THE LIVED EXPERIENCE OF MORAL INJURY IN THE CONTEXT OF INTIMATE PARTNER RELATIONSHIPS: A PHENOMENOLOGICAL EXPLORATION by SARA KUBURIC A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES GRADUATE COUNSELLING PSYCHOLOGY PROGRAM We accept this thesis as conforming to the required standard …………………………………………………….. Mihaela Launeanu, Ph.D., Thesis Supervisor …………………………………………………….. Derrick Klaassen, Ph.D., Second Reader …………………………………………………….. Tennyson Samraj, Ph.D., External Examiner TRINITY WESTERN UNIVERSITY February 13, 2018 © Sara Kuburic and Mihaela Launeanu PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY ii ABSTRACT Moral injury (MI) represents a unique psychological suffering instigated by one’s transgression of moral values, beliefs, and expectations. MI has a serious negative impact on the psychological, existential, behavioural, and relational aspects of an individual’s life. At its core, MI shakes and sometimes shatters one’s sense of self, perception of humanity, and overall worldview, bringing into question fundamental values of the human existence. Thus far, research studies on MI have focused almost exclusively on investigating MI within the military context, and no study has yet investigated the lived experience of MI. The present study aimed to examine the lived experience of MI in the context of intimate partner relationships. To this end, adult participants who self-identified as having experienced moral injury due to emotional abuse and/or infidelity within their intimate partner relationships were interviewed using hermeneutic phenomenology as research method. Through the phenomenological analysis of the participants’ lived experience, six core thematic meanings of MI emerged: (1) self-estrangement, (2) transgressions and discord, (3) sudden awareness, (4) lostness and sorrow, (5) will to change, and (6) the aftermath. Phenomenological writing further elaborated these thematic meanings in an effort to uncover the phenomenon of MI in the context of intimate partner relationships. The findings of this study uncovered the phenomenon of MI as a process of unraveling, becoming and transforming through suffering. The theoretical contributions and clinical implications of this study are discussed in terms of emphasizing the transformative potential of moral injury experienced in relational context. Moreover, this study revealed the importance of self and self-estrangement in the experience of MI, in addition to other key components of the phenomenon (i.e., awareness and agency). PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY Keywords: moral injury; moral suffering; intimate partner relationships; hermeneutic phenomenology; lived experience; moral transgressions. iii PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY iv TABLE OF CONTENTS ABSTRACT....................................................................................................................ii LIST OF APPENDICES................................................................................................. ix LIST OF FIGURES ......................................................................................................... x ACKNOWLEDGMENTS .............................................................................................. xi CHAPTER 1: INTRODUCTION .................................................................................... 1 CHAPTER 2: LITERATURE REVIEW .......................................................................... 6 Definitions and Conceptual Milestones ................................................................................... 6 Transgression of moral beliefs ............................................................................................ 7 Ethical failure. .................................................................................................................... 8 Loss of trust and betrayal. ................................................................................................... 9 Embodied suffering............................................................................................................. 9 Transgressions inflicted by self and others .......................................................................... 9 Trauma and moral dissonance ........................................................................................... 11 Distorted will. ................................................................................................................... 11 Conceptual Clarifications ...................................................................................................... 14 Moral distress ................................................................................................................... 14 Combat stress reaction (CSR)............................................................................................ 16 Post-traumatic stress disorder (PTSD). .............................................................................. 17 Complex trauma ............................................................................................................... 19 Betrayal trauma................................................................................................................. 19 Proposed Mechanisms of Moral Injury .................................................................................. 21 Self-attribution and cognitive dissonance .......................................................................... 21 Cognitive dissonance. ....................................................................................................... 25 PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY v Betrayal mechanism.......................................................................................................... 26 Protective factors .............................................................................................................. 29 Vulnerability factors ......................................................................................................... 30 Prevalence of Moral Injury.................................................................................................... 31 Manifestations of Moral Injury.............................................................................................. 33 The Assessment of Moral Injury ........................................................................................... 35 Moral Injury Questionnaire-Military Version. ................................................................... 36 Moral Injury Event Scale .................................................................................................. 36 Current Treatment Approaches for Moral Injury.................................................................... 37 Prolonged exposure........................................................................................................... 37 Peer support group ............................................................................................................ 38 Spiritual based interventions ............................................................................................. 38 CBT based intervention .................................................................................................... 39 Conclusion........................................................................................................................ 41 Rationale for the Study.......................................................................................................... 41 Personal experience. ......................................................................................................... 41 Research gaps ................................................................................................................... 43 Aims of the Current Study..................................................................................................... 44 Context. ............................................................................................................................ 44 Method. ............................................................................................................................ 47 Research Question ................................................................................................................ 47 CHAPTER 3: THE METHOD ...................................................................................... 48 Research Paradigm................................................................................................................ 49 Ontological assumptions ................................................................................................... 49 Epistemological assumptions ............................................................................................ 49 PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY vi The Development of Hermeneutic Phenomenology ............................................................... 50 Hermeneutic Phenomenological Method ............................................................................... 53 Analytical Strategy: Steps of Hermeneutic Phenomenology................................................... 55 Step 1: Turning towards a phenomenon (Implicated researcher). ....................................... 55 Step 2: Investigating the lived experience (Data collection). .............................................. 58 Steps 3-6: Data analysis overview ..................................................................................... 60 Recruitment, Sample, and Participants .................................................................................. 63 Recruitment and sample ........................................................................................................ 63 Inclusion criteria ............................................................................................................... 65 Exclusion criteria. ............................................................................................................. 65 Rationale for the recruitment criteria. ................................................................................ 66 Screening measures........................................................................................................... 66 Participants ....................................................................................................................... 68 Methodological Rigour ......................................................................................................... 68 Balancing integration. ....................................................................................................... 69 Openness .......................................................................................................................... 69 Concreteness..................................................................................................................... 69 Actualization .................................................................................................................... 70 Van Manen’s rigour criteria. ............................................................................................. 71 Reflexivity. ....................................................................................................................... 71 CHAPTER FOUR: THEMATIC MEANINGS .............................................................. 78 Participants’ Lived Experiences of Moral Injury.................................................................... 78 Tom .................................................................................................................................. 79 Annie................................................................................................................................ 84 Aaron ............................................................................................................................... 88 PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY vii James................................................................................................................................ 91 Thematic Meanings of the Lived Experience of Moral Injury ................................................ 96 Self-estrangement. ............................................................................................................ 