Moral Injury Convenings

We decided to engage consultants to develop an agenda for the convenings, facilitate the discussions, and write a recap of our findings. With our consultants, we set three high-level goals:

1. Frame moral injury based on current, accepted definitions and clarify moral injury in relationship to PTSD.
2. Facilitate discussion among participants to determine how moral injury applies to them and their constituents/clients.
3. Inspire participants to continue discussing moral injury in their personal and professional lives.

For the convenings, our facilitator provided expertise in moral injury and assisted the instructional designer in developing a 15-minute presentation that he gave at the start of each. The presentation would compare PTSD and moral injury, offer standard definitions for each term, and distinguish their features, including placing moral injury on a continuum and within a larger context of moral stress and moral distress. The biomedical field initially identified moral distress in work with nurses to describe feeling as if we know the right action to take but believing we are constrained from taking it because of personal principles or external factors such as an authority barring the action. The concept generalizes to caregivers in multiple fields and has applicability to nonprofessionals as well. Understanding moral injury as existing within multiple dimensions of affect and perception seemed critical in moving beyond current definitional limitations.

Following the presentation, the facilitator invited the group to consider Shay’s and Litz’s accepted definitions of moral injury to see how these definitions, developed from and for work with veterans, fit with the group’s understanding of the concept and its applicability to nonveteran populations.

We did not know how the groups would respond—if they would require prompting, if they would express confusion about moral injury’s importance, if they would fail to resonate with the topic. With our consultants, we purposely designed a forum allowing for questions, musings, personal stories, professional applications, and cross-discussions. Our facilitator came prepared to answer factual questions and to tease out the nuances of moral injury with each group as they conceived of it.

The passion and energy at each convening gratified us with its almost universal response, confirming our intuition about moral injury’s relevance across organizations. Participants volunteered their professional expertise and their intimate encounters with moral injury across race, religion, gender, socioeconomic background, and other demographic factors. Participants took risks, demonstrated their presence and engagement, and seemed reluctant to finish after four hours of discussion.

While each group demonstrated their interest through dynamic conversation, we also experienced some pushback about the name moral injury itself, with some participants expressing concern that it carries a perception of pathology because of the term injury or judgment because of the term moral. Participants wrestled with the problem at such length during the convenings in Washington and Los Angeles that the consultants updated the presentation before the New York convening to address the controversy by suggesting that participants consider moral injury as a placeholder for a specific kind of suffering. While this suggestion did not eliminate expressions of concern about calling it moral injury, it did spark alternative approaches for sharing the concept without necessarily requiring inclusion of or emphasis on the specific name.

As the conversations progressed from wrestling with the name and definitions, each group found its unique voice as it rose to the challenges of conveying moral injury as a specific concern in an era when mental health issues—even those issues that are not pathological and do not fall within a diagnostic purview—carry a stigma. Compassion remained a consistent watchword, as did the idea of meeting people where they are instead of where we want them to be.

In four four-hour conversations in different urban areas of the United States, we discovered that moral injury is an amorphous concept, rooted deeply in all human experience—not just veterans, not just the seemingly most vulnerable—and very, very personal.

It affects all areas of our lives, alienating and isolating us from ourselves, our interpersonal relationships, and ultimately, our communities and the world—including our spiritual connection to someone or something greater than ourselves.

We also rediscovered that it is hard to speak about our personal suffering, yet talking about it can help bring our pain out into the light to examine it, wrestle with it, figure out ways to integrate it into the flow of the rest of our lives. We realized that to take such a risk, we need to find someone we can talk to about it, someone who won’t judge us, diminish or downplay our experience, make us feel unheard, or ignore what we have to say. Teaching peers and professionals to recognize moral injury and speak to its distinctive pain must become a critical component of any approach.

We are breaking new ground. Our conversations around the country were just the beginning— frustrating because we remain unsure what to do with what we are seeing yet satisfying in our ability to give voice to this complex concept. In this articulation, we see hope and we see that we are not alone.

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The First Four Convenings

Washington DC (Dec. 1, 2015)

The first moral injury convening took place on December 1, 2015, at the Pew Charitable Trusts building in Washington, D.C. More than other groups, this convening focused on moral injury’s applicability outside a military context.

