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“In war, there are no unwounded soldiers”

Published onNov 02, 2021
“In war, there are no unwounded soldiers”
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“In war, there are no unwounded soldiers”

― Jose Narosky

Jenniffer Jack

Amerikanske Jenniffer Jack er tidligere militærpræst, Ph.d.-studerende og har tidligere undervist på en fleksibel masteruddannelse i sjælesorg på Københavns Universitet. I denne artikel på engelsk præsenterer og redegør hun for begrebet ”moral injury”, som direkte oversat betyder moralsk skade og betegner en tilstand, hvor en persons samvittighed og moral er blevet krænket. I en militær sammenhæng kan det opstå i situationer, hvor soldater deltager i handlinger, som strider mod deres personlige værdier i en grad, så det får en længerevarende psykisk skadevirkning. Jenniffer Jack redegør for, hvordan det langt hen ad vejen udvikler sig og er traumatiserende på linje med det efterhånden velkendte PTSD, og hun argumenterer for, hvorfor risikoen for moral injury er og bør være et opmærksomhedspunkt for blandt andre militære præster.

Introduction

The world has been at war for an extended period; some countries for longer, some shorter. For the US, it’s been 20 years- twice as long as the war in Vietnam, four times as long as World War II. Every country’s military forces engaged in this Global War on Terrorism have felt the pinch and strain: the longer hours, doing more with less, equipment or units that do not get fully and properly rested or refitted, and never enough training time because operations come first. This is just as true for the Chaplain Corps: with religious services to provide, people to see, comfort to offer, funerals, memorial services, and responses to traumatic events to preside over or get the troops through we find ourselves spread thinly across the battlefield. At the height of the US-led Coalition Iraq war (2003), a documentary was made about the trauma work of medical doctors in the Baghdad Emergency Room. War zone medicine can be absolutely gruesome and traumatic- for both the doctor and patient. But those doctors plainly see their patient’s wounds and are able to point to the issue in order to heal it. We Chaplains cope with wounds every day, but they are the invisible variety. These invisible wounds, the spiritual wounds of war, should be of compelling interest to us. Knowledge of these wounds and how to mend them is vital. These invisible wounds are becoming known as Moral Injuries (MI). Military Chaplains can minimize the traumatic and negative spiritual impacts of war on their flock by understanding what MI is, by being able to recognize it in their soldiers, and by considering some of the ramifications of this invisible injury.

Because Chaplains are focused on the spiritual, unseen world, and bringing hope, meaning and faith to the individual, the domain of spiritual injuries should be theirs without question. A Chaplain will understand how easily a human’s spirit can be injured even without war and that people have a “God-shaped vacuum in the heart of each man which cannot be satisfied by any created thing but only by God.” (Pascal, 1660/2016). The soul of a soldier scarred by war can be helped by a Chaplain’s comforting ministrations. Combat is one of the events that devastate the soul but its consequence, MI, is one of the least-discussed injuries recognized by Chaplains. Psychologists and psychiatrists, even medical doctors, expound widely on the topic, but military Chaplains, with their extensive knowledge of the soul and combat trials appear hesitant to join in framing this conversation. With military Chaplains on the front line, their insights are of intense interest to colleagues.

Historical backdrop

Moral injury is not a brand-new idea; books from as long ago as 1910 were published about the concept. Every military conflict has given rise to the devastation visited on the combatants’ senses and it has been known by names and incarnations: shell shock, combat fatigue, 1,000-yard stare, combat stress, spiritual injury, PTSD, wounded conscience, and spiritual harm. Edward Tick, best known for treating Vietnam War veterans for Post-Traumatic Stress Disorder (PTSD) before there was even such a diagnosis, wrote in War and the Soul: “Though the affliction that today we call post-traumatic stress disorder has had many names over the centuries, it is always the result of the way war invades, wounds, and transforms the spirit” (Tick, 2005). Jonathan Shay, father of modern MI thought, said: “Psychological casualties and physical casualties, with rare exceptions, are yoked together: what spills blood wounds spirit” (Shay, 2007). Participation in combat and spiritual injuries are unquestionably entwined, so the military Chaplain’s ability to help their soldiers should be likewise interwoven into their care.

