were each significantly correlated with greater PTSD symptoms.
Morally germane war-zone stressors may invalidate the dimensions of global meaning that had provided Service members a sense of coherence and purpose throughout life in general. Examples of global meanings that moral injury may invalidate include a belief's in the ultimate goodness of humanity or a perceived commitment to one's deepest moral standards. Although global meanings are by no means restricted to religious/spiritual domains, it is also important to recognize the common intersection between moral injury and religious and spiritual concerns in some cases. Given the role of religion/spirituality in shaping global meaning among a majority of the world's citizens (Park, 2005), many service members’ beliefs/values and future goals are likely permeated with moralities that are defined in part by the teachings and behavioral norms of their particular faith tradition or spiritual community (Segal & Segal, 2004). Many service members’ subjective experience of moral injury may therefore be framed in religious or spiritual meanings. As such, in drawing on meaning-making models such as Park's (2010) work, one would anticipate that negative moral emotions toward self and others to co-occur with or potentially supersede anxiety symptomatology in the manifestation of PTSD symptoms.
Meaning-making frameworks are also important from a social-functionalist perspective. Specifically, some social-functional models posit that moral emotions and their associated action tendencies occur automatically and without conscious deliberation in response to experiences and simultaneously amplify the intensity of corresponding moral judgments (Haidt, 2001; Horberg, Oveis, & Keltner, 2011). Consequently, in attempting to make sense of strong, involuntary moral reactions following war-zone experiences, service members may make extreme, negative meanings regarding themselves, others and war-zone events in the form of global, internal, stable attributions (Litz et al., 2009), which, in turn, reinforce the initial negative moral emotions and discourage positive social interactions. As an example, a religiously devout service member who experiences PTSD symptoms and strong emotions of shame following a morally injurious stressor may interpret these difficulties to mean that he or she has been spiritually corrupted and therefore no longer “fits” within his or her religious community. In distancing him- or herself, the service member may engage in behaviors that are more consistent with the new “corrupted” identity, reinforcing shame and creating more distance from the predeployment social network. In this example, the individual's moral injury reflects an interplay between PTSD symptoms, moral emotions, and meaning making, which lead to social isolation and an entrenched negative self-concept. Thus, integrating social-functional models of moral emotions with meaning-making and theories of PTSD that extend beyond fear may help to explain how moral injury can produce and maintain symptoms of PTSD and impede social functioning following war-zone experiences.
The Role of Positive Moral Emotions in Moral Repair
Although the discussion thus far has focused on the role of negative moral emotions in moral injury, social-functionalist models of morality may also hold important implications for moral repair, which Litz et al. (2009) define as the “successful integration of [a] moral violation into an intact, although more flexible, functional belief system” (p. 701). Within the context of morally injurious stressors, the tendency of positive moral emotions to increase the flexibility of cognitive schemas and encourage social approach behaviors may assist moral repair in the wake of moral injury. Unfortunately, compared to negative moral emotions, far less research has been done on positive moral emotions generally, and to an even lesser extent in military populations. As a result, any assertions that are currently made about the role of positive moral emotions in moral injury and repair must remain speculative for the time being. However, because of their potential for understanding the process of transitioning in and out of military moral systems, we believe it is important to draw attention to positive moral emotions as having potential applications for the treatment of moral injury.
Furthermore, the relevance of positive moral emotions for the treatment of moral injury has also increased in light of the new DSM-5 criteria for PTSD (APA, 2013). The DSM-5 now includes pervasive negative beliefs about the self and negative emotions (including the self- and other-condemning emotions discussed above) as part of the diagnostic criteria. Therapeutic attempts at relieving the negative impact of moral-injury related beliefs and emotions may be facilitated by targeting positive moral emotions, which encourage social collaboration through appetitive means rather than through aversive negative moral emotions. Although the extant research prohibits any firm conclusions at this time, three positive moral emotions (compassion, elevation, and pride) have strong theoretical implications for moral repair and so are highlighted below with proposed connections between themselves and improved functioning in morally injured Service members.
