Reconecting to Values: A Path for Dealing with Moral Injury

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Trauma is a profoundly human experience, happening to anyone regardless of gender, race, or profession. Consider trauma as being on an anxiety spectrum, with the experience being labeled traumatic as that on the far end, with perhaps a simple feeling of uncertainty being on the polar opposite. Now, anxiety is about prediction; it’s a forward-focusing experience that manifests consciously as some form of “I thought x was going to happen, but now, due to circumstances, I can’t be certain.” This is then exacerbated when the predicted thing does not in fact happen, and the degree of effect on someone is directly proportional to how contrary to the prediction the actual event is. For instance, when walking, we unconsciously predict that the terrain in front of us is largely stable, hence the elevated heart rate and associated fear when we misstep off a curb that we didn’t “see” coming. Generally, the fear response is short-lived, but imagine if, in doing so, a car also drove by nearly missing us, or, worse, we get hit and wake up in a hospital. Each iteration is a ratcheting up of mistaken prediction, leading to an increased uncertainty with how we interact in the world. Trauma is a label on that spectrum of uncertainty, where, clinically, it’s associated with the last example, where life or grave bodily harm is threatened or actually happens.

Notice that part of the issue regarding trauma is the subjective judgment concerning one’s certainty about predicted outcomes. For instance, someone watching a sports event may predict an outcome, but because they have almost zero identification with the team in question, whether they’re correct will likely have almost no effect on them. Not so much the super-fan or the person who has put down money on a bet. Gambling here is an excellent metaphor for the emotional weight or pressure we place on our predictions. The greater the bet, the greater the effect size on diminishing the quality of the relationship we have with our ability to understand the world.

As an aside, prediction here is precisely why we get an elevated emotional response when something we say would happen does in fact do so. Even when it’s a negative outcome, there’s a sense of certainty that gets carried by the prediction-outcome relationship that encourages us to believe we have a grasp on the world and our place in it. We even have a word for the pleasure we feel in predicting another person’s misfortune: schadenfreude. Admittedly, this example brings in more complications as people rarely have that sense out of explicit predictions, where instead the misfortune of another is interpreted as justification for an underlying belief in a “just world.”

For more on that and its connection to Moral Injury, the article below covers it.

While trauma is often immediately connected in terms of mental health with Post-Traumatic Stress Disorder (PTSD), there is another framework that has been getting increasing focus in research, that of moral injury. Despite moral injury's primary connection with military service, exploring moral injury as a framework for understanding an aspect of traumatic experience, particularly when such touches on one’s closely held identity, can be helpful more broadly. For one example, the moral injury frame works quite well when understanding “religious trauma,” as such often deals with the effects of an authority structure that has been associated with holding moral truths requiring behavior in individuals that violates their ethics and sense of self.

Studies of PTSD have looked at trauma through the lens of fear, most often connected with an identification of potential or actual harm to self. Moral injury looks at trauma from a frame of ethics or moral schema. Trauma's destructive potential reaches across the domains of mind and body to a viscerally existential level. The accompanying feelings, ranging from despair and anger to shame and isolation, draw a person's focus from the social to the profoundly personal. It's not simply that trauma inspires fear and wariness that makes it so debilitating; it's that the mind turns in on itself, such that what was thought to be clear in one’s relationship to the world is now no longer so, and what was believed to be true has been cast into shadow. To explore that, we need to consider first the structure of how people form their perspectives.

Viewing the World through A Moral Lens

We are, as a species, somewhat obsessed with determining what is just and right. When faced with adversity, common phrases like "that's not fair" or "it's just not right" abound, often accompanied by calls for justice, changes to a system, and/or a deep-seated feeling that something just isn't right.

"Individually and collectively, our very existence depends on our ability to reach accurate conclusions about the world around us. In short, the experience of being right is imperative for our survival, gratifying for our ego, and, overall, one of life’s cheapest and keenest satisfactions." (Schulz, 2010)

While Schulz is discussing "right" in the sense of accuracy of knowledge, the accompanying feeling is, I believe, where an innate ethic for living begins. Each usage of "right" is a form of assessment, an appraisal of the world and, in particular, one's relationship to it. We need to be correct, not merely because it feels good, but because that feeling of goodness provides a path for how one proceeds with their life. The former example of walking and stepping off a curb on a street makes this clear, where having an accurate appraisal of the world isn’t just about an issue of knowledge, but of survival.

In other words, no declaration of what is right, as a belief or statement of perceived fact, is absent of a degree of certainty as to its connection with how one should be or act. To use a philosophical phrasing, there is no statement of an "is," in the sense of the world being a certain way, without an accompanying feeling of connecting such to an "ought," or this is how the world should be now or in the future.

This is why beliefs about the world in the form of religious and political perspectives are felt to be so deeply personal and, when perceived to be threatened, result in increasingly severe reactions. To question a deeply held belief is not merely an issue of word games or a logical puzzle, but an intrinsically existential burden that the person carries to move forward in the world “correctly.” Beliefs, in the form of ideologies or worldviews, are structures for guiding behavior towards what is “right” and for one’s well-being. Of course, with this understanding, to undermine a belief is going to be taken as a threat to their personhood. We are not disembodied beings, but embedded through our bodies within a broader world.