In the prologue to The Untold War, Nancy Sherman, professor at Georgetown University and a former Chair in Ethics at the United States Naval Academy, succinctly relates the realities of war and the soul: “Combat is nothing if not existential: it pits an individual against life and its ultimate challenges. It requires seeing the unspeakable and doing the dreaded. It is a role that is immersed and transformative and lingers long after a soldier takes off the uniform. Because of the stressors it involves- unpredictable attack, helplessness in the face of that unpredictability, pervasive and gruesome carnage- it imbeds deep” (Sherman, 2010). That depth is where Chaplains must go if they intend to help their soldiers overcome these invisible, spiritual wounds. In thinking of this as an injury to the soul, only the manifestations and reactions can be seen.

Being placed in these extraordinary situations can trigger a conflict within one’s soul. Although there are mountains of gear and armament to protect the physical body, the soldier’s morals and ethics, their spirit, is at risk of damage as well. Merely being in combat provides occasion for disconcerting or agitating scenes and events, potentially damaging our understanding and beliefs about the ‘rightness,’ comprising our world. In the US Army Leadership and the Profession Guide (ADP 6-22), ethics and morality are described as “an enduring set of beliefs, laws, and moral principles that guide and create an essential culture of trust within the Army profession.” Most Chaplains will find the beliefs and laws laid down in their particular holy scriptures are what binds them to their definitions of ‘ethical’ and ‘moral.’ Truly, these two elements are the consequence of one’s spiritual belief and understanding. For our purposes, ‘spiritual’ encompasses those things of the soul; unseen and yet felt to the core of one’s being. A deeper discussion of these definitions is beyond the scope of this article; however, ethics and morality play a significant part in understanding MI. As religious professionals, we each have a reasonably good understanding of these terms, but in the world of MI, the definition is somewhat broader. While not everyone concurs with each definition wholeheartedly, we should have general agreement on the words involved with this topic, as they frame the conversation.

What is moral injury exactly? Is MI a medical diagnosis? Does it have physical expression? Is it just PTSD with a different slant?

Moral injury is not a medical diagnosis; it is a spiritual diagnosis. In the journal articles collected to date, even the recent ones, the authors universally note the lack of extensive foundational research in this field however they do indicate this injury is spiritual in nature. (Carey, et. al., (2016), Weaver, et. al., (1996)) MI and PTSD have similar physical expressions such as suicide risk, sleep issues, substance use/abuse, self-destructive actions, social problems, trust issues, fatalism, and sorrow. The PTSD/MI symptoms have an intersection but the major difference between the two is in the source of the injury. In PTSD, safety is the necessity or essential life element lost; in MI it is trust. PTSD, a diagnosis that is danger and threat based, is a clearly understood, well-researched, and much documented, becoming an American Psychiatric Association mental disorder, treatable with medicine and psychiatric care. On the other hand, MI is not well understood, sparsely researched, and there is less consensus about what it is exactly although researchers almost universally agree it is a spiritual wound.

Dr. Jonathan Shay, a medical doctor and psychiatrist, performed some of the original fundamental research, including hundreds of articles and books plus innumerable lectures. He worked extensively with Vietnam veterans in the 1990’s and has written about the damaged spirit of combat veterans, coining the modern term, “Moral Injury.” In a later discourse on moral injury, he expounded on a fellow researcher’s definition by focusing on three specific elements: “(1) betrayal of what’s right (2) by someone who holds legitimate authority (in the military—a leader) (3) in a high stakes situation,” making a point that all three elements are necessary to create MI or moral injury event (MIE) (Shay, 2014). Shay starts with a seminal transgressional event and includes a powerholder and a critical situation as essential elements, all of which are required to create a MI.