Lazarus (1991a) defines compassion as the emotion that is experienced “when one comprehends and reacts to someone else in trouble by wanting to ameliorate the suffering” (p. 821) and enhances social cohesion by encouraging caregiving between group members. In addition, a growing body of research has documented the beneficial effects of directing compassion toward oneself, a process that Neff (2003) describes as “being touched by and open to one's own suffering, not avoiding or disconnecting from it, generating the desire to alleviate one's suffering and to heal oneself with kindness” (p. 87, see Neff, 2003 for further review of the construct). Research suggests that self-compassion serves as a buffer to negative emotion while simultaneously encouraging taking responsibility for personal failures (Leary, Tate, Adams, Batts Allen, & Hancock, 2007). Thus, compassion may be ideally suited for work with moral injury in that it does not require acquittal from personal culpability in order to convey its benefits. Recently, a longitudinal study of a compassion-focused intervention with a military population found a large effect size in the reduction in PTSD symptoms and a medium effect size in alleviating depression at 3-month follow-up (Kearney et al., 2013). Changes in self-compassion mediated these outcomes, suggesting that compassion may serve as a mechanism for moral repair or perhaps as an indication that moral repair is occurring.
Elevation can be described as a feeling of warmth in response to witnessing human goodness or “moral beauty” and motivates better living and the emulation of good deeds (Keltner & Haidt, 2003, p. 305; Tangney et al., 2007). Several studies have documented the positive effect of elevation in promoting volunteerism (Cox, 2010), moral empowerment (Schnall & Roper, 2012), and altruistic behaviors (Algoe & Haidt, 2009; Schnall et al., 2008), although to our knowledge there are no studies examining elevation in military populations. However, a study of elevation with a clinical sample of anxious and depressed nonveterans found that periods of high elevation were associated with lower depressed mood, anxiety, and hostility (Erickson & Abelson, 2012). Extrapolating from these findings, one potential way that elevation may assist in moral repair is by challenging disillusionment regarding the goodness of others as well as encouraging altruistic behaviors that provide opportunities for positive attributions about the self.
Pride can be considered a positive moral emotion that provides feedback about the self as being good, competent and virtuous (Lazarus, 1991b; Lewis, 1993). A sense of individual pride may encourage postdeployment social reintegration by helping service members feel that they are a valuable asset to their social community and motivate them to fulfill social roles therein. Importantly, it is likely that the beneficial impact of pride will depend upon whether the service members perceive their social community to recognize these qualities within them as well. Of the three positive moral emotions discussed in this section, pride has received the least attention from research in either civilian or military populations and so much evidence remains to be gathered to explore whether these possibilities can be empirically demonstrated.
As noted previously, intense negative moral emotions in moral injury may combine with posttraumatic symptoms to discourage adaptive meaning-making and so limit one's ability to function as a member of his or her social community. In contrast, the cognitive broadening functions of positive moral emotions may circumvent this process by facilitating alternative moral judgments to counteract the maladaptive influence of negative moral emotions on the meaning-making process. Furthermore, the inherent tendency of positive emotions to approach rewarding stimuli may help to override the avoidance of distressing posttraumatic cues (e.g., sitting in a crowded assembly hall to witness a child's award ceremony, using self-compassion to approach distressing traumatic memories). Positive moral emotions therefore present important possibilities for supporting moral repair following morally injurious war-zone stressors.
Summary and Future Recommendations
Military service binds service members together in part through cultivating moral emotions that promote loyalty, fidelity and cohesiveness. The cultivation of these traits can be highly beneficial in that they increase both the individual's and the group's chances for survival in the context of armed conflict. However, when moral codes of conduct are breached, the same emotions that function to promote cohesion can instead be turned against others or the self, resulting in potentially destructive emotional and behavioral responses such as destructive anger, alienation, and social withdrawal.
It has been argued here that the interplay between moral emotions and their larger military or civilian social context is a fundamental component of moral injury. Furthermore, an initial attempt has been made to explore how moral emotions and associated social processes can explain the relationship between moral injury and PTSD symptoms in service members. However, although we have argued that the contexts of military socialization, war-zone deployment, and civilian reintegration amplify the salience of moral emotions, this does not mean that moral emotions are unique to military contexts or moral injury. Rather, consistent with our review, social-functionalist accounts of moral emotions would suggest that moral emotions are likely to be salient for many forms of interpersonal trauma where social trust is violated.
