Part III. Conclusions: Theoretical and Practical Implications
Chapter 10. Practical Implications
What do the findings of this study imply for practice? Given the nature of the research topic – moral distress – I found this question particularly important, deserving thorough deliberation. This involved identifying the main implications for the individual, military, political and societal levels, followed by a new search for relevant literature, in line with the grounded theory approach of this study. Eventually, a variety of considerations and suggestions emerged. This chapter is devoted to discussing these, moving from the individual level to the military, political and societal levels
The Individual and Interpersonal Level
Beginning at the individual and interpersonal level, the following implications pertain to morally distressed veterans, therapists, religious/spiritual counselors, colleagues, family members, friends and other individuals. The considerations and suggestions concern the value of focusing on guilt and blame, addressing shattered assumptions, developing a more elaborate moral vocabulary, and encouraging both introspection and ‘extrospection’.
Guilt and Blame
One of the key insights resulting from this study’s findings is that moral distress is inherently tied to moral questions of guilt, shame and blame, questions that need to be taken seriously.
Litz and his colleagues have also made this point, but given that therapists are ‘often too eager to relieve guilt, and, thereby, undermine the patient’s need to feel remorseful’ (2009, p. 703), it seems an important one to underscore. As Litz and colleagues argue, morally distressed veterans should be able to speak about the event without it being excused and thus without it being invalidated. In relation to this, self-forgiveness can be an important step toward healing from moral distress (Litz et al. 2009, Nash and Litz 2013). My research suggests, moreover, that such space for moral judgments and forgiveness is also valuable in cases of perceived betrayal and anger, when blame is directed toward others. For instance, my research points to veterans’ felt need for genuine remorse and genuine efforts of reparation on the part of the political leadership, in order to restore a violated moral relation of dependency and trust.
At the same time, my findings indicate that when veterans keep feeling that they or others fail in correcting the injustice done, they remain unable to grant themselves or others forgiveness. This brings me to Lifton’s work on military trauma (1973), in which he distinguishes between ‘static guilt’ and ‘animating guilt’. Static guilt, Lifton claims, is an unproductive kind of guilt, often felt at only the unconscious level. It brings the veteran no further, leaving him stuck in a spiral of guilt, shame and anger, and in feeling unworthy
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of good things to happen. Static guilt means that the veteran keeps focusing on perceived guilt and cannot envision himself beyond that guilt. Animating guilt, in contrast, involves an ‘active imagery of possibility beyond the guilt itself’ and ‘bringing oneself to life around one’s guilt’ (Lifton 1973, p. 127). It entails an interaction between blaming oneself and having a vision of a future where this may no longer be necessary. For this reason, Lifton argues, animating guilt is the kind that can foster healing. Following Lifton, a similar distinction might be made between static blame and animating blame. In the case of static blame, the veteran remains stuck in anger against those who hurt him and perhaps also in ever-failing attempts to make the wrong-doers correct their wrongs. Animating blame, in contrast, involves anger about the injustice done by others in combination with an imagery of a life beyond a preoccupation with anger, even if this injustice will never be corrected. To be sure, transforming static guilt and blame to animating guilt and blame is easier said than done, but it seems that an awareness of such a distinction might be an important starting point for veterans stuck in moral distress.
Some might be inclined to say that, at least in clinical practice, a focus on forgiveness of self and others is inappropriate, as this would force the therapist to judge the accuracy of a patient’s feelings while the therapist’s moral judgment should be irrelevant. However, it should be noted, efforts to alleviate guilt are just as much based on a moral judgment as a focus on forgiveness is. Making a moral judgment is inevitable and always bears relevance.
For one, it influences the course taken in therapy sessions, as the therapist has to decide whether or not to try to challenge the patient’s feelings of guilt and anger or treat them as appropriate emotions. Furthermore, just as ill-considered condemnation of a patient’s actions might harm the patient, the opposite might also be harmful. When a veteran’s expressions of guilt are met with efforts of deresponsibilization, he may perceive this as yet another moral betrayal and feel further alienated from others (see also Lifton 1973, Bica 1999, Boudreau 2011). As stated, judging one’s own actions as wrong and ‘owning up’ to them may be imperative to make sense of them.