Moral Injury Focus

Dr. Rita Brock, Founding Director of the Soul Repair Center at Brite Divinity School, Texas Christian University and currently head of the Shay Moral Injury Center at the Volunteers of America (VOA), has studied MI from the pastor’s viewpoint. Brock takes the more religious or spiritual view that MI is trauma of the moral conscience and that one’s moral foundations or personal faith cannot make sense of the experience, resulting in pain or self-condemnation, and that it deals with high stakes situations with no clear right or wrong choices and harm being done. She indicates that it can come from being the actor, witness or survivor of an MIE. Her focus is on how the experience is remembered and understood within the veteran’s mind. Her studies highlight the spiritual care a soldier needs as witnessed by her work with the VOA.

Dr. Brett Litz, a clinical psychologist currently at Boston University, Director of the Mental Health Core of the Massachusetts Veterans Epidemiological Research and Information Center at the Veteran’s Administration (VA) Boston Healthcare System, has performed as principal investigator, with much of his research at the VA. He has written hundreds of articles and books dealing with trauma and traumatic loss, choosing to use the term ‘moral injury’ because of the insufficiency of the current mental health diagnoses available. (Litz, et. al., 2009) defines MI as "perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long term, emotionally, psychologically, behaviorally, spiritually, and socially" (Litz, et. al., 2009) Additionally, “This may entail participating in or witnessing inhumane or cruel actions, failing to prevent the immoral acts of others, as well as engaging in subtle acts or experiencing reactions that, upon reflection, transgress a moral code. We also consider bearing witness to the aftermath of violence and human carnage to be potentially morally injurious.” (Litz, et. al., 2009) Litz’ basic premise is that a person can witness, act or fail to act on or in some situation or event that violates deeply held moral beliefs or expectations, thereby causing a MI. Additionally, Litz focuses on the self as the violator where Shay’s definition requires a powerholder who is violator. Litz’ broader understanding is the one used most often by VA centers when discussing Moral Injury. (Litz, 2015)

Litz developed the following tool, highlighting the difference between PTSD and MI, to see both side by side, and in review the significant differences. While PTSD is focused on an actual physical threat trigger, MI is focused on a violation of deeply held moral values. Additionally, those suffering PTSD have feelings of fear and horror, while those suffering from MI suffer from guilt and shame. Finally, in the necessity or essential life element lost, those who suffer from PTSD lose safety; those who suffer from a MI lose trust.


PTSD

MORAL INJURY

Triggering Event

(A1 Criterion)

Actual or threatened death or serious injury

Acts that violate deeply held moral values

Individual’s role at time of event

Victim or witness

Perpetrator, victim, or witness

Predominant painful emotion (A2)

Fear, horror, helplessness

Guilt, shame, anger

Reexperiencing

(B Criteria)?

YES

YES

Avoidance or numbing

(C Criteria)?

YES

YES

Physiological Arousal

(D Criteria)?

YES

NO

What necessity is lost?

Safety

Trust

(Litz, et. al., 2009)

Additionally, there are two fundamental elements to address when dealing with a possible MI. The first element, confidentiality, drives soldiers to their Chaplain because they appreciate the sanctity of the confessional or do not want others to know their particular problems. Often times confidentiality is the main reason the Chaplain is sought out, as soldiers know their problems will not be discussed nor ever be held open to the scrutiny their medical records could be. In the US military, sanctity of the confessional is codified by regulation (AR 165-1 (2019), JG 1-05 (2018)).

The second element that should be reviewed is inferring whethe rall individuals who have experienced the same or similar MIE now suffer from MI. What makes one person’s moral injury not another person’s moral injury? The injury is a personal construction due to the very nature of it being a violation of deeply held personal beliefs. Since deeply held beliefs are bound up in the person, it is possible that what affects one deeply will not affect another in the very same way. Some individuals will look at an event or issue with more subjectivity while another will look at the very same thing with a rigid or fixed concept about right and wrong. Determining why the same MIE will cause a brutal gash in one person’s soul and not affect the next so severely is a good question, deserving of deep and serious research. Its answer is not readily available nor apparent.