97 Transgressions and discord ............................................................................................. 105 Sudden awareness ........................................................................................................... 111 Lostness and sorrow........................................................................................................ 117 Will to change................................................................................................................. 120 The aftermath. ................................................................................................................ 125 CHAPTER FIVE: PHENOMENOLOGICAL WRITING ............................................ 131 Moral Injury as Transformative Experience: The Water Symbol.......................................... 132 Eroding Our Foundation: Self-Estrangement ....................................................................... 133 Struck by Lightning: Sudden Awareness ............................................................................. 142 Left to Drown: Lostness and Sorrow ................................................................................... 146 ‘It’s Time, Wake Up Now’: Will to Change ........................................................................ 149 Baptized by Water: The Aftermath ...................................................................................... 152 Resonance or Iconic Checks ................................................................................................ 156 Participants. .................................................................................................................... 156 Research team................................................................................................................. 158 CHAPTER SIX: DISCUSSION .................................................................................. 160 Findings that Fit with Previous Research Studies................................................................. 161 Transgressive acts and moral injury ................................................................................ 162 Experiential features of moral injury. .............................................................................. 167 Summary. ....................................................................................................................... 172 Self-forgiveness. ............................................................................................................. 174 New Findings...................................................................................................................... 175 PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY viii Self-transgressions as morally injurious acts.................................................................... 176 The role of self-estrangement in moral injury. ................................................................. 177 Moral injury as human response to transgressions. .......................................................... 179 Lack of awareness and perpetration of moral injury......................................................... 180 The experience of moral injury as process. ...................................................................... 181 The transformational potential of moral injury. ............................................................... 182 Theoretical Contributions of the Study ................................................................................ 183 The moral in moral injury ............................................................................................... 183 The role of self in moral injury. ....................................................................................... 186 The term “moral injury.” ................................................................................................. 188 Directions for Future Research ............................................................................................ 194 Strengths and Limitations of the Research ........................................................................... 196 Conclusions ........................................................................................................................ 199 References ................................................................................................................... 201 PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY ix LIST OF APPENDICES Appendix A: Participant Informed Consent Form and Confidentiality Agreement ................... 219 Appendix B: Client Resources ................................................................................................ 223 Appendix C: Pre-Screening Interview ..................................................................................... 224 Appendix D: Screening Assessments....................................................................................... 225 Appendix E: Semi-Structured Interview Questions ................................................................. 233 Appendix F: Debriefing Document ......................................................................................... 234 Appendix G: Resonance Check Questions............................................................................... 235 Appendix H: Demographic Questionnaire ............................................................................... 236 Appendix I: Suicide Response Protocol................................................................................... 237 PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY x LIST OF FIGURES Figure 1. PTSD and MI, Venn Diagram..................................................................................... 19 Figure 2. The Causal Framework for Moral Injury .................................................................... 22 Figure 3. The Integrated Model of Moral Injury ........................................................................ 29 Figure 4. Thematic Meanings of Moral Injury ........................................................................... 97 Figure 5. Theme of Self-Estrangement .................................................................................... 100 Figure 6. Theme of Transgressions and Discord ...................................................................... 106 Figure 7. Theme of Sudden Awareness .................................................................................... 112 Figure 8. Theme of Lostness and Sorrow ................................................................................ 117 Figure 9. Theme of Will to Change ......................................................................................... 120 Figure 10. Theme of The Aftermath ........................................................................................ 125 PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY xi ACKNOWLEDGMENTS Tom, James, Annie and Aaron - I am grateful for your strength, your vulnerability, and your truth. I feel incredibly honoured to have been invited into your world of deep sorrow and emotionality. I am in awe of the force and resilience of each and every one of you. You have moved me and evoked in me a strength to unravel in my own suffering and become truer to my own lived experience. Mihaela - Thank you, truly. I cannot imagine having gone through this process without your dedication, passion, support, and guidance. It has been a privilege to work with you and learn from you. This has been a scholastically demanding and personally challenging process, so thank you for helping me navigate the storm of phenomenology and for protecting my truth. Derrick - Your rigorous feedback and fresh perspective have been invaluable. Thank you for challenging me while encouraging me, and for providing the space and the freedom for discovery. The research team - I want to thank each and every one of you for your willingness to reconnect to your sorrow and freely share your voice. Your dialogue and feedback has been an instrumental part of my research. To my family - Everything I am and everything I have accomplished has been influenced by your incredible love, unceasing support, and selfless sacrifice. Thank you for instilling in me a passion for knowledge, and a confidence to always pursue my dreams. Ezra – You continually inspired me to pursue my passion, speak my voice, and be the best version of myself. I cherish the way you saw and loved me even in my deepest suffering. Your unwavering support has made my experience one of transformation, healing, and freedom. Thank you for always believing in me, challenging me, and valuing this work. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 1 CHAPTER 1: INTRODUCTION [E]very man is more than just himself; he also represents the unique, the very special and always significant and remarkable point at which the world's phenomena intersect, only once in this way and never again. That is why every man's story is important, eternal, sacred; [I]n each individual the spirit has become flesh, in each man the creation suffers, within each one a redeemer is nailed to the cross. Few people nowadays know what man is […] I do not consider myself less ignorant than most people. I have been and still am a seeker, but I have ceased to question stars and books; I have begun to listen to the teachings my blood whispers to me. My story is not a pleasant one; it is neither sweet nor harmonious, as invented stories are; it has the taste of nonsense and chaos, of madness and dreams — like the lives of all men who stop deceiving themselves. Each man's life represents the road toward himself, and attempt at such a road, the intimation of a path. No man has ever been entirely and completely himself. Yet each one strives to become that — one in an awkward, the other in a more intelligent way, each as best he can. (Hesse, 2013, p. 9) PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 2 These words written by Hesse (2013) beautifully summarize the unique journey of being human, a journey that is complex, spiritual, and enveloped in suffering. These evocative words moved me, for they resonated deeply with my own experience. My journey began when I was just a child. I remember the day that changed my life and simultaneously evoked my suffering – Wednesday, March 24 (1999) – the start of the NATO bombing of Yugoslavia. Since that day, months were enveloped in fear, turmoil, endless darkness of bunkers, deafening sounds of bombs, and threatening food rations. Slowly, the distinction between night and day ceased to exist, for the attacks began to last for endless hours imprisoning us. We were always waiting, anticipating. The first sirens sounded the end of my childhood. All the sirens following just mocked with inducing panic. I began wondering – was this the end? No one I knew died during the bombings, but everyone I knew changed. Many years later I encountered my own deep transformation in an intimate partner relationship. It had a remarkable resemblance to my childhood experience – inner sirens that alarmed danger, the endured struggles, and the basic restrictions that began to feel normal. I persevered, but I changed. It was a warm Californian winter night. I can still recall the intimate, low-dimmed scotch bar with its walls stacked with vintage bottles and large warped mirrors. I sat across my best friend and stared at the flickering candles placed in the middle of our small round table. The quiet murmur of indistinguishable voices and the secretive atmosphere of the tucked away corner PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 3 of the European café soothed my never ceasing ache which has grasped my soul and consumed me with unescapable energy. I was usually never out that late, and the unfamiliar atmosphere served as an enveloping distance from my truth, of my reality, of my sorrow. The conversation flowed effortlessly as my friend, whom I have met on my first day of college years, spoke of things of the past. Recalling anecdotes of the person he understood me to be. The next thing I remember so vividly were tears rolling down my face as I suddenly lost my ability to breathe. Out of nowhere, I began to weep uncontrollably. I remember seeing uncomfortable glances of other patrons. I remember the shame of my tears forcing my head down, with my eyes fixated on the dying candle. I did not dare to look up at the observant audience. I remember thinking: What is wrong with me? Pull it together Now, Sara. I felt ambushed by my sorrow, for I did not accept it. I did not know why I was crying until I finally gave myself permission to say things I’ve been too scared to admit. To say things to my friend that I could not say to myself. I am not happy. I feel mistreated. I don’t trust my partner. . I feel coerced to be someone I am not, and live the life I don’t want. However, I believe it’s my fault. I believe I deserve it. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 4 I have lost sight of who I am. I am failing my partner, and I am failing myself. He does not think I am ever enough. And, neither do I. I feel broken. I can’t keep going on like this. With time, these words only became truer to my experience. I began to drown in hopelessness and seek relief by pretending my feelings were not real and taking refuge in my busy schedule. It got much worse before it got better. Six months later, I found myself sitting surrounded by paramedics experiencing what I perceived as death, finally realizing that the panic was an outcry that shattered my last attempt of self-deception. I realized that no one could save me. But I remember deciding to fight for myself. To seek myself. Salvation felt a lot like condemnation for no one understood my experience. And as I began making decisions, I faced the reality that sometimes went against my worldview. In an effort to experience freedom, I did what was necessary and slowly began to re-establish my sense of morality and worldview. There was no other way out. In the research literature, a fairly new concept has emerged – moral injury (MI) – as a way to uncover aspects of this human intricacy. This relatively novel concept has caught the attention of many researchers and clinicians in the field of psychology as it is one of the first PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 5 constructs that attempted to capture holistically how an individual, “a remarkable point at which the world's phenomena intersect” (Hesse, 2013, p. 9), responds to moral, relational transgressions, and to grasp the impact that moral transgressions have on the existence of an individual. The words written by Hesse (2013) have challenged the approach I1 have taken towards this project. In science, many, such as myself, have attempted to understand the human phenomena but have struggled because of their inherent experiential chaos. Science has often attempted to simplify, quantify, and limit human experiences by striving to make them explicit, tangible, and entirely understandable – encountering the risk of doing the experience injustice and taking away its truth. This is why I chose the method of hermeneutic phenomenology for this project, for it is driven by “being swept up in a spell of wonder about phenomena as they appear, show, present, or give themselves to us” (van Manen, 2014, p. 26). Hesse (2013) stated: “My story is not a pleasant one; it is neither sweet nor harmonious, as invented stories are; it has the taste of nonsense and chaos, of madness and dreams — like the lives of all men who stop deceiving themselves” (p. 9). In this research, I aspired to uncover and represent the raw, unpleasant, chaotic, dreamlike experience of many, without being bounded by the need to oversimplify. Simplifying an experience such as MI would rob it of its essence. And just like Hesse, I stopped deceiving myself and began to understand that lived experiences cannot be anything other than complex, for truly, this is the beauty and the curse of human existence. 1 It is important to note, that throughout the thesis whenever a first-person pronoun is used, it is the researcher speaking. This style of writing is utilized as a way to adhere to the phenomenological nature of the study. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 6 CHAPTER 2: LITERATURE REVIEW Man is a mystery. It needs to be unraveled, and if you spend your whole life unravelling it, don't say that you've wasted time. I am studying that mystery because I want to be a human being. Fyodor Dostoyevsky This chapter will provide a summary of how the construct of moral injury (MI) was discussed within the research literature. More specifically, the chapter will: (a) highlight the current definitions of MI, (b) differentiate the construct of MI from related constructs; (c) discuss the proposed mechanisms behind the development of MI, and (d) outline the main MI symptoms, assessment tools, and psychotherapeutic approaches for treating MI. Lastly, the rationale of the study, its purpose, and research question will be addressed. Definitions and Conceptual Milestones The concept of morality – and what is considered moral – has been debated and changed throughout the history of Western moral philosophy. Philosophers’ debates of such matters date back as far as fourth century Greece (MacIntyre, 1998); and although the phenomenon of MI may not be novel, the concept and the term “moral injury” emerged more recently out of the writings of Vietnam War veteran and war activist Camillo “Mac” Bica (Bica, 1999; Brock & Lettini, 2012;). Bica spoke openly about the ethical and moral struggles of war within the framework of what is now identified as moral injury, giving the world its first glimpse of this construct. Since then, psychology has adopted the term ‘moral injury’, and expanded this concept to what it is today. This section of this chapter will review and discuss the most important conceptual milestones in understanding MI and the evolution in our understanding of this concept. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 7 Transgression of moral beliefs. Litz et al. (2009) developed the first theoretical conceptualization and definition of MI, and in their view, MI occurs as a result of Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply-held moral beliefs and expectations. This may entail participating in or witnessing inhumane or cruel actions, failing to prevent the immoral acts of others, as well as engaging in subtle acts or experiencing reactions that, upon reflection, transgress a moral code. (Litz et al., 2009, p. 697) This definition focuses on the concept of transgression of morals, beliefs, and expectations. This comprehension of MI is exclusively cognitive and behavioural, centered around the perceived violations of moral beliefs and expectations, and the individual’s actions or inactions surrounding inhumane and cruel events. In line with this cognitive understanding of MI, Litz et al. (2009) proposed cognitive dissonance as the mechanism explaining the development of MI: when someone experiences a dissonance between their moral values or beliefs and their actions, one may develop moral injury if this conflict deepens and it is not resolved. Litz et al.’s cognitive focus is also noted in their working model, addressed later in the chapter, which has heavily borrowed concepts from attribution theory (Fiske & Taylor, 1991) and social psychology (Baron, Byrne, & Suls, 1989) to propose an understanding of the development of MI. Litz et al. (2009) have also recognized that moral emotions (e.g., shame, guilt) that emerge from transgressing moral beliefs play an important role in MI, but understood these emotions solely as outcomes or consequences of the cognitive dissonance stemming from violating one’s moral beliefs. Whereas Litz and colleagues have the merit of proposing a first coherent definition and model of MI and recognized the role of cognitive dissonance and moral emotions in MI, their definition only captures the cognitive and behavioural features of MI. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 8 Ethical failure. Interestingly, unlike Litz et al. (2009) who emphasized the transgression of moral beliefs and expectations in the genesis of MI, Drescher et al. (2011) highlighted the disruption of ethics and justice as that which is being transgressed. Drescher et al. (2011) built upon, and expanded the conceptual model developed by Litz et al. (2009), and proposed another definition of MI that aimed to “describe disruptions in an individual sense of personal morality” (p. 8) brought on by engaging or witnessing immoral, inhumane acts as yet another key feature of MI. Disruption in an individual’s confidence and expectations about one’s own or other’s motivation or capacity to behave in a just and ethical manner. This injury is brought about by bearing witness to perceived immoral acts, failure to stop such actions, or perpetration of immoral acts, in particular acts that are inhumane, cruel, depraved, or violent, bringing about pain, suffering, or death of others. (Drescher et al., 2011, p. 9) By reading the definition, one can conclude that the phrase “personal morality” (p. 8) used by Drescher et al. (2011) was a blanket statement for the individual’s understanding of his or her confidence, expectations, motivations, and capacity to behave ethically. The concept of disruption of one’s confidence regarding their abilities to act immorally is an element not mentioned in previous research. However, the authors did not identify how ‘disruption’ is different from ‘transgression’ used by Litz et al. (2009). The aspect of one’s motivation and capacity’to behave unethically brought about a unique dimension to MI, alluding to the mechanism of MI as a result of perpetration. Drescher and colleagues (2011) addressed the elements and the relationship between ethics and behaviour that concluded that the capacity to act in an immoral way can lead to MI. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 9 Loss of trust and betrayal. Nash et al. (2013) contributed to the understanding of the construct of MI by stating that the loss or betrayal of trust was at the core of MI: “moral injury is not merely a state of cognitive dissonance, but a state of loss of trust in previously deeply held beliefs about one’s own or other’s ability to keep our shared moral covenant” (Nash et. al., 2013, p. 3). Their research was the first place that set cognitive dissonance apart from MI’s profound experience of loss of trust, betrayal and self-betrayal. Nash et al. (2013 have also touched upon one’s shattered or broken worldview as unique consequences of MI. Embodied suffering. Shay (2014) built upon the theory of Litz et al. (2009) and stated that his theoretical understanding complements that of Litz et al. (2009) in two ways: (1) by clarifying who is the perpetrator of MI, and (2) by addressing the physiological manifestations associated with MI, not just the cognitive dissonance. While Litz et al. (2009) claimed that the perpetrator of MI is one’s self, Shay (2014) asserted that the perpetrator is the “powerholder” (p. 184). In addition, Shay (2014) claimed that physiological arousal symptoms are an important aspect of MI, and asserted that the body codes MI as a physical attack, mobilizing it for danger and counterattacks, and thereby leaving a lasting imprint on the physiology in the same way manner as a physical attack. Lastly, he argued that physical and moral trauma are both important: both can coexist, and each can cause the other (Shay, 2014). Transgressions inflicted by self and others. As research advanced in the area of MI, the relatively high incidence of instances of harm and suicide among people who suffered from MI began to emerge, yet no direct correlation between these incidents and MI was initially studied. Bryan et al. (2014) worked to bridge this gap by exploring MI as a possible contributor to selfinjurious thoughts and behaviours (SITB). Until the results of this study came out, much emphasis was given to the role that betrayal and transgressions perpetrated by others have in PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 10 developing MI and its consequences (Nash & Litz, 2013; Shay, 2014), yet the results of the study (Bryan et al., 2014) found that the betrayal aspect of MI had no effect on SITB. SITB was a real problem for many military personnel, and the study found that transgressions committed by oneself – that had a strong relationship with the feelings of guilt, shame, and hopelessness – were associated with a more severe suicidal ideation, while transgression by others (strong relationship with indicators of emotional distress such as insomnia and PTSD symptoms) were associated with the highest rates of suicide attempts (Bryan, Bryan, Etienne, Morrow, & RayStannerud, 2013). Since transgression committed by