Addressing Ethical Struggles
A second consideration for the individual level concerns the value of going beyond the specific morally distressing event. My research showed that veterans may struggle not only with feelings of guilt and anger about a particular event, but also with a more general sense of moral disorientation and resultant ethical questions. Though Litz and his colleagues likewise acknowledge that a ‘morally injurious event’ violates ‘beliefs about right and wrong and personal goodness’ (2009, p. 698), their treatment model is confined to beliefs about the event and does not address wider beliefs. To reiterate a metaphor used earlier, their model addresses the injury, but not the changed moral ‘body’.
Reviewing the literature on treatments that might help fill this gap brought me to the Shattered Assumptions Theory (Janoff-Bulman 1992), which does attend to a person’s wider beliefs, claiming that an event is traumatic because it shatters core assumptions about the self and the world. According to this theory, all people initially hold the unconscious
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assumption that the world is benevolent (that people essentially are genuine), that the world is meaningful (that things in life generally make sense, that life is fair and that people get what they deserve), and that the self is worthy (that they themselves ultimately are good persons worthy of good things). Exposure to utterly cruel or meaningless events violates these assumptions. Proper treatment, therefore, has to address not only the traumatic event but also the assumptions it has shattered, namely by promoting a more flexible self- and world-view that can be reconciled with the trauma. This more flexible view would hold that
‘[t]he world is benevolent, but not absolutely; events that happen make sense, but not always;
the self can be counted on to be decent and competent, but helplessness is at times a reality’
(Janoff-Bulman 1992, p. 174).
The Shattered Assumptions Theory approach makes it possible to address the potential damage done to a veteran’s fundamental moral beliefs. Yet, two things might be added to this approach. First, besides the beliefs and expectations that most people arguably hold (the world as benevolent, and so on), beliefs and expectation that are more particular to certain groups or individuals may also be worth addressing. In the case of a morally distressed soldier, one could think of typical military values such as comradeship and courage. Also, one could consider the soldier’s military role. A commander will feel particularly responsible for his unit’s safety, whereas a military nurse will feel particularly committed to helping others without exception. Explicating the role of such more specific beliefs and expectations may help veterans to make sense of their moral distress.
Second, it may be necessary to address ethical questions before being able to work on a more flexible self- and world-view. As argued, a veteran’s experience may have shattered not only his trust in people’s ability to do right, but also his trust in the very notion of ‘doing right’.
It may have damaged the very moral frame of reference which he used to make judgments of right and wrong. It seems that in cases of what I call moral disorientation, something else has to happen before a veteran can come to believe that ‘the world is benevolent, but not absolutely’. In such cases, the veteran struggles not only with moral questions of ‘am I/are others good or bad?’, but also with ethical questions of ‘what is good and bad in the first place?’. These ethical questions, then, should also be addressed. This could mean, for instance, that the veteran obtains a better understanding of morality in general and the moral complexity of war and military action in particular, to be better able to make sense of the disorientation he feels, and thus to find re -orientation.1 The more elaborate moral vocabulary argued for in the previous section could provide helpful words in this process.
The Value of a Moral Vocabulary
A third consideration resulting from this study concerns the value of an elaborate vocabulary to deal with moral distress. My findings indicate that both veterans and their environment
1 Similarly, Vietnam veteran/philosopher Bica (1999, p. 82) argues for the value of enabling a ‘morally injured’ veteran ‘to understand the theoretical nature of war – its moral, social, and political underpinnings – the profound indoctrination process he has endured, the nature of moral values, and the existential reality of war’. However, as his use of ‘indoctrination’
indicates, Bica bends toward an anti-war approach that frames military ideals and self-perceptions as deceptive myths, which may not be helpful to veterans who do not agree with this stance.
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currently lack the language to address the potential moral ambivalence of veterans’
experiences. They lack, for instance, a proper word for feeling guilty and not guilty at the same time and generally lack available ‘stories’ with which to grasp and explain experiences of moral distress. This absence is not just an issue of representation and communication. As shown, language and stories are of paramount importance for making sense and coming to terms with one’s experiences.