Initial conversation centered on the reality of moral injury, with a consensus that favored the belief that moral injury exists within the perspective of the sufferer, but it is nevertheless a very real and significant source of pain. The group struggled with what they perceived as a narrowness in the current accepted definitions.

One participant suggested the failure to apply the term suffering to the sufferer of moral injury in any of the definitions represented a distinct failure to capture the essence of moral injury, and the majority agreed. Others underscored the criticality of determining a flexible vocabulary so that health care professionals and the general public can identify moral injury and work with it. The group recognized that anyone who deals with situations where there is moral tension faces difficult choices and few absolutes exist in the lines among duty, responsibility, and morality.

The group also emphasized the importance of viewing moral injury through various cultural lenses, as a lack of cultural sensitivity includes a high-level risk of reinjury. As part of one’s culture, the group discussed the importance of a religious or spiritual connection to ameliorate moral injury but acknowledged the reality that some theologies create obstacles by casting moral injury as a form of sin or necessary suffering.

Overall, the participants believed we could find approaches to alleviate the effects of moral injury, though one universal pathway is unlikely to resonate with every sufferer. The consensus reached is that we must develop multiple pathways that acknowledge the individual and unique circumstances that give rise to moral injury. We can then help sufferers understand their experience within a framework that makes the most sense to them.

Identified the caregiver dimension of the moral injury experience.

Example: Do we tell a dementia patient his wife is dead every time he remembers to ask for her?

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Los Angeles (February 17, 2016)

The second moral injury convening took place at HSBC headquarters in Los Angeles on February 17, 2016. Of all groups, this convening clarified best the multidimensional aspects of moral injury beyond a basic continuum from moral stress to moral distress to moral injury.

This group focused early and with great understanding on defining moral injury through various examples such as experiencing a house fire and continuing to feel unsafe, which participants suggested demonstrated moral injury as related to a religious or spiritual authority and the perception of a betrayal of trust. The group built on this dimension by adding betrayal of trust between people in authority roles but also between people perceived as having similar status. Another dimension included national instances of trauma that led to moral injury such as the Civil War in the United States, the Holocaust in Germany, apartheid in South Africa, and events such as bombings and the atrocities committed at Abu Ghraib prison. While each instance gives rise to individual experiences of moral injury, they may also include a dimension of cultural moral injury from events committed in our name.

Various participants voiced concerns about the term moral injury as off-putting, judgmental, and a barrier to treatment. Consensus arose around the limitations of the current definitions, with a perception that they attempt to cover the self, society, and authority simultaneously. Some participants suggested an emphasis on empowerment to counter the risk of victimization and to rely on peer-to-peer assistance to help people with moral injury.

Two social scientists responded to the current definitions by suggesting a multidimensional approach to defining moral injury, suggesting that moral injury might fall along two axes. One axis represents the morally injured sufferers’ perception of their role in the transgression; that is, whether they feel they have committed an act of commission or an act of omission. Also on this axis, the person may alternatively feel that someone else committed the transgressive act, which the morally injured person experienced directly, witnessed, or learned about from someone else.

A second axis involves the specific type of inner conflict morally injured people experience. They may feel they have betrayed their own deeply held beliefs; they may experience a loss of trust in others, particularly those in authority; or they may feel both kinds of conflict. These two participants felt that current moral injury scales could be adapted for use with this model.

This approach allows for verbal description of an individual’s sense of moral injury as not just all or nothing, but greater or lesser, along the specific axes. This model also allows for the possibility of a visual representation of an individual’s type and degree of moral injury by graphing the degree of the person’s response along the axes.

Overall, incorporating the idea of moral injury as a human experience with a religious/ spiritual/existential component seemed critical, as did finding ways to present moral injury as treatable and as something that we can build resiliency toward to help policy makers support healing initiatives.

Identified the multi-dimensionality of moral injury, including:

• The role of the individual versus others as active or culpable agents
• The depth of the betrayal of trust
• The betrayal of moral beliefs
• The variety of cross-over

A Sufferer May Both Perpetrate and Experience Moral Injury

Perpetrates: A superior tells a priest to reassign to a new parish another priest accused of being a pedophile. By reassigning the person, the priest wittingly risks betrayal of the new congregation where the pedophile may act again and of the current congregation by failing to pursue prosecution.