self, often referred to as “Transgression-Self” (Bryan et al., 2014, p. 155), entails inner conflict and emotional distress, and suicidal individuals possess extremely negative self-perception and are often self-critical about perceived defectiveness, the high correlation between the two is to be expected (Bryan, 2011; Bryan, Clemans, & Hernandez, 2012; Bryan, Morrow, Anestis, & Joiner, 2010; Kenzler, Bryan, Morrow, & McGeary, 2012; Selby et al., 2010). These findings suggested that there is a likely relationship between the Transgression-Self and the self-deprecatory aspect of MI (Drescher et al., 2011), more so than any other dimension of MI. It is the individual who expresses distress concerning the “rightness” or “wrongness” of his or her action who may experience more powerful suicidal crises and have an amplified risk for SITB. Bryan et al. (2014) re-focused the research of MI on Transgression-Self, asserting its importance as relevant as other-transgression. It was a conceptually significant contribution following Shay’s (2014) claim that MI occurs only when the ‘other’ is the perpetrator, not the self. Although Litz et al. (2009) and Drescher et al. (2011) have acknowledged that MI can occur by either witness or conducting a transgression, Bryan and colleagues (2014) helped reinforce PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 11 the idea that the transgression-self is an important element to MI that was slowly disappearing within the literature. Trauma and moral dissonance. Jinkerson (2016) proposed a definition of MI based on the available MI descriptions, empirical descriptions of MI symptoms, and its theoretical distinction from PTSD: Phenomenologically, MI represents a particular trauma syndrome including psychological, existential, behavioural, and interpersonal issues that emerge following perceived violations of deep moral beliefs by oneself or trusted individuals (i.e. morally injurious experiences). These experiences cause significant moral dissonance, which if unresolved, leads to the development of its core symptoms. (Jinkerson, 2016, p. 5) Jinkerson (2016) was the first to identify MI as trauma; however, he did not specify what kind of trauma. Given the previous conceptual links between MI and betrayal of trust (Litz et al., 2009; Nash et al., 2013; Shay, 2014), one could infer that the trauma syndrome encountered in MI may have overlapping features with the construct of betrayal trauma (Kaehler & Freyd, 2009). Additionally, Jinkerson (2016) was the first to identify MI as a syndrome, and explicitly stated that it has psychological, existential, behavioural and interpersonal components. Specifically, he offered a set of core and secondary symptomatic features of the MI syndrome, which will be further discussed later on in the thesis. Jinkerson (2016) replaced the term “cognitive dissonance” (Nash & Litz, 2013), with “moral dissonance”, yet he did not explain its meaning but merely stated that the unresolved moral dissonance leads to the core symptoms of MI. Distorted will. Most recently, Powers (2017), in his theoretical exploration of MI, suggested that MI can be understood as “the commitment of one’s active willing in a powerful PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 12 and compelling moral orientation that is understood at some point to be false” (p. 333). He proposed that the common consequences of MI, or rather, feelings such as shame, guilt, and moral anguish/ambiguity act as markers of MI. Powers claims that by experiencing these emotions, the individual becomes aware of “the moral orientation that governed their willingness to be pathogenic” (p. 334). Such an awareness pierces through the deep-seated ideology and simultaneously illuminates the problematic nature of the “good” to which the individual has oriented his or herself. Particularly in the military, Power argues that service members’ agency and identity were coerced by the overwhelming force of the government; thus, moral injury occurs when individuals realize that their agency and honor were co-opted by others. Powers (2017) offers three ways in which such a conceptualization helps nurture an enhanced understanding of MI: (1) it allows for a description of the experience in both diffused and acute cases in an integrated conceptual way, meaning that such a conceptualization is comprehensive enough to allow for an understanding of situations in which an individual can pinpoint the moment of awareness (acute cases) as well as of individuals who are unable to do so, but have experienced sustained feelings of moral ambiguity (diffused cases). (2) It enables a more precise differentiation between trauma experienced by veterans as compared with trauma experienced in other contexts. In other words, the interplay of individual agency and identity as something that is “devoured” (p. 335) by the force of the government, shaping their deepest sense of “good” (p. 335) leaving them with an agency that has “no meaningful effect in the world” (p. 335). Powers (2017) suggests that this process of molding one’s agency and identity differentiates moral trauma within the military context and outside the military context. (3) The framework of distorted “good” and compelled will neither excuses nor totalizes the behaviour of PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 13 the individual. Rather such a framework removes the moral binary approach of labeling individuals as “victim” and “oppressor”. It approaches individuals without denying the “wrongness” of the violence of modern combat and by simultaneously recognizing that individuals applying such violence have restricted power (and will) to escape commands. Simultaneously addressing the “wrongness” of one’s actions and their limited agency to do otherwise, Powers (2017) argues, will allow for a more natural and realistic integration of traumatic event. Such an approach, he argues, would leave necessary space for the appropriate negative emotions, as well as lessen the intensity thereof. Summary. There are multiple aspects being brought forth by each conceptual understanding of MI. In sum, MI was defined as an inter-personal suffering that affects the individual psychologically, behaviourally, and existentially stemming from a transgression, disruption, or violation of one’s morals, beliefs, ethics, and/or expectations of self and others. MI is characterized as a trauma syndrome that occurs following a morally injurious event (MIE) due to unresolved moral dissonance. Individuals suffering MI can be either, or both, perpetrators or victims of immoral acts. MI triggers are thought to be self-perceived transgressions and violations of morals and/or beliefs, and the experience of MI encompasses a sense of betrayal by self or others. The transgression and betrayal are thought to become self-perceived once one becomes aware of submitting their will to a moral orientation that in retrospect they perceive as wrong. The consequences of MI involve loss of trust in self and others’ ability to act in accordance to morals, and one’s loss of trust in divinity and perceived worldview (Drescher et al., 2011; Jinkerson, 2017; Lind, 2017; Litz et al., 2009; Shay, 2014). The individual suffering stemming from MI may feel as a disruption in identity and character, as well as negative moral PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 14 emotions (guilt, shame). In conclusion, the impact of moral transgression is an intense, unbearable inner conflict that may lead to a plethora of mental health struggles including suicide (Bryan et al., 2014; Clarke & Kissane, 2002; Currier et al., 2015; Currier, Holland, & Malott, 2015; Dombo, Gray, & Early, 2013; Drescher et al., 2011; Houtsma, Khazem et al., 2017; Jinkerson, 2017; Lind, 2017; Litz et al., 2009; Maguen & Litz, 2013; Nash & Litz, 2013; Shay, 1994, 2003; Verges et al., 2013; Yan, 2016). While there are several significant conceptual milestones in developing our current understandings of MI, there is not yet one definitive theoretical perspective, nor definition, which is comprehensive enough to be exclusively used for the purpose of this research. Therefore, an amalgamation of the available research and understandings of the evolving concept will be used to set the foundation for this thesis. Conceptual Clarifications Although the concept of MI seems to capture a broad array of suffering, it also has a very unique depth that is not captured by other conditions. To better comprehend this distinctiveness, it is important to differentiate MI from theoretically similar concepts such as moral distress, combat stress reaction (CSR), post-traumatic stress disorder (PTSD), complex trauma, and betrayal trauma. Moral distress. Jameton (1984) defined the term “moral distress” (MD) as a phenomenon in which one knows the right action to take, but is constrained from taking it. This constraint creates a subjective experience of moral distress that typically occurs when one’s values and perceived obligations are incompatible with the needs and views of the environment (Epstein & Delgado, 2010). MD is strongly and protractedly integrated into one’s thoughts and views of the self (Epstein & Delgado, 2010). Although frequently implied in numerous PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 15 explanations, a key element of MD is not stated in the definition: MD involves a threat to one’s moral integrity (Epstein & Delgado, 2010), defined as a sense of wholeness – a sense of selfworth that derives from having distinctly-defined values that are congruent with one’s actions and perceptions (Hardingham, 2004). MD is often perceived as an immediate reaction; however, MD can lead to moral residue, which holds a more chronic consequence (Hamric, 2009). Webster and Bayliss (2000) define moral residue as “that which each of us carries with us from those times in our lives when in the face of moral distress, we have seriously compromised ourselves or allowed ourselves to be compromised” (p. 208). Although the concept of MD and moral residue are closely related, each possesses a unique feature. The main model for explaining how the two concepts interact is called the Crescendo Effect, which Epstein and Hamric (2009) have defined most succinctly as a gradual build of moral discontent or distress. The model consists of a dual crescendo effect, one of moral residue and one of MD. Simply put, the MD crescendo arises as the situation unfolds, but it never drops back to zero. Therefore, a moral residue crescendo occurs gradually after repeated situations of MD. Additionally, new MD situations remind the individual of the powerlessness in past situations, building the residue crescendo. MD was discovered within the contexts of nursing, and recognized by the following manifestations: frustration, anger, feelings of belittlement, unimportance, or unintelligence as well as isolation in experience (Elpern, Covert, & Kleinpell, 2005; Epstein & Delgado, 2010; Wilkinson, 1988). There appear to be three potential consequences of MD and moral residue (MR): (1) the individual becomes numb to ethically-challenging situations (Epstein & Hamric, 2009), (2) the individual may engage in different ways of conscientiously objectifying the trajectory of the situation (Catlin et al., 2008), and (3) the individual may burn out (Meltzer & PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 16 Huckabay, 2004). The consequences of MD appear to be less permanent and detrimental than the ones from MI, which appear intense, trauma like, and wounding. MI is a multifaceted phenomenon that has overlapping features from both MD and MR. The lasting effect and the compromise of wholeness and sense of worth found in MR are both facets of MI. However, for moral residue to become a substantial problem, there need to be multiple morally-distressing situations. This is unlike with MI, where a single event can yield lasting consequences. A clearer distinction is that moral residue requires a morally-distressing situation where the individual feels powerless to do what is right. For MI to occur, the individual can either observe or partake in an MIE, varying in intensity from a powerless experience to a controlled experience. The individual does not have to immediately perceive the event as being morally compromising, but can do so in retrospect (Litz et al., 2009). An event becomes MI when it is perceived as a transgression; it can be immediate or delayed (Jinkerson, 2016). Unlike MI, MD is an immediate