Several other scholars have also noted that present-day societies lack adequate language for the moral complexities of military practice. Verkamp (1993), for instance, contends that soldiers’ feelings of guilt are often reduced to an issue that needs psychological treatment, while Kinghorn (2012) argues that the moral aspects of war acts tend to be judged in legal terms only, namely by the standards of the Geneva Conventions and military Rules of Engagement. Verkamp (1993) and Tick (2005) point out that societies used to have spiritual and symbolic practices to guide warriors through warfare, but these no longer exist.
These developments are problematic for the same reason: veterans are left without constructive narratives to deal with the moral impact of having gone to war. No matter how legally justified the actions of a soldier are, these actions may still have wounded him.
Similarly, no matter how dysfunctional guilt feelings may be in psychological terms, these feelings may also be considered appropriate. It should be added, however, that no matter how
‘inhumane’ and ‘monstrous’ an individual’s actions may be according to societal standards, the tragedy of violence is that it is very human.
Addressing the moral impact of military practice, then, seems to require a more complex moral vocabulary than one limited to binary categories such as ‘guilty–innocent’,
‘responsible–not responsible’, ‘perpetrator–victim’, ‘inhumane–humane’ and ‘functional–
dysfunctional guilt’. It seems to require a better understanding of such terms as ‘values’,
‘norms’ and ‘dilemmas’. As Dutch soldiers have reported (Baarle et al. 2017), understanding ethical terms helped them to recognize, understand and communicate about moral dilemmas on deployment, which indicates that having a more elaborate moral vocabulary may also work preventively.
Of course, in addition to separate words, narratives play an important role in meaning-making, and besides language, the role of practices should not be forgotten. These issues are addressed in the section on the societal level (see below), which will discuss ancient and new
‘purification’ rituals and the narratives they convey about war.
Encouraging both Introspection and ‘Extrospection’
A final important suggestion for the individual level concerns the value of going beyond introspection. As this study showed, moral emotions are not only about one’s relation to oneself but also about one’s relation to others. Anger is usually directed at another person, and feelings of guilt and shame have to do with how one perceives oneself as seen through the eyes of others. Accordingly, moral distress may provoke certain behavior to others, for instance, a preoccupation with injustice expressed in volunteer work and/or in aggressive responses to daily injustices.
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Because moral distress has such a strong social dimension, a veteran should be enabled to look not only inward but outward as well. Lifton (1973) and Bica (1999), who share this contention, point out the importance of enabling a veteran to understand his experience in the context of the images and rhetoric prevailing in society about war, the armed forces and military action. Regarding active forms of ‘extrospection’, Litz et al. (2009) emphasize the healing power of ‘making amends’, while Shay (1994) argues for being able to share one’s experiences with the wide community without condemnation. Shatan (1973) says that collective self-help efforts may be instrumental in healing. In short, looking outward and going outside the self, both figuratively and literally, may help morally distressed veterans re-engage with the world in which they live.
The Level of the Military Organization
Just as it may be valuable for veterans to look outward, it is important that efforts to address moral distress go beyond the level of the individual veteran. Before considering this study’s implications for the political and societal level, it is worth looking at a level that has received no explicit attention so far, namely the level of the military organization.
When researchers and policy makers discuss how the military can help prevent mental health problems, the answer is usually: good training, ethical leadership and unit support (see e.g. Cossar 2008, Jones et al. 2012, Vermetten et al. 2014). This is also the case in discussions on
‘moral injury’ (Kilner 2002, Shay 2002, Frankfurt and Frazier 2016). A currently popular answer is resilience, which refers to the ability to ‘bounce back’ after stressful events. Resilience-promoting training and leadership, it is believed, would substantially decrease the risk of PTSD and other disorders and possibly even foster ‘post-traumatic growth’ (Tedeschi and Calhoun 1993, APA 2011, Eidelson et al. 2011, Lester et al. 2011, Boermans v. 2012, Mulligan et al. 2012). But what do ‘good training’, ‘ethical leadership’, ‘unit support’ and ‘resilience’ entail exactly? The interpretations given are diverse, if formulated at all, and often without critical consideration (see e.g. Eidelson et al. 2011, MacLeish 2012 for critical evaluations).