Over the last 30 years, leaders in the field developed an understanding of MI, each with a similar definition but with a different focus. The fact that these are injuries to one’s soul or spirit runs through each conclusion. Shay determined that MI requires three elements: the event (betrayal), by legitimate authority, and having high stakes. Brock agrees with Shay regarding the essential elements but concentrates on bringing the mind back into harmony with the injured soul. Litz has the somewhat broader view that in witnessing, acting or failing to act in some personally morally reprehensible situation, a person can suffer from a MI.

Examples and considerations

These clinical descriptions of the concept give an academic understanding, but concrete examples might make the MI construct clearer. Consequences from these situations have a real possibility of causing MI or being classified a MIE. Examples of PTSD abound but one cannot so routinely point to some behavior, issue, or event to identify it as MI/MIE. The events of these stories are a true compilation though the names have been changed.

It’s Friday night and the young soldiers decide to walk into town for some fun after the exhausting week. Marie and her cohort were certainly friends: they had shot guns and marched in unison as a team; together they had eaten, run thousands of laps, lugged rucksacks on every field exercise, plus cleaned the barracks, cleaned their weapons and cleaned classrooms. They even slept within an arms’ reach, above or below or just across the hall. Together they shared fears and disappointments, exuberance and joy, favored one drill instructor, disliked another. These shared experiences were building blocks to the tight-knit friendships she thought they now possessed. It had not been easy getting here either. Extra study helped her through the advanced schooling and the extra work paid off, Marie graduating at the top of the class with a promotion included. Now they were junior members of a professional military team, going out on the town together at their first duty station, money in their pockets and fun on their minds.

But by the time Marie crawled back to the barracks in the stillness of Saturday morning, all she wanted was a couple of aspirin, two hot showers, and her bed. Through tears of shame and humiliation, she wondered, how it could have happened to her. Marie thought they had her back, that she could trust them. So what if she was dancing with that higher ranking sergeant, the one she had seen around the base? When he dragged Marie into the back room, away from the pool tables where they had been playing and she squeaked with fright, knowing the situation was getting away from her, a shout to her friends went unanswered. After glancing at the noise, they all turned back to the pool table, away from Marie. She saw them, they saw her; and it was obvious Marie wasn’t happy about what was happening.

What happened in the back room of the bar is not the topic: military sexual trauma is outside the scope of this article. As Marie has multiple specific traumas in play, the individuals we will examine are the friends who turned away and willfully chose not to see what was going on.

First, let us determine if this can this be classified as MI or MIE. Using the VA definition, it can: the friends clearly bore witness and failed to prevent an act that transgressed deeply held moral values (sexual violation). Although an assumption, to consider it immoral for a young woman to be raped by anyone, particularly a fellow soldier, it is a fair and expected assumption. Then, from the Litz chart determining whether this event would be classified PTSD or MI, we see that the event violates deeply held moral values and they were witnesses (saw what was happening to their friend). The predominate emotions would be guilt and shame over not helping their friend; these individuals would think about or avoid thinking about this event as something shameful, with guilt attached, although it probably would not bring up physiological reactions. Trust is the life necessity that is lost, not safety. Finally, it can be supposed that the friends who turned away and refused to help Marie could suffer from MI.

A second example is Peter, a senior sergeant. Peter has had a long career with many duty stations and positions of increasing responsibility. He worked his way up the ranks and was respected for his level head and thoughtful mindset. Peers consulted with him and subordinates looked up to him for practical, by-the-book leadership. Peter believed there was a right way and a wrong way: the right way was his first and only choice. Superiors wanted him in their ranks because he was dependable; if anyone could be counted on, it was him. All of his annual reports have him listed as an exceptional leader, truthful, and straightforward.