Experiences: Bound by his vows, the priest may experience moral injury from violating his moral code and may feel guilt, shame, and a variety of other moral injury-related emotions.

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New York, NY (April 14, 2016)

The third moral injury convening took place in New York City at Riverside Church on April 14, 2016. More than other groups, this convening considered moral injury in relation to identity, and it recognized that gaining better understanding of moral injury can help us shift our viewpoint and contextualize events differently.

The group grasped immediately the dimensions of moral injury from the perpetrator and experiencer perspectives, such as the veteran ordered to commit an act that violated his moral beliefs, or the mother who suffered child abuse herself who then abuses her own children. They recognized that moral injury does not have to occur because of a bad decision but may occur simply because something bad happened.

The group discussed how many veterans interpret moral injury as intense guilt and may feel more comfortable with that term when seeking help, while others have a positive, visceral response to the term moral injury. Many participants had not heard of moral injury and evidenced clear and immediate recognition for understanding how it affects sufferers. The group identified moral injury as having less stigma than PTSD: people label PTSD sufferers as “crazy,” but moral injury is relatively unknown and so generates questions instead of labels.

Finding practical ways to heal became a primary concern for the group, who expressed frustration at the lack of available approaches. The subjectivity of moral injury coupled with the need to reflect different value systems for individuals requires a flexible response that honors the person suffering and helps him or her understand the events in relationship to his or her moral code. The power to tell one’s story seems paramount, and finding ways to help people do so in a nonjudgmental arena seems like the first task to tackle.

Volunteers of America representatives reiterated the organization’s current programs and its commitment to educating the general population about moral injury, devising better ways to reach those who need help, and building a foundation whose purpose is to seek approaches for addressing moral injury.

Identified the critical role identity plays in moral injury

Moral Injury and Personal Codes

We all live by codes—some are formal, as in the military—but we all have something we live by. When our code is violated, we need to be able to talk about the code and its personal effect—but we must understand that we ourselves are more than a code.

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Chicago, IL (June 23, 2016)

The fourth moral injury convening took place at the Pritzker Military Museum and Library in Chicago on June 23, 2016. More than other groups, this convening focused on the veteran population and on moral injury across the lifespan.

The group immediately recognized a need for better working definitions that include elements from all three of the current definitions because people have had experiences that reflect all three. The definitions should also address the loss of stability created by moral injury and contain a spiritual aspect.

The group explored time as it relates to moral injury—we may feel different about an event at different points in our life cycle—and how moral injury can happen in a short span, such as in war zone, or over a longer period, as can occur for caregivers.The group considered how moral injury can cross generations, such as families with Holocaust survivors who still experience trauma several generations removed.

They also discussed cultural moral injury, including what events all cultures may perceive as traumatic and what happens with moral injury when two cultures collide. The group discussed how the military creates its own code of acceptable behaviors, but the further some veterans move from military life, the more they recognize the discrepancies between military and civilian codes. Life transitions seem to become particular danger spots for intense reactions such as suicide. One participant underscored the necessity of providers leaving all preconceptions out of client interactions and focusing on whether the client feels an event was morally violative.

The term moral injury bothered some, and the consensus became that the name is far less important than the problem, so finding ways to discuss the effects of moral injury even if the name is never mentioned is critical. It is important to find language that resonates with the individual and avoid labeling as much as possible. Some participants mentioned the need to remember that providers are working with a whole person, not just someone who is a veteran. It’s important to honor that aspect of their identity but leave open pathways that help the person view other aspects as well.

The group also highlighted the need for various organizations addressing moral injury to work together to share information, educate the public, and ensure we reach the widest population. Volunteers of America representatives spoke of the Center it is creating to help reduce the silos among various groups and disseminate information, training, and other resource materials. Consensus became that addressing moral injury in both a top-to-bottom and bottom-to-top strategy could help a wide population, particularly veterans, through greater interactions, peer help, partnering and collaborating at grassroots levels, and maintaining the connections among groups and the people they serve.

Identified that moral injury can affect people differently across their lifespan.