Below, I consider two prevalent, generally unquestioned interpretations: encouraging a sense of purpose and promoting a can-do mindset. This will show that what may seem good, ethical, and so on, may have considerable downsides. After discussing these two interpretations, which serve as a warning against the perils of imposing a sense of purpose and a one-dimensional can-do mindset, I will discuss several alternatives.
Encourage a Justifying Sense of Purpose?
Given that feelings of guilt and senselessness contribute to moral distress, it may seem helpful to convince soldiers that their actions were actually justified and meaningful. Indeed, such efforts have been signaled, in the US armed forces at least. US military chaplains and psychologists have reported trying to help soldiers struggling with guilt by justifying their
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actions (Lifton 1973, Kilner 2010). Currently the largest resilience training program in the US military encourages a sense of meaning and purpose in personnel in order to prevent mental health problems (Hammer et al. 2013, Matthews 2013). According to US Lieutenant-colonel Kilner (2002, 2010), military leaders have ‘the obligation to justify killing’ so that soldiers will not suffer guilt.
While explicit justification may apply to some armed forces more than others, many militaries depict military practice as virtuous and meaningful, for instance in their recruitment campaigns (see e.g. Woodward 2000, Dutch Ministry of Defense 2013, 2017, Hein 2014). However, my findings showed that some situations do not allow soldiers to see their job as such. They suggest that veterans may see more value in condemning their own or others’ actions and in denouncing their mission as meaningless, whereas the imposition of a justifying sense of purpose may instead create a ‘puppet show’ experience of fakeness and betrayal. This is in line with literature showing that both confidence and doubt can offer guidance, and that not only pride but also guilt, blame and regret can give meaning to one’s life (Lifton 1973, Held 2004, Litz et al. 2009, Rietveld 2009), and with the fact that military practice is inevitably morally complex. Imposing a justifying sense of purpose, thus, may actually have iatrogenic consequences. It may not only give rise to a sense of betrayal after soldiers return from deployment, but also increase the risk that they will do things on deployment they will later come to regret.
Overly laudatory portrayals of mental health interventions, it is worth noting, carry similar dangers. Current studies on resilience emphasize that deployment is an opportunity for personal growth and speak ambitiously about the potential of resilience training to prevent mental health problems (Eidelson et al. 2011, MacLeish 2012). These studies hypothesize, for instance, that resilience skills enhance the ‘ability to handle adversity, prevent depression and anxiety, prevent PTSD, and enhance overall well-being and performance’ (Reivich et al.
2011: 26). Similarly, as critical scholars have pointed out, evaluations of the currently largest resilience training program have been ‘overly enthusiastic’, continuing a ‘history of hyping that began with the program’s initial development roll-out’ (Eidelson and Soldz 2012, p.
1). Rather than promote positive thinking in soldiers, such keen hype may adversely affect them. To be sure, emphasizing resilience over a focus on mental disorder has its benefits.
But, again, incorrect claims that good training will protect soldiers from mental health problems may both encourage them to do regrettable things and, afterwards, engender a sense of betrayal.
Promote a Can-Do Mindset?
While training instructors and commanders may stress that military practice is just and purposeful, at the same time, a ‘can-do’ mindset is often encouraged in the military, especially in informal talk. A can-do attitude entails the belief that all situations are ultimately solvable and all tasks ultimately doable, and extensive deliberation on larger questions is unhelpful (Soeters et al. 2006, Arundell 2009). Differently put, it entails a no-nonsense solution-directed pragmatism, which readily sees worries about the meaning
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and purpose of one’s work as obstacles to problem-solving. Indeed, as this study discusses throughout, Dutch soldiers tend to discard the belief that their job serves a higher purpose even before their deployment, and focus on doing their job as best they can instead. A study
and purpose of one’s work as obstacles to problem-solving. Indeed, as this study discusses throughout, Dutch soldiers tend to discard the belief that their job serves a higher purpose even before their deployment, and focus on doing their job as best they can instead. A study