reaction to an event, an acute stress which can slowly evolve into longlasting consequences if such events are repeated due to the moral residue effect. However, MI does not require repeated events, rather, one event can cause long-lasting consequence and symptoms. Combat stress reaction (CSR). Due to the fact that all of MI research is conducted with military personnel (Drescher et al., 2011; Frankfurt, 2016; Litz et al., 2009; Shay, 2014; Yan, 2016), it is important to distinguish MI from CSR in order to allow the concept of MI to be relevant – but not limited – to the military context. CSR is an acute stress reaction that occurs on the battlefield or in the immediate aftermath of combat (Cohen, Zerach, & Solomon, 2011). This condition occurs when the soldier is unable to cope with both external and internal pressures and is overwhelmed with anxiety. CSR symptoms in individuals are not identical and vary between PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 17 labile polymorphic manifestations, such as psychomotor retardation, restlessness, withdrawal, startle reactions, paranoid reactions, and confusion. Despite the variability, CSR constitutes a severe functional impairment. Some of the unique characteristics of CSR are a negative impact on self-esteem as well as a chronic impact on mental health, physical health, and global functioning (Cohen, Zerach, & Solomon, 2011). CSR is considered to be a major risk factor for the development of PTSD, which is the most prevalent and prominent war-induced psychopathology (Hoge & Castro, 2006). Aspects of CSR are relevant to MI, such as the exposure to traumatic events, withdrawal/isolation, and low self-esteem, as will be discussed later under the theoretical models of MI. However, some consequences of CSR are not currently characterized as aspects of MI, such as psychomotor retardation, startle reactions, paranoid reactions, and confusion. Additionally, CSR has a short duration, while MI carries more chronic implications for the individual’s life and recovery. MI implies a deeper, longer-lasting, and more significant impact on the individual’s essence of overall being. MI is, therefore, more complex than functional impairment. Post-traumatic stress disorder (PTSD). MI shares many features with PTSD; most saliently, the development of both conditions occurs after intense situations and both are associated with psychological problems, social issues, and affective changes (Jinkerson, 2016). In addition, both PTSD and MI include avoidance symptoms, re-experiencing painful memories, and the increased risk of suicide and substance use (Hendin & Haas, 1991; Jinkerson, 2016; Maguen et al., 2011; Shay, 2003; Stein et al., 2012). There are also several important distinctions between MI and PTSD. First, the etiology of the two concepts is different (Jinkerson, 2016). To help clarify this point, it is important to note PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 18 that according to the American Psychiatric Association (2013) trauma is defined as a “perceived threat to self, or others, sexual violence, or witnessing harmful acts” (Jinkerson, 2016) and PTSD develops from the exposure to such traumatic event. In effect, PTSD is primarily a physiological disorder based on persistent and exaggerated fear appraisals that follow life threatening events and subsequently develops into avoidance behaviours (Jinkerson, 2016). Although it is common for PTSD and MI to co-occur, there are two primary differences in terms of their symptoms. The development of MI is not primarily triggered by an experience of intense physiological distress, like in the onset of PTSD (Jinkerson, 2016; MacNari, 2002; Marx et al., 2010). Instead, MI develops out of a deeply felt moral conflict, which stems from the perceived moral transgressions performed by the self or others (Jinkerson, 2016). Whereas guilt and shame are hallmark symptoms of MI, PTSD does not necessary involve guilt and/or shame. Moreover, PTSD can occur without a human interaction (e.g., PTSD following an earthquake), while MI cannot; in this sense, MI shares some critical features with complex, relational, and betrayal trauma rather than with PTSD. The following figure represents the symptomological distinctions between MI and PTSD according to Litz et al. (2009): PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 19 Figure 1. PTSD and MI, Venn Diagram This being said, research studies have noted that many combat veterans who have received clinical help associated with combat trauma were identified with both MI and PTSD. Due to ambiguous encounters that occur in today’s military experiences, there is almost constant physiological arousal and extremely recurrent moral conflict, which often leads MIEs and psychological trauma to be chronologically analogous (Jinkerson, 2016). Therefore, it is not surprising that identical threats and events can produce dual-syndrome responses of PTSD and MI in the military. Unfortunately, this led to a conflation of the two constructs although they are conceptually and symptomatically different. This challenge to differentiate PTSD and MI in clinical practice has contributed to ineffective therapeutic approaches for MI partly due to their focus on treating exclusively the PTSD symptoms while ignoring the suffering of MI, including suicide and self-injurious behaviours. Complex trauma. As previously mentioned, MI may share certain key features of complex trauma. Complex trauma is defined as a trauma involving interpersonal relationships and characteristically includes numerous traumatic interactions over a prolonged interval (Beck et al., 2015). Commonly, complex trauma has been studied and primarily detected in military settings, intimate partner violence (IPV), physical and sexual childhood abuse. A unique feature of MI that distinguishes it from the typical understanding of complex trauma is that MI could also develop after a single incident of transgression (Litz et al., 2009). Betrayal trauma. Betrayal trauma is identified as a trauma “perpetrated by someone close to the victim” (Gomez, Kaehler, & Freyd, 2014, p. 675). Freyd (2008) states that betrayal trauma is and occurs when “the people or institutions on which a person depends for survival significantly violate that person’ s trust or well-being: Childhood physical, emotional, or sexual PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 20 abuse perpetrated by a caregiver are examples of betrayal trauma” (p. 76). Betrayal trauma theory (e.g., Freyd, 1996, 1997) distinguishes traumatic events by the degree of betrayal present in the event (Gomez, Kaehler, & Freyd, 2014). Betrayal trauma is thought to elicit a kind of ‘betrayal blindness’ or unawareness of the abuse to protect the relationship they may have with the perpetrator. Some of the common consequences of betrayal trauma are: alexithymia (Goldsmith, Freyd, & DePrince, 2012), anxiety, depression, panic attacks, suicidality, anger, physical health complaints (Edwards, Freyd, Dube, Anda, & Felitti, 2012; Gomez, Kaehler, & Freyd, 2014), PTSD (Kelley, Weathers, Mason, & Pruneau, 2012), self-blame (Ulman, 2007), and dissociation (Freyd & DePrince, 2001; Gomez & Freyd, 2014; Gomez, Kaehler, & Freyd, 2014). Betrayal trauma research states that dissociation occurs more frequently among survivors of abuse perpetrated by someone trusted and close (high-betrayal traumas), rather than strangers or non-interpersonal events (low-betrayal traumas) (Platt & Freyd, 2015). Additionally, the theory states that high- versus low- betrayal experiences manifest in symptoms that may differ. In every close relationship there is a development of an attachment, and some of the attachments are thought to have “a key survival function of its own, namely protection” (Bowlby, 1988, p. 121). Therefore, betrayal trauma is defined as a trauma “involving a violation of a trust necessary for survival” (Kaehler & Freyd, 2009, p. 262). Normally it would be beneficial for one to detect betrayal as a way to prevent forthcoming violations, yet, since detecting betrayal results in immediate damage to the attachment within a close relationship, usually by a caregiver, an individual may find it more advantageous to remain unaware of the violations (Freyd, 1996). This element of attachment in betrayal trauma could be assumed to be similar within a military population where everyone’s life is dependent on orders given by someone in power, someone who has the ‘caretaker’ role. The struggle between the feelings of betrayal and survival would be PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 21 a prevalent dynamic within the military. Although there appears to be a symptom overlap between betrayal trauma and MI, it is important to note betrayal trauma occurs and has greater consequences when it is perpetrated by someone close to the victim or that has authority over a victim; such a distinction is commonly not found within MI. However, an exception to that is Shay’s (2014) research, where he argued that for MI to occur, there must be betrayal by someone in power and in a high stake situation – where one’s survival is dependent on another. Generally, within literature, the severity consequences of MI have not been found to correlate with the closeness of the relationship to the perpetrator or the victim. Additionally, dissociation has not been accounted for as a symptom or consequence of MI. MI emerged as a construct to explain the unique suffering of many, a suffering that cannot be fully understood with any of the aforementioned theoretical concepts that preceded the emergence of MI. It is imperative to recognize and be able to conceptually distinguish MI from ostensibly related terms, as this conceptual clarification limits the confusion and sets a stronger foundation for understanding the still evolving theoretical framework of MI Proposed Mechanisms of Moral Injury Self-attribution and cognitive dissonance. Litz et al. (2009) proposed a cognitive and behavioural conceptualization of MI. They borrow from self-attribution theory and heavily utilize the concept of cognitive dissonance. In summary, Litz et al. (2009) claimed that MI occurs when an individual experiences a transgression of morals and then attributes that transgression to represent them as a whole – as a bad person. If their actions and their beliefs led to a cognitive dissonance that was not reconciled, it led to moral emotions such as shame and guilt. If these emotions were not dealt with, the individual may start to withdraw from society, failing to experience forgiveness and experiencing self-condemnation. This self-condemnation can then PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 22 lead to chronic intrusion and/or avoidance numbing. Likewise, it can lead to self-harming and self-handicapping behaviors. Engaging in such behaviours would then reinforce their beliefs that they were a “bad person”. This feedback loop (Litz et al., 2009) is depicted in the figure below: Figure 2. The Causal Framework for Moral Injury Litz et al. (2009) stated that MI requires an act of transgression that severely contradicts an individual’s personal or shared expectations, rules, and code of conduct. These transgressions can occur during or after a triggering event, such as wrongdoing, the inability to prevent unethical behaviour, or the witnessing or learning about such events. For MI to occur, the individual must be aware of the cognitive dissonance and inner conflict between the action, on one side and his or her moral beliefs or expectations, on the other side. At times, the context and the presence of others may moderate the degree to which the individual finds the event initially dissonant or conflictual. However, Litz and colleagues (2009) have argue based on Higgins (1987) that individuals will eventually face the task of reconciling their moral conflicts and PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 23 coping with their fears of social condemnation and rejection including at times literal punishment. Further, Litz and colleagues (2009) discussed how moral emotions are related to moral beliefs. Moral emotions are motivated by the expectations of others’ reactions to a perceived transgression. For example, embarrassment motivates an individual to adhere to accepted moral standards as a way to gain approval or inclusion (Keltner, 1995). Likewise, positive emotions, such as other-oriented gratitude and self-oriented pride, play a role in shaping moral behaviours. Much