Clearly, not all beliefs are equal in emotional weight; hence, the demarcation of beliefs as holding greater intent is associated with ideologies or worldviews. Remember the example of the sports game, where one’s degree of response to being wrong about an outcome is directly connected to how personal the person feels in connection with the team.

From this, we can say that the degree to which a feeling of moral weight accompanies a person's declarations of fact or belief is determined by:

1. The personal perception of how central the belief is to a particular area (Value) of life.

2. How many other areas (Values) of life the belief is connected to.

3. The degree to which those areas (Values) are considered fundamental to self-image or an identity.

Let's consider an example of car manufacturers and the pride in ownership that sometimes occurs, as this is particularly relevant these days in the abrupt change owning a Tesla went from liberal pride in helping out the environment to a symbol of one’s far-right allegiance. Whether another person agrees with owning a particular brand of car is incidental for Point-1, but add in how the manufacturer is or may be connected to nationalistic pride for Point-2, and that such is considered quite important in Point-3, the result can be a fiery declaration of group identity.

As another example, if the issue at hand is a belief concerning when life begins as it pertains to abortion, then Point-1 is often sufficient for accruing a great deal of moral weight, increased even more as other areas (Values) of life are considered and believed important.

The reason Values are associated with areas of life is that this is how people think and talk about their beliefs when there is moral weight attached. Remember that being right is about an accurate appraisal of the world; it is the projection of the relationship between the person and the world of their experience. We frame these relationships through the verbal shorthand of Values.

We can take a few common Values as examples:

• Honesty/Trust: the relationship between one's inner assessment and outer declaration

• Family/Friendship: the relationship between self and others

• Independence/Freedom: the relationship between one's desire to act and the ability/social support to do so

• Integrity: the relationship between one's stated adherence to a particular Value and the continued alignment of their behavior with it

• Self-worth: the relationship between the internal-individual and external-social assessment of one’s importance

Note that none of these Values have any particular form of behavior attached to it. Further, none of them comes with any built-in or innate number for the level of their importance. Indeed, that very importance may shift depending on the circumstance. There are situations where honesty may be considered subservient to life if telling the truth is perceived as leading directly to harm. Many find situations where their family or a friendship is considered more important than their self-worth. This in no way means that honesty/truth or self-worth no longer matter to the person, it's simply that we assess a situation via a shifting hierarchy of Values, not in one that is rigidly formed.

Where we get into mental health trouble is precisely when Values are no longer looked at as tools for assessment, but as identifiers for an absolute connection to a particular behavior. Instead of looking at ourselves as relational beings, we are reframed as being rigid automatons. Within this rigidity is where moral injury finds room to fester, and returning to relational-ness provides the space for healing.

Moral Injury Healing through Meaning-Making

The utilization of Values as an initial or foundational tool for experiential assessment grants an immediate moral weight to situations that is difficult to disconnect. When a person lies, it is immediately thought of as a betrayal, and only later, if ever, is there a consideration of why the person acted that way. When we act contrary to a particular Value, the chastisement and accompanying sense of shame happen first, and only later, if ever, is there an attempt at understanding the contextual constraints that led us to that behavior.

People are meaning-making beings, and the gears of that process can be gummed up through trauma, sometimes so severely as to result in severe deficits to mental health. As part of this view of people as meaning-making beings, Values are considered universal. However, the behavioral manifestation in life and the degree of their importance are individually and socio-culturally determined. Our Values do not separate us from one another or contribute to a sense of shame and loss. Rather, it is the rigid conflation of particular behavior with Values and the conception of Values as belonging to a hardened hierarchy instead of a situationally shifting one that leads to the lasting harm of trauma.

"In a study of 23 clinical professionals with extensive backgrounds working with Veterans, Drescher et al. (2011) found that the most commonly mentioned warning signs of a moral injury included social problems (e.g., isolation, aggression), trust issues (e.g., lack of confidence in social contracts), spiritual and/or existential issues (e.g., loss of faith, questioning personal morality), self-depreciation, and a sense of betrayal, as well as PTSD and other mental health symptoms." (Currier, Holland, & Malott, 2013)

Consider all these symptoms from within a framework that looks at Values as tools for assessing the relationship between self and world. We have here negative behavioral manifestations for Values of trust (lack of confidence in social contracts), spirituality (loss of faith), self-worth (self-depreciation), community (isolation), and integrity (betrayal). Is it any wonder that the person no longer feels confident in their ability to assess their relationship to the world? The very tools previously used to do so have been shown, at least so it is believed by the person, to be worthless.