Our review also suggests a number of additional areas for exploration that may prove beneficial for the study of moral injury and for the service members and veterans confronted with these concerns. Although the present review draws upon a number of established literatures to support and explain the socioemotional underpinnings of moral injury, it has largely done so indirectly. With very few exceptions, moral emotions have typically been assessed with regard to PTSD rather than in examinations of moral injury per se. Although PTSD may be considered an important correlate of moral injury, moral injury may also occur with other disorders frequently associated with trauma (i.e., depression, substance use) and even in the absence of active PTSD symptoms. If moral injury is a broad clinical construct that exists in the intersection of multiple emotional, cognitive and social pathways (as has been argued here), then it would reasonably be expected to show observable correlations with an equally broad array of processes. These may include emotional competencies, such as emotional awareness, clarity and regulation. Furthermore, moral injury should demonstrate associations with measures of social attitudes and social role functioning.
From the standpoint of resilience and recovery, it is as yet unclear what factors prevent moral injury from occurring in the wake of traumatic events and promote healing afterward. For example, when confronted with a potentially morally injurious event, how do service members respond to negative moral emotions in such a way as to maintain adaptive functioning? Additional questions pertain to the best clinical practices for moral injury. Current front-line interventions for trauma have shown efficacy in reducing PTSD in military samples (Eftekhari et al., 2013; Monson et al., 2006), but client drop-out, nonresponse rates, and concerns about the fit between their proposed therapeutic mechanisms and moral injury bring into question the appropriateness of these interventions for all forms of trauma (Nash & Litz, 2013; Schottenbauer, Glass, Arnkoff, Tendick, & Gray, 2008).
As a complement to these treatment approaches, interventions that promote mindfulness and target the elicitation of positive moral emotions (e.g., self-compassion) may work to improve spiritual, social, and psychological functioning by promoting tolerance and adaptive responses to negative moral emotional states (Gilbert, 2009; Hayes, Strosahl, & Wilson, 2011; Neff & Germer, 2013). It would be advantageous if researchers conducting these interventions with service members included validated measures of moral injury as part of their measured outcomes (e.g., Currier, Holland, Drescher, & Foy, 2013; Nash et al., 2013). Also important to the clinical care of service members and veterans may be the adequate training of clinicians in approaching clients’ shame and guilt, so as to prevent perceptions of empathic failure and further social alienation (Dearing & Tangney, 2011).
Although to our knowledge no clinical interventions have yet formally explored the benefits of social-functionalist models, we suggest that moral injury presents a timely and important opportunity to do so. Understanding the social functions of aversive moral emotions may help inform treatments for moral injury. For example, although we have already reviewed the damaging impact of shame in moral injury, some research suggests that shame also plays an important role in self-forgiveness. Woodyatt and Wenzel (2014) have shown in college samples that avoiding shame hinders genuine self-forgiveness by preventing perpetrators from acknowledging values-inconsistent behavior and reaffirming a positive moral identity. In contrast, although acknowledging violations temporarily increased shame, it resulted in overall reductions in shame on follow-up compared to controls and greater self-trust in the ability to behave in a values-consistent manner going forward. Recognizing the social functions of moral emotions aside from their aversive or hedonic qualities thus presents a potentially valuable contribution to psychotherapy interventions for moral injury.
Another major implication of the preceding discussion is that comprehensive care for morally injured returning service members will include active collaboration with their social networks, as these communities are likely to play powerful roles in eliciting and framing moral emotions. Research indicates that veterans who have suffered a loss of meaning in connection with a traumatic experience are more likely to seek help from both clergy and mental health professionals (Fontana & Rosenheck, 2005). It is therefore crucial for care providers in these two professions to coordinate services to the fullest extent possible. Because of this, mental health care professionals should ask about how morally injurious experiences have influenced clients’ religion and spirituality. Further, based on responses to such assessments, mental health providers should be ready to collaborate with spiritual care providers, including chaplains and community-based clergy. Correspondingly, as many individuals may turn to clergy members for help before mental health clinicians, spiritual care providers should be equipped with a sufficient understanding of mental health problems and treatment options so as to know when to refer or advocate for mental health treatment.
These points reinforce the socially embedded nature of moral injury and its accompanying emotions and behaviors. To this end, they are consistent with social-functionalist approaches to moral emotions, which we have incorporated here to explain in part the struggles of service members and veterans grappling with the morally wrenching realities of war. Although much more work remains to be done on this front, it is our hope that the foregoing discussion will encourage researchers, clinicians, and community leaders alike to collaborate in pursuing this important task of understanding and healing the moral wounds of war.