of the existing research has focused on self-oriented negative emotions, such as guilt and shame, and how they influence moral behaviour (Tangney, Stuewig, & Mashek, 2007). Litz et al. (2009) defined guilt as a “painful and motivating cognitive and emotional experience tied to specific acts of transgression of a personal or shared moral code or expectation” (p. 699). Unlike shame, guilt, Litz and colleagues claim, is associated with an individual’s decreased participation in illegal or risky behaviours, and often results in his or her making amends. By contrast, shame consists of a global negative evaluation of the self (Lewis, 1971) in tandem with behavioural propensities towards avoidance and withdrawal. Consequently, shame produces more toxic interpersonal difficulties, including diminished empathy for others and augmented anger, which can lead to devastating life changes. Tangney et al. (2007) have indicated that shame is far more damaging to emotional and mental health than guilt and, therefore, Litz et al. (2009) concluded that shame may represent a more integral part of MI. Based on preceding works addressing shame and guilt, such as Lee, Scragg, and Turner (2001) and McCann and Pearlman (1990), Litz et al. (2009) maintain that during the process of reconciliation, an individual may face emotional turmoil and distress due to the process of reconciling discrepant ways of seeing the world and self that are caused by severe or sudden PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 24 disparities between self and other schemas and the transgression. As noted above, if an individual feels remorse, he or she will experience guilt; however, an individual will experience shame if he or she blames him or herself and perceives the event to be a personal inadequacy and flaw. Guilt responses are temporarily functional due to the heightened motivation that they instill in the individual in order to correct behaviour or identify means of correcting harmful ways of interpreting the experience. Litz et al. (2009) posited that the type of attribution accompanying the moral violation greatly influences the effect that the moral violation will exert on the individual (cf. Weiner, 1985). If the attributions regarding the transgression are perceived as stable (i.e. enduring; experience of being tainted), internal (i.e. seen as a disposition or character flaw), and global (i.e. not context dependent), Litz and colleagues (2009) believe it will cause lasting moral emotions, such as shame and anxiety, due to uncertainty and the expectation of being judged. If these aversive psychological and emotional experiences lead to withdrawal (and concealment), the individual is obstructed from corrective and reparative experiences that would counter the accompanying attributions and foster self-forgiveness (Litz et al., 2009). These intense emotions generally lead to withdrawal and, as time passes, the individual will, according to Litz and colleagues (2009), become more convinced that he or she is unforgivable. As a consequence, the individual will not engage in self-forgiveness, will fail to see a path towards renewal and reconciliation, and will, thus, experience self-condemnation. The behavioural, cognitive, and emotional consequences of severe, unreconciled moral conflict, withdrawal, and self-condemnation are postulated by Litz et al. (2009) to mirror avoidance as well as the re-experiencing and emotionally-numbing symptoms of PTSD. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 25 Litz et al. (2009) argue that intrusive, automatic, and unbidden emotional and psychological processing reminds a person experiencing MI that he or she needs to address the inner conflict. If the individual perceives the experience to be specific (context dependent), not stable (time-locked), and external (extraordinary demands), the individual will experience reduced conflict and higher moral repair. This dynamic occurs because the individual learns to integrate the moral violation into an intact, functional belief system, even though it may be more flexible than the original framework with which he or she started. Re-experiencing the MI may involve painful recollections with concurrent selfcondemnation and aversive emotions, such as anxiety, shame or dysphoria (Litz et al., 2009). One of the consequences of re-experiencing MIEs is the tarnishing of relational expectations and the weakening and destabilizing of self-esteem, which renders MI as an aversive experience. As a result, many service members withdraw, unable to allow themselves to experience a correcting and disconfirming interpersonal experience. Thus, feelings of being unworthy of forgiveness or being tainted can lead the individual to come full circle (feedback loop, in Fig.2). In the worst case scenario, the service member is left suffering isolation, helplessness, and hopelessness. There are myriad manifestations of MI, such as self-harming and self-handicapping behaviours and demoralization. The most harmful of these manifestations is the possibility of enduring changes to an individual’s and others’ belief systems that reflect deteriorating overaccommodations of moral transgressions, culpability, or expectations of injustice (Litz et al., 2009). These changes could occur due to the re-experiencing and avoidance cycle that forms a new schema, which, over time, become rigid, ingrained, and resistant to countervailing evidence. Cognitive dissonance. Nash et al. (2013) proposed that cognitive dissonance is the primary mechanism behind MI; however, it is important to understand the limitations of PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 26 cognitive dissonance in explaining the full mechanism of MI. According to Festinger’s (1957) theory, the arousal of cognitive dissonance occurs when two cognitions are discrepant. For example, it occurs if an individual’s behaviour is incongruent with one’s attitude (Beauvois & Joule, 1997; Hermon-Jones & Hermon-Jones, 2002; McGregor, Newby-Clark, & Zanna, 1999). It is believed that greater discrepancies lead to greater cognitive dissonance (Voisin & Fointiat, 2013). Feeling cognitive dissonance generates a state of discomfort that possesses a motivational dimension to change cognitions and achieve dissonance reduction. The discrepant act is perceived as violating a social norm, such as causing harm to another person (Cooper & Worchel, 1970; Voisin & Fointiat, 2013). The act of the individual is deemed unwanted and in its nature possessive of negative consequences (Cooper, 1999; Cooper & Fazio, 1984; Voisin & Fointiat, 2013). Cognitive dissonance, although it portrays the conflict that occurs within MI, does not take into account a dissonance between cognition and emotion and/or spirituality. It does not include the ethical or moral dimensions of violations such as MI (Litz et al., 2009). It also promotes conscious change for the individual to lower dissonance. In its nature it is a prosocial process, which allows an individual to correct their behaviour and be accepted by society. MI, on the other hand, is not primarily associated with prosocial behaviours because individuals who experience MI are not compelled to change, but rather they oftentimes engage in withdrawal, lack of self-forgiveness, isolation, and self-harming behaviour (Litz et al., 2009). Betrayal mechanism. In 2014, Shay proposed an alternative three-fold structure of MI development in which all three components must be present: (1) A betrayal of what is right, (2) by someone who holds legitimate authority, (3) in a high stakes situation. His theory very much borrows from that of betrayal trauma – he believes the mechanism behind MI is the act of betrayal by someone who either holds authority, whom one depends on, or both. He connects PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 27 betrayal, and conceptualizes it, as a catalyst to the changes and individual encounters such as a deterioration to “their character, their ideals, ambitions, and attachments begin to change and shrink” (p. 5). Furthermore, he claims that MI can impair and/or destroy an individual’s capacity for trust. Shay (2014) asserts that when social trust is destroyed, it is replaced by an expectancy of exploitation, harm, and humiliation from others. With such an expectancy, individuals are left with a number of limited options: “strike first; withdraw and isolate oneself form others; create deception, distractions, false identities, and narratives to spoil the aim of what is expected” (p. 5). In summary, Shay (2014) claimed that betrayal, loss of trust, lowered expectations, and unhealthy coping, respectively, are the mechanisms behind developing MI. An integrated model of moral injury (IMMI). Lind (2017) proposed a model that addressed MI as constituting a result of both transgressions perpetrated by the self (Litz, 2009) and by authority figures (Shay, 2014). IMMI identifies both types of transgressions as having the same mechanism of shame that potentially leads to similar psychological consequences. In contrast with Litz et al.’s (2009) model, the IMMI postulates that “schema violations and maladaptive accommodations are involved in MI” (Lind, 2017, p. 91). However, differing from the model proposed by Litz and colleagues (2009), the IMMI incorporates spiritual schema and the maladaptive ways in which they may change as part of MI. IMMI proposes four schema violations involved in MI: (1) moral identity, (2) divine beings, (3) self, and (4) world. Lind (2017) stated that regardless of whether an individual’s morals are guided by ethics of justice or ethics of care, MI transcends contexts and is a matter of ultimate significance. IMMI has built upon Aquino and Reeds’ (2002) definition of moral identity, defining it as “a set of personal moral values, goals, behaviours, and traits (Lind, 2017, p. 92). Lind (2017) argued that moral identity is infused with the concept of sacredness and, PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 28 therefore, concludes that a moral violation is a spiritual violation. The author states that the violation of moral identity defines moral injury. Lind (2017) conceptualized sacredness based on a cognitive-behavioural framework by proposing that anything can be sanctified by integrating sanctity as part of its schema. The ability to describe a schema as something sacred depends upon the extent to which ultimate importance, transcendence, or boundlessness is part of the schema. Desecration, on the other hand, is perceived as a violation of a schema that contains sanctity. Such violations are believed to be often reported and frequently present in MI. Schemas regarding the world and the self may contain spiritual information other than sanctity. For example, schemas regarding divine beings may include the belief that God is benevolent, just, and in control. Often these schemas parallel the one many hold regarding the world, believing the world to be benevolent, just, and controllable (Janoff-Bulman, 1989). Individuals with spiritual strivings may attempt to nurture closeness with the divine and achieve integration with the world, such as humanity, the cosmos, or nature (Lind, 2017). However, such a connection may be disrupted in MI, leaving an individual feeling disconnected from a larger human community. MI transgresses these deeply held beliefs and, as a consequence, such schemas must be altered to take into account the individual’s transgression; thus, the individual’s self-concept must be altered to describe the self as being fundamentally tainted or immoral (Lind, 2017; Litz et al., 2009; Opp & Samson, 1991). Such a judgment assists in maintaining the belief that the world is coherent and meaningful. Alternatively, the individual may revise the schema he or she had of the world by labeling it as being unjust, broken, and incomprehensible (Lind, 2017). If the former occurs, it is likely that the individual will experience feelings of shame, guilt, depression, PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 29 and expectations of future punishment. This schematic belief of the world is preserved, but at the cost of suffering punishment because of the negative revised schema of self. If that occurs, the individual may lose a sense of social trust (Shay, 2014) and experience spiritual conflict, fatalism, and loss of caring (Drescher et al., 2011). This may result in actions of aggression and rage. The IMMI model is further summarized in the figure below: Figure 3. The