Not every traumatic event, thankfully, results in the same degree of lasting mental health effects. To determine why, we can use the same three criteria here as before, substituting traumatic experience for belief:

1. The perception of how central the traumatic experience is to a particular area (Value) of life.

2. How many other areas (Values) of life is the traumatic experience connected to?

3. The degree to which those areas (Values) are considered fundamental to self-image.

Consider the betrayal of trust. Points 1-3 are all concerned with meaning-making, the structure of a person's worldview, and the degree of their connection to it. This is why the suffering from broken trust is more significant when it happens with those closest and diminishes to almost nothing if the person or organization has little connection to the Value.

There is an increased chance for moral injury to occur when a particular Value is 1) cut off from a relational hierarchy and placed in an absolute one, 2) that Value is then connected indelibly with a particular form of behavior, and 3) the behavior is violated.

This tri-part path for moral injury is why such trauma associated with the military and other organizations of rigid structure is likely so high; their centrality to a person's life is all-encompassing, the areas of life they're connected to are equally broad and the person's self-image is deeply conflated with that of the organizational structure. When such a system is considered to have failed, there is little room for maneuverability; the person's assessment tools, or Values, have been disconnected from the profoundly human relational system.

"The meaning-making model posits that recovering from a stressful event and its distress involves reducing the discrepancy between the appraisal of that event and global beliefs and goals within the person (Park, 2010). Meaning making coping such as positive reinterpretation coping has been shown to decrease the initial appraisal-global meaning discrepancy, which results in decreased distress (e.g., Folkman & Moskowitz, 2007)." (Riley & Park, 2014)

Featured Image by Dylan Guest

"Global beliefs" (see Footnote for further explanation) are synonymous with one's basic system or schema of Values. The discrepancy noted has been looked at here as a difference between the relational hierarchy of Values innate to each person (global beliefs and goals) and the rigidity with which Values are often associated with particular behaviors of self and/or other (appraisal of event). The hoped-for healing occurs when this difference is decreased.

To decrease the discrepancy and effect change upon chronic symptoms requires an appreciation for one's innate ability for meaning-making and reclaiming Value as being centered within one’s humanity, not in any particular behavior. This is an active, continuous response to experience of noting the variability in Values each situation possesses and how any single situation does not encompass the whole of how a Value can manifest behaviorally in a life.

This is a reminder that we as a species and individuals lie, cheat, and steal, but we also show love, charity, and forgiveness. A broken promise is not the end of honesty and trust, any more than a lost dollar is the end of wealth and personal potential. The meaning-making of Valued appraisal is at the core of our self-stories, each narrative brimming with creative possibility. No situation, organization, or ideology can hold that potential in its entirety, and we should not let any restrain the healthy growth and exploration of our lives.

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References:

Nash, W. P., & Litz, B. T. (2013). Moral injury: A mechanism for war-related psychological trauma in military family members. Clinical Child and Family Psychology Review, 16(4), 365–375. doi:10.1007/s10567-013-0146-y

Riley, K. E., & Park, C. L. (2014). Problem-focused vs. Meaning-focused coping as mediators of the appraisal-adjustment relationship in chronic stressors. Journal of Social and Clinical Psychology, 33(7), 587–611. doi:10.1521/jscp.2014.33.7.587

Schulz, K. (2010). Being wrong: Adventures in the margin of error. New York: HarperCollins Publishers.

Further Reading:

The Moral Injury Workbook

Currier, J. M., Holland, J. M., & Malott, J. (2014). Moral injury, meaning making, and mental health in returning veterans. Journal of Clinical Psychology, 71(3), 229–240. doi:10.1002/jclp.22134

Currier, J. M., Holland, J. M., Drescher, K., & Foy, D. (2013). Initial Psychometric evaluation of the moral injury questionnaire-military version. Clinical Psychology & Psychotherapy, 22(1), 54–63. doi:10.1002/cpp.1866

Turner, J. E., Goodin, J. B., & Lokey, C. (2012). Exploring the roles of emotions, motivations, self-efficacy, and secondary control following critical unexpected life events. Journal of Adult Development, 19(4), 215–227. doi:10.1007/s10804-012-9148-0

Footnote:

"Contemporary models of coping suggest that maladjustment after trauma ensues from a mismatch between distressing realities associated with the stressor and one’s meaning system. According to Park (2010), there are two distinct aspects of this meaning making process, global and situational meaning. Global meaning refers to a person’s fundamental beliefs/values, goals, and subjective sense of purpose–all of which function together to infuse life with security and significance. Situational meaning largely refers to a person’s appraisal of specific events. Per Park’s model, the magnitude of posttraumatic symptomatiology corresponds to the extent to which certain dimensions of global meaning have been violated by a traumatic event. Challenges in recovery, as observed in cases of moral injury, may then arise to the degree that Veterans cannot integrate the appraised reality of their warzone experiences into global meaning and/or they cannot accommodate beliefs/values or life goals to “make sense” or (situationally) construct meaning out of these stressors. The process of working through such discrepancies is considered successful if the experience is reappraised in such a manner that it is either integrated into global meaning or if the Veteran adaptively revises his or her disrupted meaning structures to match the appraisal of the stressor." (Currier, Holland, & Malott, 2013)