Moral Injury and Transformation

The goal is not to fix people, but rather to help them understand for themselves what happened and begin to figure out what they want to do with their understanding.

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Tulsa and Oklahoma City (November 9-10, 2016)

The Volunteers of America Oklahoma affiliate convenings took place on November 9 at the Boston Avenue United Methodist Church in Tulsa and November 10 on the Oklahoma State University campus in Oklahoma City. Each afternoon session lasted approximately four hours, with 110 participants in attendance in Tulsa and 73 in Oklahoma City.

Each presentation began with a brief introduction by the facilitators offering some personal context about the effects of moral injury in their lives, followed by a comparison and contrast of PTSD and moral injury. The presentation then highlighted how moral injury can affect almost anyone, particularly those who encounter or work within high-stakes situations where moral judgment may affect the outcomes of people’s lives. The didactic portion concluded with practical suggestions for starting the moral injury conversation with suspected sufferers, as well as a reminder that anyone in any job role can help simply by providing compassionate, empathetic listening.

In the second half of the afternoon, the facilitators divided participants into small groups to discuss a scenario-based exercise of a suspected moral injury sufferer. Participants applied the knowledge gained from the presentation, as well as from their own job roles and life experience, to identify crisis points, hallmarks of moral injury, and compassionate approaches. Following the exercise, the facilitator and participants discussed questions and shared stories about moral injury.

Both groups appeared engaged throughout and participated at various points during the initial presentation when the facilitator checked in with them to ensure understanding, as well as during the scenario-based exercise. The Tulsa group focused more on discussing the definitions and parameters of moral injury, with their discussion revolving more specifically around working with veterans.

By contrast, the Oklahoma City group spent more time discussing the practicalities involved in responding to moral injury and talked more about moral injury among a variety of nonveterans. In particular, the group explored the need to respond to moral injury among Native Americans and the importance of using culturally appropriate forms and resources when doing so.

Overall, both groups seemed to appreciate the opportunity to identify moral injury within their various experiences and and expressed a desire to obtain more resources and training for helping sufferers.

Seek to become more comfortable talking about and approaching moral injury.

1. Look for places in your life and job role to make small, compassionate changes to your approach to others.
2. Consider how moral injury affects you personally and professionally.
3. Apply the concept in your daily life by looking for hallmarks of moral injury in books and other media.
4. If you find yourself in a situation where you can’t help, take steps to ensure you do no harm.

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Common Themes of The Convenings

Despite having no knowledge of preceding conversations, each subsequent group echoed common themes. For example, almost all participants believed that Volunteers of America and anyone interested in the pervasive effects of moral injury needs to get the word out about it—that is, we must talk about it with everyone we encounter and give it a voice even though we have not developed a complete vocabulary for it. We also achieved almost 100 percent consensus that current and most widely accepted definitions simply do not go far enough in describing moral injury or adequately capturing the level of suffering associated with it, particularly the propensity for suicide, which increases the sense of urgency for developing ways to address moral injury.

Because it is subjective, personal, painful, and difficult to capture easily, participants believed we must spend more time considering how to present and approach moral injury. In addition, most participants agreed that while it’s critical to address and identify moral injury where it exists, not all suffering is or rises to the level of moral injury. We will need to tease out the differences with great care to avoid hurting someone we are trying to help and yet avoid diluting moral injury to a point where it loses any significant meaning.

Across the four conversations, these ideas crystalized:

1. Moral injury differs from what we typically recognize as trauma, and at present, much of moral injury lies beyond our ability to describe it accurately.
2. We have to be able to describe moral injury better so that we can talk and educate people about it.
3. We should not pathologize moral injury, yet we should take note of how it can contribute to mental health issues, particularly to suicide.
4. Moral injury has profoundly spiritual and religious facets for many people.
5. Equally, many people will not feel comfortable using religious or spiritual language, and we need to find ways to talk about moral injury with them.
6. Moral injury will require multiple pathways to address it that include biological, mental, and spiritual dimensions to reach the widest group.
7. Moral injury is subjective and personal, so we need to relate to sufferers’ personal context and respect their experience.
8. Moral injury has multidimensional aspects, including the ability to affect us as an experiencer, a perpetrator, or both. It affects our self-perception and identity, and it can affect us differently at different points along our lifespan.

