Moral Injury and Beyond

Understanding Human Anguish and Healing Traumatic Wounds

Renos K. Papadopoulos, Renos K. Papadopoulos

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781351862462
• Edition: 1
• Topic: Psychology
• Subtopic: Post-Traumatic Stress Disorder (PTSD)
• Index: Psychology

Moral Injury and Beyond: Understanding Human Anguish and Healing Traumatic Wounds uniquely brings together a prominent collection of international contributors from the fields of psychiatry, psychology, philosophy, theology, military chaplaincy and acute crisis care to address the phenomenon of moral injury. Introduced in the 1990s to refer to a type of psychological trauma, experienced especially by soldiers who felt that their actions transgressed the expected moral norms, this innovative volume provides a timely update that progresses and redefines the field of moral injury.

The ten ground-breaking essays expand our understanding of moral injury beyond its original military context, arguing that it can fruitfully be applied to and address predicaments most persons face in their daily lives. Approaching moral injury from different perspectives, the contributors focus on the experiences of combat veterans and other survivors of violent forms of adversity. The chapters address thought-provoking questions and topics, such as how survivors can regain their hope and faith, and how they can, in time, explore ways that will lead them to grow through their suffering. Exploring moral injury with a particular emphasis on spirituality, the early Church Fathers form the framework within which several chapters examine moral injury, articulating a new perspective on this important subject. The insights advanced are not limited to theoretical innovations but also include practical methods of dealing with the effects of moral injury.

This pioneering collection will be essential resource for mental health practitioners and trainees working with people suffering from severe trauma. Due to its interdisciplinary nature, it will be useful not only to those academics and professionals engaged with moral injury but will be a source of inspiration for any perceptive student of the complexities and dilemmas of modern life, especially as it interfaces with issues of mental health and spirituality. It will also be invaluable to academics and students of Jungian psychology, theology, philosophy and history interested in war, migration and the impact of extreme forms of adversity.

Chapter 1

The traumatising discourse of trauma and moral injury

Distress and renewal

Renos K. Papadopoulos

Trauma and moral injury

This book and this chapter address the complexities of moral injury. “Trauma” is the Greek word for injury and these two terms/words are closely interlinked. It was in the course of exploring the complexities of trauma that the concept of moral injury emerged (Litz, Stein, Delaney, Lebowitz, Nash, Silva & Maguen, 2009; Shay, 2002, 2014; Shay & Munroe, 1999). Therefore, it is important to first examine the relationship between trauma and moral injury in order to delineate the appropriate context of the subject matter of our book, in general, and of this chapter in particular.

As it is known, the primary meaning of trauma has been confined to physical injury. Trauma, in Greek, means wound or injury; more precisely, it refers to the mark that is left when one’s skin is pierced. Hence, traumatology predominantly refers to the medical speciality that deals with patients brought to accident and emergency (A&E) hospital departments. The metaphorical meaning of trauma in relation to psychological rather than somatic wounds is as old as the word itself. Even Homer used to use trauma to refer to non-bodily injuries. The New Testament also uses trauma metaphorically.

However, as my etymological research has revealed (Papadopoulos, 2002, 2007; in press b), in Greek, the root of the verb “to pierce” (titrosko) is the verb “to rub” (teiro), which has two meanings: to rub in and to rub off or rub away. Rubbing in, in effect, results again in piercing, in creating a wound and, therefore, it has an identical effect to that of piercing. Contrastingly, rubbing off or rubbing away has a completely different effect, that of erasing and cleansing, of burnishing and buffing, etc.; that is, resulting in forms of renewal. This meaning is not an abstract etymological observation, it is also corroborated by the actual reality: in addition to (and not instead of) causing injurious and traumatising effects, the powerful experiences that enter one’s life in a disruptive way also erase, to varying degrees, many established and accepted ways of being, and previously unquestioned assumptions about life and its priorities, thus creating the possibility of developing refreshed positions and revitalised identities.

Needless to say, the pain of the rubbing-in effect of trauma invariably outweighs all other possible effects to such an extent that the renewing possibilities are often neglected or even ignored completely. Yet, in actual reality, everybody who is exposed to devastating events and circumstances does experience both effects. Everyone who has worked with severely traumatised individuals will have heard such persons saying (directly or indirectly), and in addition to complaining about their pain and suffering (from the wounding effects of trauma), that the entirety of their experience of adversity (their realisation of their limitations, the facing of the unexpected, etc.) made them rethink and reconsider many important aspects of their lives. In struggling to make sense of the overwhelming impact the calamitous and shattering events had on them, they were forced to reconsider many fundamental issues of life in general.

