Journal of Psychology and Theology

Religious Considerations and Self-Forgiveness in Treating Complex Trauma and Moral Injury in Present and Former Soldiers

Being in the military, especially if deployed in combat or combat potential settings, can create opportunities for self-condemnation--occurring through moral injury or apart from and within the context of complex trauma. Moral injury is internal conflict due to doing or witnessing acts not in line with one's morals. Complex trauma involves a prolonged history of subjection to totalitarian control and involves danger, stress, and inability to escape from the situation. Combat can be interpreted as fitting these criteria. We first examine how military deployment might lead to self-condemnation due to moral failures by wrongdoing or when soldiers let down their peers and themselves. We examine soldiers who develop complex trauma and explore its contributions to self-condemnation. Religious issues are likely to be involved. Active wrongdoing, moral failure, and failures of church- and culture-created religious expectations contribute. Soldiers need the skill of self-forgiveness through secular and religiously tailored programs delivered via psychoeducational groups, workbook, or online.

The number of people who have served or will likely serve in the military is large (Cornum, Matthews, & Seligman, 2011). In Iraq and Afghanistan alone, over 1.64 million military personnel have served (Hoge et al., 2004; Smith, et al., 2008). When one considers the number of living veterans from other conflicts, this represents a substantial proportion of the population in the United States. Deployment affects spouses, children, and extended family members and friends (for a review, see Sheppard, Malatras, & Israel, 2010). There is an increased demand for clinical services from mental health professionals, and the demand is likely to increase.

One important problem among military personnel that psychotherapists will be required to deal with is self-condemnation. Self-condemnation is defined as criticism and condemnation of oneself (along with accompanying moral emotions from among guilt, shame, remorse, regret, self-blame, etc.) due to perceived (a) moral wrongdoing (including omission of doing one's duty or acting in accord with one's conscience), (b) failure at living up to one's standards (which is also considered a moral failure), or (c) failure to live up to one's expectations (which might not be considered a moral failure at all). Combat soldiers face many moral and ethical challenges (Drescher et al., 2011; Litz et al., 2009). They may violate their own deeply held moral beliefs, witness the unethical behaviors of others, or question the justness of their own countries involvement in war. As a result they suffer internal conflict between their morally questionable actions and internal beliefs. In addition, soldiers often witness great human suffering and cruelty that shatters their core beliefs about humanity and sometimes about God, both of which might result in doubts, questions, and conflicts about their faith. They may experience challenges to their conception of God and question the goodness or power of God. They may also lose the belief that humans are redeemable. They may deal with these moral, ethical, religious, and spiritual challenges during active duty, in periods of non-deployment or while deployed, or later as veterans (Fontana & Rosenheck, 2004). These experiences result in internal conflict, which is considered moral injury (Litz a al., 2009). Dealing inadequately with the results of these stressors can produce self-condemnation, which can impair physical health, mental health, relationships, and spiritual functioning (Fontana & Rosencheck, 2004; Witvliet, Phipps, Feldman, & Beckman, 2004). Dealing adequately or successfully coming to terms with moral injury results in moral repair (Drescher et al., 2011; Steenkamp et al., 2011).

The central argument in our article is this. Chronic and severe self-condemnation, often (but not always) arising from moral injury, is a substantial risk for military personnel. Such self-condemnation can occur in response to mere moral injury or can be part of complex trauma. Self-condemnation has serious possible sequelae (i.e., physical health, mental health, relational, and spiritual effects). Self-condemnation occurs because people have been victims of, have perpetrated, or have witnessed moral wrongs and person-person violence (i.e., moral injury that triggers in people severe internal conflict), which may have resulted in a traumatic reaction, especially if the trauma was complex trauma. Self-condemnation can be dealt with through various means that can aid recovery. One of those ways is through responsible self-forgiveness. However, responsible self-forgiveness must occur within the context of (a) appealing to God (or, for people who do not believe in God, appealing to some high power or what a person believes to be sacred) for divine forgiveness and favor; (b) making amends for wrongs that one perpetrated himself or herself or allowed to be inflicted without trying to prevent them; (c) examining and dealing with expectations that might have been too ambitious, perfectionistic, or unrealistic; (d) adjusting one's self-perception (i.e., self-image, self-concept, and self-esteem) to accept oneself as a valuable, though fallen, human being; (e) practicing a life in which virtue is habitual; yet (f) giving oneself room to fail (Worthington, 2006). These have given rise to six steps to self-forgiveness (Worthington, in press, a). That intervention program has undergone an initial clinical test in an in-patient treatment program for alcohol and drug addiction (Scherer, Worthington, Hook, & Campana, 2011), and we are continuing to test it in other contexts.