We categorized the actions required to address the themes as related to definitions, concepts for understanding and educating, and concepts for addressing moral injury.

Definitions

1. Develop definitions that capture moral injury with greater accuracy.

2. Use more affective language, such as including the word suffering.

3. Develop a common, simple vocabulary with which to talk about moral injury among providers and to sufferers.

Understanding & Educating

1. Develop synonyms for moral injury such as soul wound, identity injustice, intense grief, or existential distress to help reach the widest population. Be able to discuss it in religious/spiritual and/or existential, affective terms.

2. Ensure that we do not pathologize moral injury even though it may occur as an underlying factor in mental health issues, particularly the propensity for suicide.

3. Recognize that a continuum of severity exists that includes moral tension, moral distress, and moral residue, all of which can contribute to moral injury.

Acknowledging & Addressing

1. Avoid “treating” or trying to “heal” moral injury, as this language pathologizes the issue and suggests a cure rather than holistic and often incremental improvement.

2. Seek approaches from multiple disciplines to increase the tools that sufferers have for examining their moral injury and to lower the risk of pathologizing the concept.

3. Ensure that approaches have applicability to both veterans and nonveterans as well as multiple cultures with respect for a variety of experiences.

Critical Concerns

A critical issue is how to develop the common vocabulary and approaches to educate and assist people. Despite its historical roots, moral injury remains largely unexplored, and the risk of reinjuring sufferers who already feel vulnerable is high. We need people who will not reinjure us. One practical approach to moral injury will be training that helps professionals and peers hold space for sufferers through deep listening and other techniques that draw on treatment for trauma, guilt, shame, and other moral emotions.

Each group also acknowledged that we do not all need to train as social workers, therapists, psychologists, psychiatrists, or clergy to provide a therapeutic presence and recognize moral injury when it is present. We can each recognize it as a human condition arising from extraordinary, personally painful events that people experienced, witnessed, or perpetrated. The experience haunts sufferers and creates a barrier between them and their personal wellbeing.

Thus, many of our common themes also become our primary challenges. Education seems to be the starting point—the more we educate ourselves and others, the greater our power becomes to garner interest and effect change. And education helps us all, for while moral injury does not occur for everyone, it can affect anyone.

We don’t currently know the prevalence of moral injury, but we do know we are most fragile in those moments when we feel our integrity is compromised, whether we are forced into making an action that violates our personal code or are experiencers of such an action. The concept of moral injury resonates with almost every population, particularly in Western society. We can find the commonalities among sufferers—soldiers and veterans; first responders; victims of abuse, sexual assault, and trauma;medical and legal professionals; caregivers; and so many others—to provide a template for beginning to address their pain. We must maintain constant vigilance, however, to make sure we respect each individual’s experience to help him or her reintegrate best and find relief from suffering.

Challenges and Recommendations

The organic, independent ways in which the common themes arose across the four convenings highlight the broad and deep resonance of moral injury. Equally, the points of confusion and even frustration that tempered the joy of grasping the importance of moral injury mean that we must build partnerships with which to address moral injury from many angles. It is a complextopic made more so by the aspects of subjectivity and personal experiences—what causes one person to experience moral injury may not trouble another person to any significant degree. As with many complicated issues, a one-size-fits-all approach is unlikely to create lasting, useful improvements for sufferers.

We will need to break down the challenges into smaller steps that allow us flexibility, creativity, and mindfulness as we wrestle with the concept itself, how to educate people about it and engender the necessary support to achieve change, and how to develop practical approaches for working with sufferers to help them fulfill their potential.

Challenge: The Definition

Our first challenge is to develop a definition that incorporates more affective language, such as including the word suffering, and that offers a simultaneously broad but specific set of parameters for the concept of moral injury. For those who have worked with moral injury to this point,these three definitions remain the standards.

Recommendation:

While each group agreed that we need a better definition, none reached a consensus on new language. We should continue to explore the possibilities around a new definition, including developing a series of descriptions for moral injury that help illustrate the current meanings while we work toward a short, clear, and more definitive delineation.