As a senior non-commissioned officer (NCO), Peter was specially selected for the important job of standing up a new unit with a cutting-edge capability. He took it gladly, thinking that excelling at this position would put him in line for a coveted final promotion before retirement. He worked hard day and night: meetings, inspections, new equipment to install, new staff to bring on board, procedures to develop, soldiers to train. Peter worked well with the commanding officer (CO) and the executive officer (XO), in sync on almost every matter. Then the CO fell seriously ill and had to be replaced. The new CO was a polar opposite: overbearing, dictatorial, duplicitous, sly, and treacherous. The new CO terrorized his staff, abusing them emotionally to the point that the XO, all the primary staff officers and almost 60% of the enlisted support staff requested transfers out of this new special unit; further, he undermined Peter’s authority with the enlisted soldiers.

Peter was horrified; time and again he tried to get staff to stay, protecting them as best he could. He also tried to get the CO to behave more reasonably, more professionally. But in the CO’s mind, Peter became a scapegoat for all that was going wrong in the unit. In the end, higher headquarters came down to investigate matters. Although most of the enlisted staff and senior NCOs supported Peter during the investigations, several new staff officers supported the CO; they had been told that Peter was incompetent. Additionally, the general who had selected this new CO sent the investigating team. In the end, Peter chose retirement over transferring to a position with less responsibility, essentially a demotion. While this new CO narrowly avoided censure during this investigation, only a year later a second investigation brought him early retirement instead of the general’s star he had coveted.

This is a classic case of toxic leadership with multiple traumas in evidence. Concentrating on Peter only, the Shay 3-part definition seems made for this situation. Toxic leadership can be seen as (1) “a betrayal of what’s right,” (2) “by someone who holds legitimate authority (in the military—a leader),” (3) “in a high stakes situation.” Peter was most certainly betrayed by the replacement CO and in ways only a commander can accomplish. Peter had expected to excel at this job as he had before, yet the new CO made public accusations of incompetence; while Peter’s subordinates respected and worked well with him, Peter’s supervisor, this new leader, worked very poorly with him. Finally, Peter took on creating the new unit as a challenge and anticipated that it would help him make one more promotion before he retired, however, to avoid the crushing weight of this toxic environment, he retired early with less pay than he had planned on. In looking at Litz’ chart in determining PTSD or MI classification, we can see that the event violates deeply held moral values (human dignity and an expectation of a respectful work environment). Peter was the victim of toxic leadership; it is easy to believe the predominate emotions would be shame and anger (possible demotion instead of a promotion and having to retire early); it is also easy to believe that Peter would think about or avoid thinking about this event as something shameful and with anger but that it probably would not incite physiological reactions. Trust is the life necessity that is lost and not safety. It can be expected that Peter may suffer MI.

Headline

Do not believe that it is only the infamous or publicized incidents of war that could be classified as an MIE. This is not the case. It is very possible that the event causing a soldier shame or guilt, loss of trust or soul-crushing despair, and about which they can- or did- do absolutely nothing is much less front-page story and far more prosaic. While our long war has provided many situations for both the Chaplain and their troops to see events that would cause in them a MI, the basic definition is still that some situation has deeply and profoundly caused distress in one’s soul because it damages tenets held so dearly, so the actual MIE need not be front page news.

Military Chaplains hold a unique position in regard to this specific injury: no medical doctor nor psychologist can do more than the Chaplain in helping a soldier overcome MI. We understand the spirit, the soul and are able to help soldiers find God’s answers. However, the ramifications of Chaplains knowing little beyond the basics of MI is that we do not provide more input to frame the wider conversation, nor do we collegially share with each other about how to treat this injury, and because it is a personal injury and requires a personal cure, it becomes harder to find general solution processes.

Our psychologist and psychiatrist counterparts are framing spiritual injury in their views; military Chaplains should vigorously add to the conversation, developing both the wider spiritual understanding and the possible consequences of ignoring MI, or treating them as PTSD. Chaplains’ assessments should be a fundamental part of the core understanding, as providing spiritual guidance is a major contribution in repairing MI.