When struck by such truly “awe-some” and “awe-ful” adverse experiences, ordinary people become philosophers, but not of the armchair type. Deeply perturbed and troubled by the unpredictable and catastrophic turn of events, and facing the life-shattering consequences of the experienced adversities, they are shaken to the core of their being, and in deep anguish they struggle to make sense of what has befallen them and to reassess most aspects of their lives. Expressions such as “my life and whole world have turned upside down” express the devastating impact such adversities have on people. Often, without any effective forewarning and regardless of their own personal background (educational, ethnic, cultural, gender, age, race, etc.), they are confronted by painful and unfamiliar questions: e.g. “what is the use of struggling so hard to build up what I thought would be a future for myself and my family, only to then lose everything?”; “how is it possible for people to treat fellow human beings so inhumanly?”; “what should my new priorities for everyday living be now?”; “why do society, the powers that be, or the divine powers permit such appalling destructiveness or injustices?”; “why me?”, “why has this happened to me?”, etc. All these questions about life, meaning, morality, destiny, the divine, etc. are essentially of a philosophical, theological, existential or ethical nature, and they emerge spontaneously in persons who are exposed to severe forms of adversity which lead to traumatising experiences. These questions affect the totality of one’s being and, thus, they may also be called ontological.

It is important to identify, more explicitly, the reasons that lead affected persons not only to refrain from sharing such “philosophical” questions with others, but also not to discern them more clearly in their own minds, despite the fact that such agonising questions (regardless of how ill articulated they may be) do arise in every person who is overwhelmed by such soul-wrenching experiences of severe forms of adversities. I differentiate the five interrelated reasons that follow.

(a) Perceived priority: to eliminate the “trauma pain”

Such experiences are so agonising, that the main focus tends to be restricted to a need that is consider central and of absolute priority: to get rid of the suffering that is inflicted by the exposure to adversity. This need forces itself to the forefront, as the unquestionable priority, and above all other considerations. As I emphasise, rhetorically, in the training programmes I offer, “The trauma story screeches!” The “trauma story” cannot be ignored, and the “trauma pain” demands urgent attention and immediate relief. This priority is experienced not only by the affected persons themselves but also by those who come into contact with them, in whatever capacity, as friends or helpers. Indeed, it is very difficult to concentrate on any other aspects of the totality and complexity of the experiences when this pain is so excruciating; consequently, the pressing need is to find any means to soothe and neutralise this pain. Therefore, it is understandable that any other preoccupations with big, difficult and unanswerable questions, such as the meaning of life, tend to be sidetracked, pushed away and silenced. However, they cannot be eliminated totally, and are always lurking somewhere in the background in every traumatised person.

(b) Hierarchy of tolerable and preferred forms of pain

Neither the caregivers nor the affected persons themselves are used to addressing issues about the meaning of life, morality, the nature of destructiveness, divine (non-)intervention, etc. It is not easy to delve into such fundamental questions because they can be very distressing. The distress they cause can even be more painful than the actual “trauma pain” itself, because these questions are unfamiliar, they are not so easily comprehensible and they address central belief systems, which are invariably taken for granted and are, by and large, invisible.

The general implicit approach society follows in comprehending trauma follows a reasonably clear linear causality that appears to be fairly logical and intelligible. It is widely accepted that severe adversity causes some form of trauma, mostly understood in mental health terms. According to this formulation, adversity is the cause and trauma the effect. Regardless of the degree of severity of the trauma itself, the very conceptualisation of this type of pain appears to be clearly understandable and, hence, bearable.

By contrast, what we could call “existential/ontological pain” – i.e. the pain emanating from the big unanswerable questions – is significantly less bearable because of its very nature, as well as due to the realistic difficulties in grasping it, its nature and effects. The paradox is that, on the one hand, the distressing effects from this type of pain are unmistakably felt, but, on the other hand, their causes and overall comprehension of the entire experience are intangible and more elusive than the causes and comprehension of the “trauma pain”, which appears to be understood in terms of a fairly clear-cut cause–effect equation. The whole process of discerning, identifying and addressing existential or philosophical questions is confusing and disorienting; most certainly, it is not part of most persons’ repertoire of everyday living.

As it is well known and amply documented, even the “trauma pain” is more difficult to be grasped and addressed than physical pain, precisely because of the same three broad reasons: (i) its causes and overall conceptual formulation are more elusive and bewildering than somatic pain; consequently, (ii) “trauma pain” is less bearable than somatic pain, i.e. it is more troublesome and problematic than the seemingly obvious causes and overall formative process of somatic pain; and (iii) the tangible reality of bodily pain makes it far more familiar than “trauma pain” – the former is an unavoidable part of our repertoire of everyday living, whereas the latter is not.

It is for these reasons that the phenomenon of “somatisation” is so widespread. In short, somatisation refers to the misattribution of psychological stress and trauma to physical symptoms and bodily complaints. Evidently, people find it easier to focus upon, and to complain about bodily pains than to connect with the various forms of the distressfully subtle, indefinable and incomprehensible forms of psychological pain (e.g. De Gucht & Fischler, 2002; De Gucht & Maes, 2006; Gureje, Simon, Ustun & Goldberg, 1997; Kellner, 1990; Kirmayer & Robbins, 1991; Ryder, Yang & Heine, 2002).