Challenge: The Name

Another significant challenge we face is what to call moral injury. While the term is established within research circles and is gaining some wider recognition in connection with veterans, many people balk at what they perceive as a judgmental or pathologizing label. Yet, as with detailing a distinct update to the current definitions, we could not achieve within any of our groups consensus on a new term. We suggested some possibilities, including identity disruption, soul wound, spiritual suffering, and soldier’s/warrior’s heart, yet none seemed to resonate or take root within the collective imagination.

Recommendation:

As with the definition, our focus may need to turn toward describing the multiple facets of how moral injury feels without worrying too much about discovering the perfect name. In fact, our inability to pin the concept to one encompassing term may be fitting in its reflection of the subjectivity of the experience. In advertising, for example, experiential marketing is one method for gaining consumers’ buy-in in which companies allow people to try a product or service for themselves within a controlled environment so that they can draw their own conclusions about the offering.

By approaching moral injury as an experiential issue and allowing sufferers to “try on” definitions and terms that fit most closely with their subjective experiences, we may overcome the naming concern.

Challenge: Capturing the Moral Injury Concept

Amorphous concepts make for difficult communication at best. If we could capture moral injury within a universal term and definition, we would likely find it significantly easier to share the idea with a wider population. Yet we have an opportunity to turn what may seem like a disadvantage into an advantage by playing on its shifting and very personal factors.

As participants in our New York group stated, people will ask about moral injury precisely because they do not know what it is, whereas other more clearly definable issues such as PTSD lead people to believe they understand—and make judgments about— what it is, even if their knowledge is somewhat narrow and biased.

Moral injury compels us to explore what it means to ourselves and encourages us to view it through the sufferers’ eyes. We know it won’t be easy to develop ways to educate people about the reality of moral injury, the various circumstances that can give rise to it, and the various ways it may manifest in a person’s life, using language that resonates across a wide variety of socioeconomic, racial, religious, ethnic, and geographical circumstances. We will need to get creative in how we reach out to people, we will need partners willing to share their expertise, and we will need sufferers willing to share their stories.

Recommendation:

As challenging as we may find developing a multifaceted campaign for education, the act of creating this campaign will deepen our understanding and empathy for moral injury sufferers and lay the foundation for our future endeavors. We believe our increasing comprehension will propel us in directions that empower sufferers to give voice to their experiences. It may also foster the personal growth and community ties we believe will become markers for measuring how sufferers’ lives improve when they address their moral injury.

Challenge: Avoid Pathology

As we progress from planning how to educate people about the concept of moral injury, we must avoid pathologizing moral injury. Our goal is to find ways to help people change their relationship with their experiences so that the events stop preventing them from seeking and finding personal fulfillment. In pursuit of this goal, every convening group believed strongly that moral injury arises from natural and common human responses to extraordinary circumstances. Most participants agreed, however, that left unaddressed, moral injury can contribute to physical and mental health problems. We must balance the knowledge of moral injury’s pervasive effects against the reality that moral injury is not a pathological condition that requires medical intervention.

Western culture wants to treat, prevent, eradicate, vaccinate, or otherwise cure those problems that ail us. Unfortunately, that approach to moral injury does not work and may do greater harm because the medical model that insists something is “wrong” with sufferers can reinforce their isolation and alienation from other people.

It is easy to want to treat moral injury with a standard, empirical model of 12 sessions with a psychologist. This model may relieve some of the sufferers’ symptoms but do little or nothing to lessen their moral injury because the therapy does not address the root cause of the sufferers’ pain. The message they receive at this point, covertly or overtly, is that they somehow resisted the therapy and remain complicit in their suffering. Blaming the sufferers for failure of this imperfect technique inevitably alienates them further and may discourage them from seeking any kind of support in the future. To be clear, empirically validated treatments can work well for some psychological diagnoses, but because moral injury is not a mental disorder, such treatment is misapplied.

Recommendation:

We should reject language and—even more important—processes that overtly or covertly rely on turning sufferers into patients.

Conclusions

So, what do we do with a concept that is hard to name, hard to define, hard to talk about, and does not respond well to a culturally established ideal of how to fix problems? Many participants expressed frustration at the lack of verified, successful approaches. Moral injury has been with us unnamed for a long time, but we still don’t seem to know what to make of it.