Military Chaplains should take the lead in defining and outlining treatment. Since this is a spiritual injury, acquired in combat and other traumatic situations in which soldiers find themselves, no other religious professional is more able to see and understand this injury on a regular basis. Yet few religious professionals have written extensively on this topic. Best practices or relevant methodology for treating MI should be shared liberally among military Chaplains.

In the end, each MI must be handled person by person, Chaplain and soldier together. But in the background, we should be working toward a shared community of understanding methods and techniques that provide good triage and treatment for soldiers. Working cooperatively to develop a solid platform from which to combat the adverse effects of war is essential. We must all help fill in the blanks, get involved and do the hard work of figuring out then sharing the solutions.

Chaplains well understand there is a moral component to war that is beyond the jus in bello; pivotal actions occur when broken humans wage war, and regardless of moral underpinning, a soldier’s morals and ethics will be stretched to unendurable limits in war. Ultimately, knowing more about this topic provides increased insight into a combat soldier’s needs; where once a Chaplain might have considered only PTSD and sent the individual to the combat stress team for treatment, now perhaps will think of the more subtle and less specific conclusion of a moral injury, an injury which that Chaplain is well-poised to recognize and help the soldier toward God’s healing influence. This topic of Moral Injury should be of great interest to the military Chaplain. We should enter the discussion in greater numbers, present our findings and add to the understanding of how best to deal with spiritual injury.

By understanding the MI construction, recognizing it in their soldiers and thinking further on its consequence we military Chaplains can help to minimize the negative spiritual impacts on our soldiers. We have seen that trauma to a soldier’s spirit is not an unusual event in wartime; the many wars of the 20th century have borne witness to damaged souls returning from the battlefield up to and including the latest long war. This trauma is becoming known as MI and is a construct developed predominately by psychologists and psychiatrists. As an injury that relates directly to one’s personal ethics and morals, this wound is in the unseen realm, one’s spirit. As a general understanding by the US VA healthcare system, who use the broader view, MI is defined as traumatic or unusually stressful circumstances, that people may perpetrate, fail to prevent, or witness, and that contradict deeply held moral beliefs and expectations. (VA, 2021) Shay defines it more narrowly, adding the necessary element of a powerholder into the mix. Brock, however, focuses on repairing the damage to one’s soul. All three of these researchers and many others agree that MI is an injury to the spirit.

Conclusion: the Chaplains’ perspective

As Chaplains, we prefer to focus on the hope, meaning and purpose that is so often lacking in the wounded soul, so learning to recognize MI is essential. We have seen that it manifests with PTSD-like symptoms, specifically guilt, shame, and anger; the soldier will re-experience or avoid thinking about the issue, however trust is the life necessity lost, not safety as in PTSD. Conversations with a soldier might present as suicidal thoughts; they might present as risky behavior; they might avoid people or situations; or they might not know exactly what is wrong, just that something is not right. Because most of these are also indicators of PTSD, Chaplains cannot say with certainty that a soldier has, or only has, MI. Each of these manifestations can just as easily be seen or taken as PTSD, a diagnosis which falls most appropriately into a medical review. But in walking through Litz’ chart (above) we can ask at least five questions from the matrix, and in reviewing the fundamental elements of the event, provide a basic triage. This series of questions will give us some clues as to whether we are able help with what might be MI or whether medical or psychiatric care is more appropriate, because although MI is similar to PTSD, the treatment regimens are not the same.

The few minutes with a Chaplain, allowing them to check the pulse of a soldier’s soul on returning from a warzone isn’t enough. Without fail each individual wants to just get the checks and signatures, completing the paperwork so they can go see their family, returning to some semblance of normalcy. All they saw and experienced downrange is packed into a box that they will look at later. The limited time spent on determining how the soldier’s soul is reacting to the events they witnessed or experienced downrange is barely enough to make any sort of accurate determination. This is where having a solid series or sequence of chaplain-endorsed triage questions would be useful.