Since 1998, self-forgiveness has been studied less than has other types of forgiveness (see Fehr, Gelfand, & Nag, 2010), but the pace is increasing. Self-forgiveness has been referred to within articles on moral injury in combat veterans (Drescher et al., 2011; Litz et al., 2009), but it has not yet been studied empirically within a population of veterans, combat veterans, or active military personnel. Theories of self-forgiveness (Hall & Fincham, 2005), tests of the theory (Hall & Fincham, 2007), measures of dispositional self-forgiveness (Thompson et al., 2005), state self-forgiveness (Wohl, Wahkinney, & DeShea, 2008), and remorse and self-condemnation (Fisher & Exline, 2006, 2010) are available, but they have been developed largely for the student population and wholly for civilians. Research is accumulating on predictors of self-forgiveness and failure to forgive the self within civilian populations (Fisher & Exline, 2006; Hall & Fincham, 2005, 2007). Studies of self-forgiveness interventions have been done, but few have been published (see Campana, 2010; Exline, Root, Yadavalli, Martin, & Fisher, 2011; Scherer, et al., 2011).

We consider the likely sources of self-condemnation that veterans or active duty military personnel might encounter, especially those who have seen combat. Although there are common experiences that deployed soldiers will have to deal with, we suggest that these problems will be especially acute when people develop complex traumas. We describe self-forgiveness as a coping strategy for stresses arising from self-condemnation, and discuss the particular considerations for adapting a psycho-educational self-forgiveness intervention for military personnel and veterans. The articles in this special issue seek to promote research in coping with trauma, especially considering religious factors in coping. Our research efforts in this regard are just beginning, and we initiate that research with the present conceptual and theoretical work. After we have surveyed the issues, we will conclude the article by setting forth plans for a research agenda.

Self-Condemnation in Soldiers and Veterans

Self-Condemnation as a Stress Response to Perceived Wrongdoing

The perpetration of acts that one personally finds morally repugnant, disagreements with orders that are nevertheless followed, and observing others doing morally repugnant acts can result in self-condemnation among soldiers (Litz et al., 2009). When traumas faced in combat are compounded with self-doubt, regret, guilt, and shame, soldiers might vigorously, unrelentingly, or intermittently condemn themselves (Maugen & Litz, 2012). Intense intermittent, frequent, and chronic self-condemnations are stressful (Worthing ton, 2006). Judgment by family members, military peers or superiors, and civilians can trigger or reinforce self-condemnation as well as provide the added stress of dealing with the condemnation of the others (Hoge et al., 2004). Witvliet et al. (2004) have shown that condemnation from others is stressful. Both self-condemnation and condemnation by others activate the stress response and produce attempts to cope (Worthington, 2006). Coping might be effective at relieving negative stress responses. It also might--despite short-term stress relief--have long-term negative sequelae if the self-condemnation persists (Hoge et al., 2004; Pargament & Sweeney, 2011). The results often are long-term problems, stresses, and increased risks for problems in physical health (Hassija, Jakupcak, Maguen, & Shipherd, 2012), mental health (Maguen et al., 2009; Sher, 2009), relationships (Litz et al., 2009), and spiritual functioning (Pargament & Sweeney, 2011). Such effects have been documented in military populations as well as civilian populations (Smith et al., 2008).

Litz et al. (2009) inquire whether there is a distinct syndrome of psychological, biological, behavioral, and relational problems that arises from serious or sustained morally injurious experiences. They ask whether existing disorders, such as posttraumatic stress disorder (PTSD), can sufficiently explain the sequelae of perpetrating moral injuries. Among Vietnam veterans, PTSD has been related to participating in atrocities (Beckham, Feldman, & Kirby, 1998). Witnessing atrocities--even if one did not actively participate (Hiley-Young et al., 1995)--puts a veteran at risk for PTSD. However, perpetration is more personally injurious than is mere non-participatory witnessing. Killing is an especially strong predictor of chronic PTSD symptoms--better than virtually all other indices of combat (Fontana & Rosenheck, 2004; MacNair, 2002; Maguen et al., 2009; Maguen et al., 2010). Maguen et al. (2010) studied 2,797 soldiers in the Iraqi Freedom campaign. Maguen et al. (2010) reported that about 40 percent of the soldiers reported killing or being responsible for killing during their deployment. Even after controlling for combat exposure, killing was found to predict PTSD symptoms, alcohol abuse, anger, and relationship problems. Maguen et al. (2010) observed that military personnel returning from modern deployments are at high risk of mental health conditions and related difficulties in psychosocial functioning related to killing in war. …

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