Yet even without a name or a cohesive plan to address it, we have already begun to help people who suffer with moral injury. Particularly in Los Angeles and Chicago, which both included many Volunteers of America affiliate members, participants were already working with various aspects of moral injury’s suffering by encouraging people to find a narrative for their pain and by using peer support with veterans. Volunteers of America, which got its start within a generation of the United States’ Civil War, suspects it has been addressing some form of moral injury from its inception.

What we know from our experience is that providing a therapeutic presence is a strong initial step toward helping moral injury sufferers. While some people will benefit from working with a licensed professional, those people who feel uncomfortable with that pathway can still receive assistance and find relief from other resources. We can pool our knowledge within Volunteers of America and then reach out to our many partnering organizations to craft a variety of responses that meet people at almost any point in their journey.

Our challenge then becomes to synthesize the knowledge we have with the research and information available outside Volunteers of America to create the Moral Injury Healing and Outreach Center. We will examine practices used by the U.S. Department of Veterans Affairs to work with moral injury; trauma-informed care; various religious and spiritual practices intended to relieve suffering; and other programs we adapt and develop specifically for addressing moral injury.

As we completed the first round of convenings, we came away with a clear sense that while we will face challenges in our journey to define and operationalize approaches to moral injury, we see no barriers we find unconquerable. We can make this concept accessible, we can educate the general population, and we can establish approaches that will help give sufferers relief. What began as a vague need simply to do something is starting to crystallize into action.

The Future

Volunteers of America has been pursuing its educational journey on moral injury for about 18 months. We have already learned so much, and we know we have so much more to discover. We know our society feels moral injury’s effects at every level—personally, in close relationships, and in larger relationships to one’s community, country, and the world.

When people view everything through a lens of suffering, it becomes harder to see hope for themselves and to have compassion for others. Volunteers of America wants to foster massive change at all levels to spark a meaningful shift that we believe will have a ripple effect individually and globally.

Approach 1: Continuing the Conversations

To begin, we plan to host additional convenings in smaller cities in more rural areas to ensure we hear many voices and viewpoints. We collaborated with our Oklahoma affiliate to hold convenings in Tulsa and Oklahoma City, and are currently planning to visit southern cities including Shreveport, La., and Mobile, Ala. In addition, we hosted a condensed session with Volunteers of America’s national board at our 2016 Boston meeting.

We need a culturally diverse response to moral injury, and we want to make sure we listen carefully to the requirements and concerns of a wide array of populations. One of our goals is to achieve a level of understanding and expertise for reaching out to communities struggling with the effects of moral injury in the aftermath of widespread tragedy, as well as helping groups in opposition find common ground by sharing their relationships to moral injury.

Places such as Sandy Hook, Conn., and Ferguson, Mo., represent just two of the many communities grieving losses and struggling to make sense of injustices. Volunteers of America believes fostering conversations that directly tackle the painful issues of gun control, mental instability, racism, and other underlying factors may help communities in crisis begin to implement systemic and sustainable changes.

We know the strength found in sharing a burden, and we believe sharing the burden of moral injury begins with naming and talking about it.

Approach 2: The Moral Injury Healing and Outreach Center

One of the primary advantages of moral injury is that once we describe it, most people can recognize various aspects of it for themselves, within their families, or among the populations they serve. We might have a hard time providing an exact definition, but that challenge does not keep people from grasping the power of moral injury at an intuitive level.

Volunteers of America will leverage that power to reach more people through our planned Moral Injury Healing and Outreach Center. The Center will build on our long-time work with veterans and our more recent exploration of moral injury, expand this understanding to help nonveterans as well, and allow us to examine moral injury more deeply and broadly. We will continue to address the challenges laid out for developing a stronger encompassing definition and vocabulary and for offering pathways toward respite, as well as serve as a clearinghouse for information and resources to build our knowledge base and share it globally.