That also brings us to possible consequences of military Chaplains remaining silent in the face of MI definition. The worst-case scenario is that if we don’t speak up, we do not get a say about what constitutes MI, an obvious spiritual injury. The MI discussion is being framed mostly by medical and psychiatric specialists. A spiritual injury needs a spiritual repair: that means the Chaplain. This is our home field advantage. Additionally, remaining detached from the issue will not benefit a Chaplain community of knowledge. If injuries to the soul have been happening as long as there have been soldiers going to war, military Chaplains have a long story to tell. That narrative should be shared, not only to help their brethren but to determine the size and shape of these kinds of wounds. No particular faith group has ownership over soul repair: but if trust is lost, one certainly finds it again in forgiveness. Answers to MI are surely found in that universal trait, within the soldier’s understanding of God. Chaplains sharing knowledge can only help our soldiers. Military Chaplains have a massive job on their hands, in activities both of prevention and postvention, caring for the spirits of their soldiers.

Finally, we are not only religious professionals, but we are also military professionals, and the study of war includes the spiritual damage to our soldiers; it is both important and urgent. Proverbs 2:6 tells us “For the LORD gives wisdom; From His mouth come knowledge and understanding.” If this article has interested you at all, I urge you to look into spiritual injury. Take up your pens; make a difference by having the voices of military religious professionals heard and heeded regarding a topic so visible in our daily workload.

References

Army Chaplain Corps Activities, Army Regulation (AR) 165-1, (2019).

Army Leadership and the Profession, Army Development Pamphlet (ADP) 6-22, (2019).

Brock, R. N. (2017). Moral Conscience, Moral Injury, and Rituals for Recovery. Moral Injury and Beyond. Papadopolous, R., ed., New York: Routledge.

Bible, The New American Standard. (1990). The Lockman Foundation, AMG International.

Carey, L., Hodgson, T., Krikheli, L., Soh, R., Armour, A., Singh, T., & Impiombato, C. (2016). Moral Injury, Spiritual Care and the Role of Chaplains: An Exploratory Scoping Review of Literature and Resources. Journal of Religious Health, 55:1218–1245, DOI 10.1007/s10943-016-0231-x.

Journeyman Pictures. (2013, December 16). Battlefield ER: The brutal life of a warzone medic [Video]. YouTube. https://www.youtube.com/watch?v=DmDL14dUkb8

Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy.

Clinical Psychology Review.

Litz, B. T. (2016, 2015). Adaptive disclosure: A new treatment for military trauma, loss, and moral injury (1st ed.). The Guilford Press.

Pascal, B. (2016). Pensées. (Samizdat, Translated from “Texte de l’édition Brunschvicg”). Garnier Paris (coll. Classiques). (Original work published 1660).

(Note: Commonly paraphrased from original correct quote: “What is it, then, that this desire and this inability proclaim to us, but that there was once in man a true happiness of which there now remain to him only the mark and empty trace, which he in vain tries to fill from all his surroundings, seeking from things absent the help he does not obtain in things present? But these are all inadequate, because the infinite abyss can only be filled by an infinite and immutable object, that is to say, only by God Himself.”)

Religious Affairs in Joint Operations, Joint Guide (JG) 1-05, (2018).

Shay, J. “Leaders Actions to Prevent Moral and Psychiatric Injury,” 1st Annual Marine Corps Combat/Operational Stress Control (COSC) Conference (June 18–19, 2007).

Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182–191. https://doi.org/10.1037/a0036090

Sherman, N. The Untold War: Inside the Hearts, Minds, and Souls of Our Soldiers (New York: WW Norton & Company, 2010).

Tick, E. (2005). War and the soul: Healing our nation's veterans from post-tramatic stress disorder. ProQuest Ebook Central https://ebookcentral-proquest-com.ezproxy.liberty.edu.

Veterans Administration (VA). https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp. (2021).

Weaver, A., Koenig, H., & Ochberg, F. (1996). Post Traumatic Stress, Mental Health Professionals, and the Clergy: A Need for collaboration, Training, and Research. Journal of Traumatic Stress, Vol. 9, No. 4.

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