Accordingly, it is now possible to identify a hierarchy of tolerable types of pain, with physical pain being the most easily graspable and, therefore, in a sense, the most preferred (so to speak), and “existential pain” being the least comprehensible and, hence, the least tolerable and least preferred pain. In relation to these two, “trauma pain” (psychological pain) lies in between them, i.e. it appears to be more accessible and tolerable than “existential pain”, but is more disturbing and less graspable than physical/bodily pain.

Consequently, it is instructive to identify two types of distorting transformations: somatisation of psychological (trauma) pain and psychologisation of existential pain. Whereas somatisation is a well-known and much-researched phenomenon, psychologisation is not.

My argument here is that this hierarchy of tolerable and preferred pain is crucial in not only appreciating the complexities of psychological trauma but also in providing a conceptual framework to comprehend moral injury, as will be discussed below. To sum up, the key criterion of this hierarchy is the combination of the comprehensibility and accessibility of the nature of the distress involved, along with the degree of tolerance for the experienced anguish.

(c) Difficulties in selecting appropriate conceptual frameworks

Related to the above, it should not be forgotten that beyond the individual’s own abilities and resources to address big, philosophical questions that are associated with “existential pain”, it is very difficult to objectively conceptualise such distressing issues. To begin with, even calling them “questions” is problematic and not entirely accurate. These are not clearly formulated and neatly phrased questions. People do not ask themselves or others “what is the meaning of life?” or “how do I reconcile my previous value system with what has happened to me now?” or “in what ways has this devastating experience impacted on my being?”. Instead, they experience some incomprehensible and inarticulate puzzling states of bewilderment, anguish and disorientation.

Regardless of the affected person’s individual strength, educational status, psychological sophistication and courage, or the amount and quality of support they may receive from caring others, in such circumstances, the usual means of comprehending life difficulties prove to be inadequate in grasping the complexities of these predicaments, which are experienced as extraordinary. One needs to have the appropriate conceptual tools and frameworks to comprehend such states and, objectively, these are not readily available to the majority of people. I am using the adverb “objectively” here in order to emphasise that these conceptual difficulties are over and above any personal factors, the individual’s own history, psychological make-up, etc.; these difficulties are inherent in the very nature of the phenomena themselves.

Lacking the appropriate means to grasp and deal with the complexities of “existential pain”, what is instead widely and readily available all around us is a plethora of ready-made sets of philosophical, spiritual and other moral and metaphysical systems which eagerly offer to supply us with definitive answers to all of our life questions and predicaments. These set systems, which come in all shapes and sizes, vary from being serious and well-established frameworks with long-standing and illustrious traditions to ephemeral, makeshift, superficial and opportunistic structures. All these aim at providing formulations that define “the problem” as well as the means of delivering “solutions” towards resolving it. However, for the average modern person, these set systems as well as the definitions, explanations and answers that they provide, appear to be either too abstract or too distant and inapplicable to the immediate realities of the experienced distresses.

This does not mean that every single one of these schemata is completely worthless. Clearly, they exist because they succeed, to a degree, in serving some purpose for some people at some time in their lives. The difficulty is that for the non-discerning person, all of them appear the same and they are either dismissed as irrelevant or adopted without the required scrutiny. However, their existence indicates that people do have a need for connecting with some deeper sense of existential meaning, beyond the evanescent concerns of everydayness.

Regardless of their success or not in being relevant and applicable for individuals or groups, what matters most is that these set systems of meaning do not form part of any practical scheme of organised care for those who suffer from such traumatising disruptions of their ordinary everyday living. As we know, trauma care is often defined exclusively in mental health terms, and such frameworks disregard wider and deeper existential considerations.

(d) Societal structures of systemic organisation of help

Continuing on from the previous reason, it is important to note that the system that is operative in our society to address the plight of traumatised persons is through organised forms of caregiving that are formulated, predominantly, in psychological and even psychiatric terms. This organised system of help is based on a fairly simplistic formula, i.e. what I call “the societal discourse of the expert”. In short, this formula dictates the nature and modes of interactions between the specialists/experts and those who require their services. In order to effectively deal with tasks that we consider beyond our capabilities, we appeal to the specialist’s expert knowledge, abilities and skills to resolve them. This means that the identification of a specific and clearly delineated “problem” is directly and reciprocally linked with the existence of an identified expert that deals with it. The manner in which we formulate our “problem” dictates the type of specialist we access, and the existence of a particular expert dictates the way we define our “problem”. This means that there is a mutual and interactional definition between the two, one defining the other.

Critical questions then arise in relation to the way we experience and conceptualise distress in the context of traumatising experiences: what are th...