To help sufferers better, we will also look at adapting existing and developing new approaches using a wide array of media—traditional talking/sharing approaches; creative fiction, nonfiction, and poetry; drama, music, and other creative arts; and body-based approaches such as trauma-sensitive yoga, mindfulness/meditation, and grounding techniques. We want to train traditional helpers, including medical and behavioral health professionals, chaplains, and clergy as well as peer counselors to maximize the number and range of people who can work with moral injury sufferers. The goal is to offer help across physical, psychological/existential, and spiritual domains to ensure holistic treatment.

Approach 3: Personal Essays Book on Moral Injury

In addition, we are facilitating a book of personal essays on moral injury designed to explore its effect on individuals, their family members, and other loved ones. The book also will include information from professionals in the medical, behavioral health, and spiritual communities about moral injury. One goal of the book is to broaden acknowledgement among the medical, behavioral health, service providers, and faith communities, as well as nonprofessionals, that moral injury is a legitimate obstruction to wellbeing and recovery. We also hope to build support for programs and services addressing moral injury and to facilitate the healing process for first responders, caregivers, service providers, veterans, parents, children, and partners from the invisible damage of moral injury related to their experience.

Our original research used in tandem with outside data, methods adapted from multiple fields, and dynamic feedback among all people involved will increase the stock of ideas for this human condition, maintaining our commitment to recognizing moral injury as a natural—not pathological—response to extraordinary pain.

Approach 4: Sparking Action and Building Partnerships

Moral injury is not a psychological disorder, but rather seems to arise from destructive events that disturb the integrity of our core identity. We can view the pervasive sense of despair or loss of meaning through a religious or spiritual lens or as a philosophical or existential crisis. Both lenses reflect deep suffering.

Many of us feel helpless in the face of suffering. It is simpler to hide from another’s pain by minimizing or ignoring it or by abdicating responsibility to a professional rather than attempting to offer therapeutic presence. It’s true that many people struggling with moral injury may need some kind of professional intervention if their moral injury has persisted for a long time and underpins other problems. However, we can each at the very least let sufferers know that we recognize their pain. Alleviating their sense of isolation by demonstrating understanding and reflecting compassion for their suffering is a first step that anyone can take.

We invite you to explore more about moral injury, to examine the definitions and vocabulary, to consider where you may have seen or experienced moral injury vicariously or for yourself. We invite you to talk to others about it, both those who have and haven’t heard of it. And then we invite you to join in our vision, to contemplate how addressing this kind of debilitating isolation and despair could alter—in both small and enormous ways—how we see one another and, more important, how we respond.

Acknowledgments

We would like to thank the 271 individuals representing 86 organizations, including 12 Volunteers of America affiliates, nonprofit and philanthropic agencies, the private sector, and local, state, and federal government agencies that participated in the moral injury convenings around the country. This recap represents the depth of your concern, experiences, and candor. Thank you for your time, your passion, your willingness to explore a topic few had exposure to prior to meeting with us, and for your desire to educate yourselves and your organizations about moral injury’s impact.

This undertaking would not have been possible without the generous support, financial and otherwise, from HSBC. We would also like to thank staff from Volunteers of America national office and the participating affiliates for their logistical support and invaluable assistance regarding the local culture and needs of the various convening sites.

All of the Volunteers of America convenings were facilitated by Dr. William Gibson and Ms. Bobbi L’Huillier.

Dr. Gibson is a clinical psychologist and neuropsychologist who works in the Federal government serving veterans experiencing PTSD, moral injury, and related conditions. He received a Ph.D. in clinical psychology from St. John’s University in New York, and completed a clinical psychology internship at the Coatesville VA Medical Center and a post-doctoral fellowship in neuropsychology at the Bryn Mawr Rehabilitation Hospital. Dr. Gibson has worked in a variety of settings and with a wide range of patient populations. He is particularly interested in the roles religion and spirituality play in physical and emotional health.

Ms. L’Huillier has more than 20 years’ experience in writing and editing, from freelance to her current position on the quality assurance and spotlight writing teams for a large national business consulting and education company. She holds a BA in Writing with Emphasis in Language and Psychology from Ithaca College, Ithaca, N.Y. She is the instructional designer for all Dr. Gibson’s presentations on moral injury for Volunteers of America, as well as his PTSD presentations for The Soul Repair Center.

Ms. L’Huillier is the lead author on this paper, with Dr. Gibson collaborating.