Integrated Model of Moral Injury Protective factors. To fully comprehend the mechanism behind the development of MI, it is important to understand the protective and vulnerability factors. These personal traits play an important role in the individual’s susceptibility to and defense from developing MI. In contrast to vulnerability factors, researchers have found that traits such as self-esteem mediate the relationship between belief in a just world and self-forgiveness (Strelan, 2007). Litz et al. (2009) posit that self-esteem constitutes a protective factor against the development of MI that reduces global causal attributions and increases motivation for corrective action. Much research has been done on benefits of interpersonal forgiveness as a way to help the individual adapt and recover (Hall & Fincham, 2005). No less important, but far less studied, is the concept of self-forgiveness, which is a means of “obviating self-condemnation and shame and a vehicle for corrective action” (Litz et al., 2009). Hall and Fincham (2005) define self- PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 30 forgiveness as “a set of motivational changes whereby one becomes discerningly motivated to avoid stimuli associated with the offence, decreasingly motivated to retaliate against the self, and increasingly motivated to act benevolently toward the self” (p. 622). Self-forgiveness conceptually entails: (1) acknowledging the event, (2) accepting responsibility for it, (3) experiencing the negative emotions, (4) devoting sufficient energy to heal, and (5) committing to living differently in the future. (Enright, 1996; Hall & Fincham, 2005; Holmgren, 2002). It has been shown that lack of self-forgiveness relating to war experiences is correlated with PTSD symptom severity in Vietnam veterans, depression, general anxiety, dispositional shame, poor psychological well-being and self-punishment (Fisher & Exline, 2006; Maltby, Macaskill, & Day, 2001; Mauger et al., 1992; Witvliet, Phipps, Feldman, and Beckham, 2004). Vulnerability factors. Although some vulnerability factors for PTSD are applicable to the development of MI, other factors, such as shame proneness and neuroticism, may increase the likelihood of MI (Litz et al., 2009). Of the two, shame proneness has greater empirical support (Fisher & Exline, 2006; Litz et al., 2009; Tangney et al., 2007), linking the dispositional tendency to “expand shame to decreased empathy for others, increased focus on internal distress, and increased psychopathology” (Litz et al, 2009, p.701). Many of the variables germane to MI, such as self-condemnation, remorse, and reduced well-being, are associated with shame (Fisher & Exline, 2006). Neuroticism has been shown to be negatively associated with self-forgiveness (Litz et al., 2009; Maltby et al., 2001; Ross, Hertenstein, & Wrobel, 2007). When compared with extraversion, openness, agreeableness, and conscientiousness, shame has the strongest correlation with self-censure (Leach & Lark, 2004; Maltby et al., 2001; Ross, Hertenstein, & Wrobel, 2007; Ross, Kendall, Matters, Wrobel, & Rye, 2004). Although various MIEs are thought to trigger MI, research is now discovering that there are personality traits which may PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 31 make one further susceptible to developing MI. Shame-proneness is an explicit vulnerability factor, as shame is thought to be one of the most important symptoms of MI (Jinkerson, 2016; Litz et al., 2009). Neuroticism would make an individual self-conscious, and promote withdrawal (Litz et al., 2009), which is a critical part of developing MI according to Litz and colleagues (2009). Neuroticism also does not promote self-forgiveness which is a protective factor for MI. These findings support the proposed mechanism of MI, as well as provide a direction for treatment. Additionally, by examining the meaning that is made of possibly-encountered traumas, Currier, Holland, and Malott (2015) found that the outcome of MI was depended upon the extent to which the veteran was capable of making meaning of his or her identified stressors. In their study, Currier, Holland, and Malott (2015) provide preliminary evidence that meaning-making difficulties serve as a mediating pathway for how MIEs increase the potential for adjustment problems after service in active war zones. The study also highlights that other factors of MI contribute significantly to the difficulties that veterans experience with psychological functioning. Although vulnerability factors are a valid component in the developmental understanding of MI, it is also important to note the events which may lead to MI. In the next section, the specific MIEs that increase the susceptibility and act as potential triggers to the development of MI will be discussed. Prevalence of Moral Injury In current literature, the terms MIEs and MI are often used interchangeably due to the difficulty presented by MI not being a fully comprehensive or measurable concept (Frankfurt & Frazier, 2016). To clarify, for the purpose of this thesis, MIEs are situations that may cause MI, PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 32 not MI itself. To date, there is no available prevalence for MI, however, there is an available prevalence for MIEs. Research on the prevalence and types of MIEs concentrates exclusively on the military personnel deployed to Iraq and Afghanistan. Numerous studies present the following data: 52% of the service members reported shooting or directing fire at an enemy and approximately 40% 50% of soldiers and 65% of Marines reported killing an enemy combatant (Hoge et al., 2004; Jinkerson, 2016; Maguen et al., 2010). Additionally, 12% - 15% of solders and 28% of Marines reported killing non-combatants, although these deaths were arguably caused by the ambiguity of the enemy (Hoge et al., 2004; Jinkerson, 2016). Sixty-five percent reported seeing human remains or dead bodies, 60% reported seeing ill/wounded children or women whom they were unable to help, and 31% handled or recovered human remains. As a result of the morally and ethically ambiguous situations that arose during the conflict, it was reported that 27% of soldiers faced moral/ethical situations during deployment in which they were unsure about how to respond (MHAT-V, 2008). In 2007, 31% of SMs reported that they had insulted civilians, 5% that they had mistreated civilians, and 11% that they had unnecessarily damaged property (MHAT-V, 2008). Wisco et al. (2017) conducted a study regarding the pervasiveness of potentially moral injurious events (PMIEs) in combat veterans, with a sample of 564 personnel. The data analyzed was taken from the National Health and Resilience in Veterans Study (NHRVS), a contemporary and nationally representative survey of a population-based sample of U.S. veterans, collected September-October 2013. Types of PMIEs studied were transgression by self, transgression by others, and betrayal. The results indicated a total of 10.8% of combat veterans acknowledged transgression by self, 25.5% endorsed transgressions by others, and 25.5% endorsed betrayal. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 33 PMIEs were moderately positively associated with combat severity (𝛽 = .23, p < .001) and negatively associated with white race, college education, and higher income (𝛽s = .11–.16, ps < .05). The prevalence of MIEs within the military context is significant, making MI a relevant concept for properly approaching and treating military personnel. MIEs are also vast in their diversity, and are even considered to be present in other circumstances such as domestic violence (Bryan et al., 2014). Manifestations of Moral Injury Researchers have identified a broad range of manifestations associated with MI, also referred to as symptoms or consequences (Drescher 2011; Jinkerson, 2016; Litz, 2009). The most common symptoms of MI include: guilt, shame, spiritual crisis, loss of trust in others, deities, and self (Currier et al, 2015; Currier, Holland, & Malott, 2015; Drescher et al. 2011; Jinkerson, 2016; Litz et al., 2009; Maguen & Litz, 2013; Nash & Litz, 2013; Shay, 1994, 2003; Verges et al., 2013). In addition to these more commonly recognized components, Farnsworth et al. (2014) identify anger, disgust, and contempt as potential symptoms of MI. They explained that the function of these emotions was to “discourage others’ selfish conduct or actions that might threaten the cohesiveness of the social group” (p. 254). Moreover, in addition to the main MI symptoms, many additional psychological symptoms may occur, including anxiety, depression, anger, anhedonia, dysphoria, and intrusive thoughts and images (Drescher et al., 2011; Maguen et al., 2011; Nash et al., 2013; Stein et al., 2012). Due to the presence of shame, guilt, and an overall feeling of one’s self as being evil and/or bad, the symptoms of MI include attempts at self-punishment (Litz et al., 2009). These actions include isolation/withdrawal, sabotaging events, alcohol/substance overuse, and/or PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 34 suicide attempts (Bryan et al., 2014; Jinkerson, 2016). These social problems are believed to be the result of the symptoms, particularly loss of trust, isolation, and self-harm behaviours (Jinkerson, 2016; Litz et al., 2009; Nash & Litz, 2013). Additionally, Shay (2003) described deep demoralization as the “final state” of MI (p. 7), with demoralization being defined as an “inability to cope, helplessness, and hopelessness” (Clarke & Kissane, 2002, p. 733). As a result of MI, an individual may “begin to view him or herself as immoral, irredeemable, and unreparable or believe that he or she lives in an immoral world” (Litz et al., 2009, p. 698), and may even feel that the event is not only damaging, but that it has also changed his or her self-identity (Dombo, Gray, & Early, 2013). In a study conducted by Wisco et al. (2017) transgressions by self were associated with current mental disorders (OR = 1.65, P < .001) and suicidal ideation (OR = 1.67, P < .001); betrayal was associated with posted deployment suicide attempts (OR = 1.99, P < .05), even after conservative adjustment for covariates, including combat severity. Through self-reporting, Yan (2016) examined the impact that MI exerts upon general physical health, general mental health, PTSD symptoms, and depression symptoms. As part of a pilot study, cross-sectional data was collected from the New Jersey Veteran Affairs. One hundred OEF/OIF veterans completed a paper questionnaire. The results of the study indicate that (1) MI and combat experience positively predict PTSD scores, (2) witnessing the aftermath of battle and MI are negatively associated with mental well-being and positively associated with depression; (3) physical health status is negatively associated with depression, and (4) spirituality and MI were negatively associated with physical health. The results suggest that MI plays an important role in both the physical and mental health outcomes of the participants. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 35 Jinkerson (2016) who derived his theoretical framework from his empirical research, offers a set of core and secondary symptomatic features of the MI syndrome. Jinkerson (2016) states that, according to his study, PMIEs correlate to the syndrome model symptoms. He suggests that the core symptomatic features are (1) guilt, (2) shame, (3) spiritual/existential conflict, including the subjective loss of meaning in life (or questioning of meaning in life), and (4) a loss of trust in one’s self, others, and/or transcendental/ultimate beings. The secondary symptomatic features include (1) depression, (2) anxiety, (3) anger, (4) re-experiencing of the moral conflict, (5) self-harm (i.e., suicidal ideation/behaviour, substance abuse, self-sabotage), and (6) social problems (e.g., social alienation, other interpersonal difficulties). The author further argues that according to his study it is likely that the core symptomatic features mediate the development of the secondary symptomatic features. However, Jinkerson (2017) further states that worldview, private religious practice, and religious affiliations did not significantly predict moral injury symptoms. Jinkerson (2016) proposes that for MI to be identified, the following criteria must be present: (1) history of exposure to MIEs, (2) guilt, and (3) at least two additional symptoms, which may be drawn from either the core or secondary symptomatic feature lists. Jinkerson (2016) asserts that it is now possible to assess MI quantitatively with the delimitations and limitations that syndrome definition places upon MI identification. The Assessment of Moral Injury Jinkerson (2016) states that there are “no valid instruments that directly assess the full moral injury constellation” (p. 6) and, therefore, “individual symptoms should be measured independently” (p. 6). Therefore, the degree to which MI can be assessed accurately is contingent upon a summary of the various psychometric properties of the instruments utilized, complicating PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 36 its validity by not providing an assessment specifically for MI, which could be assessed for its psychometric property. There are currently two available tools that assess for MIEs, the Moral Injury Questionnaire – Military Version (MIQ-M) and the Moral Injury Event Scale (MIES). Moral Injury Questionnaire-Military Version. Currier, Holland, Drescher, and Foy (2015) offer an initial psychometric evaluation of a newly-developed Moral Injury Questionnaire-Military version (MIQ-M). The MIQ-M is a 20-item, self-report measure for assessing MIEs. The evaluation was conducted with a community sample of 131 Iraq and Afghanistan veterans and a clinical sample of 82 returning veterans. The results of the study provided preliminary evidence for the validity of MIQ-M as a measure of MIEs among veterans and other military personnel. The clinical sample yielded significantly higher scores across the MIQ-M items. The majority of the participants in both samples reported exposure to experiences identified in the MIQ-M items, with the exception of sexual trauma, which is likely due to low rates of reporting and did not yield favorable psychometric properties and was, therefore, excluded from the analyses. The highest endorsed MIEs were betrayal by leaders, betrayal of personal values, harsh treatment of civilians, and survival guilt. The analysis indicates that the higher scores correlate with greater combat exposure, impairments in work/social functioning, PTSD, and depression. The convergent validity analysis reinforced the usefulness of the MIQ-M as a tool to predict mental health risk factors. In addition, incremental validity indicates that MIQ-M results correlate with suicide risk and other mental health outcomes. Moral Injury Event Scale. Moral Injury Event Scale (MIES) is a 9-item self-report inventory (Nash & Litz, 2013). The nine items were subjected to the exploratory factor analysis, which reveled two latent factors that were labeled: (1) perceived transgression and (2) perceived PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 37 betrayal. These factors were confirmed via confirmatory factor analysis on an independent sample. The MIES scale, and the two subscales, have favorable internal validity and convergent validity, as well as good temporal stability. Initial discriminant and concurrent validity were also established. The Cronbach’s alpha (0.90) for the MIES showed excellent internal consistent reliability. The nine items are thought to be arise from four sources: life threat, loss, inner conflict, and wear and tear. Current Treatment Approaches for Moral Injury The four predominantly used treatment approaches for MI are: exposure therapy (Resick, Monson, & Chard, 2014), peer support therapy (Shay, 2011), spiritual-based interventions (Harris et al., 2015), and CBT-based therapy (Litz et al., 2009). There are currently no evidencebased treatments for MI, however, the U.S. government has generated – and is currently testing – interventions that focus on MI among veterans of war (Maguen & Litz, 2012). There are currently two such interventions: Impact of Killing in War (IOK) and Adaptive Disclosure (AD). The pilot testing is currently underway, and the preliminary data indicates significant improvements on overall psychiatric symptoms, depression, anxiety, greater community involvement, and the ability to share personal thoughts/feelings with others, compared to the control group (Maguen & Burkman, 2014; Burkman, Madden, Bosch, Dinh, Neylan, & Maguen, 2013). Most recently, Spiritually Oriented Cognitive Processing Therapy (SOCPT) was proposed as a way to integrate the CPT framework with pre-existing spiritual and religious resources of an individual; however, at this point only a preliminary version of the SOCPT is available (Koenig et al., 2017). Prolonged exposure. Although Prolonged Exposure (PE) and Cognitive - Processing Therapy (CPT) manuals do not mention moral injury (Maguen & Burkman, 2013; Steemkamp, PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 38 Nash, Lebowitz, & Litz, 2013) they have suggested strategies for addressing guilt and shame, to help clients conceptualize, rather than over-accommodate perceived culpability (Resick, Monson, & Chard, 2014; Smith, Daux, Rauch, 2013). Steenkamp et al. (2013) argues that the utility of PE as a treatment for moral injury is established on the assumption that the intensity of shame or guilt would respond in a manner identical to that of fear-based PTSD. It is further stated that this is not an empirically tested assumption. Peer support group. The use of peer support groups has been strongly advocated by Shay (2011). He proposes that peer support plays a key role in the central mechanism for recovery in moral injury. He believes this to be the protective benefit of cohesions, and goes so far as to say “[c]redentialed mental health professionals, myself included, have no business taking center stage in the drama of recovery for moral injury. We can be stagehands and bit players, but the real stars are the veterans who have walked in their shoes” (Shay, 2011, p. 185). Shay continues to argue that what is required for recovery is “a stable, trustworthy and safe community of other veterans that supports their safety, sobriety and self care. Recovery only happens in community” (Shay, 2009, p. 289). Spiritual based interventions. Harris et al. (2015) argue that spirituality can severely complicate recovery for individuals with moral injury. They argue that when both the situational and global meaning of higher power are disrupted, the patient must have holistic treatment which includes spiritual treatment and that this treatment is often more effective coming from a spiritual leader rather than a mental health therapist. Overall, because these men and women with moral injury are usually at developmental stages in their spiritual journeys, Harris et al. (2015) argue that it may be beneficial to review “the construct of moral injury through the lens of psychospiritual developmental theory” (p. 3). They argue that if the moral transgression challenges the PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 39 concept of Higher Power or spiritual worldview, questions from these deeply held beliefs can further spread into basic assumptions such as meaning, purpose, values, and/or worthiness of a Higher Power. All of these outcomes can lead to serious existential questions about meaning, worth, vocation, and personal faith. CBT based intervention. Litz and colleagues (2009) designed a modified CBT intervention, designed to address three principal injurious elements of combat: life-threat trauma, traumatic loss, and moral injury. They formed an approach that targets moral injury, which includes the following eight elements: (1) a strong working alliance and a trusting and caring relationship; (2) preparation and education about moral injury and its impact, as well as a collaborative plan for promoting change; (3) a hot-cognitive, exposure-based processing (emotion-focused disclosure) of events surrounding the moral injury; (4) a subsequent careful, directive, and formative examination of the implication of the experience for the person in terms of key self and other schemas; (5) an imaginary dialogue with a benevolent moral authority about what happened and how it impacts the patient now and their plans for the future or a fellow service member who feels unredeemable about something they did (or failed to do) and how it impacts his or her current and future plans; (6) fostering reparation and self-forgiveness; (7) fostering reconnection with various communities; and (8) an assessment of goals and values moving forward (p. 702). Spiritually oriented cognitive processing therapy (SOCPT). Koenig et al. (2017) sought to develop an individualized therapy that utilizes the existing spiritual and religious resources of the client to address themes such as loss of faith, spiritual struggles, and other MI symptoms. The intervention was specifically designed for those experiencing MI in “the setting of PTSD or sub threshold PTSD” (p. 4). SOCPT is manual-based, employing CPT as its PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 40 framework, and it will eventually be added to the standard CPT manual as part of an Appendix. SOCPT is a culturally sensitive modification of standard CPT that has been adapted to the spiritual beliefs of clients. The proposed treatment depends on whether or not the client is religious; in religious clients, MI may manifest by a change in religious faith or by a spiritual struggle. SOCPT focuses on correcting inaccurate interpretations of trauma by focusing on gradual exposure, processing, and cognitive restructuring using spiritual resources. The goal is to eventually challenge the maladaptive cognitive patters and address the stuck points. SOCPT does not always address guilt and shame as “erroneous interpretations of trauma” (Koenig et al., 2017, p. 150), but also as a reality that encompasses moral contexts and broader societal values. Such an approach may require confession and absolution within the individual’s faith community. Spiritual concepts, such as repentance, mercy, forgiveness, prayer/contemplation, surrender, hope, divine justice, and divine affirmations, are discussed as ways of engaging guilt, shame, anger, spiritual struggles, humiliation, and loss of faith. These therapeutic strategies are supplemented by powerful rituals involving “confession, penance, and faith community” (Koenig et al., 2017, p. 150) depending on what is appropriate for the individual’s spiritual beliefs and traditions. The goal of SOCPT is to minimize inner conflicts experienced by military personnel with PTSD and comorbid medical and psychological conditions. The results hope to assist force members and veterans in becoming better workers, family members, and citizens. Drescher et al. (2011) claimed that MI requires a unique therapeutic approach, arguing that because current evidence-based treatments are designed based on fear conditioning and extinction models, the treatments may be ineffective for helping service members who are struggling with moral conflict, rather than with fear. They concluded that a new approach and a PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 41 new set of interventions should be constructed to treat moral injury. Additionally, according to the research conducted by Yan (2016), MI plays an important role in both the physical and mental health outcomes. He underlined the need for an approach that incorporates discussions of existential and moral issues, given the significant impact that these factors have on mental and physical health. It would be beneficial to keep expanding the understanding of MI as a way to continuously adjust and develop treatments that specifically target and treat the complex nature of MI. Conclusion. The literature on moral injury is still limited, lacking a comprehensive and unanimous understanding of what moral injury is and how it is distinguishable from other similar constructs. The suggested prevalence of individuals who may encounter morally injurious events, and are therefore are at risk of developing moral injury, are significant. The current literature emphasizes the serious and potentially dire consequences of moral injury, and simultaneously illuminates the shortcoming of current interventions to address such consequences. Rationale for the Study The rationale for this study is twofold. First, this project stems from my personal experience with MI – a deep sense of self-loss, betrayal, and suffering – and my desire to further understand and uncover meaning within that experience. Second, this study aims to address several important gaps in this current research literature on MI, primarily focusing on gaining insight and understanding of the lived experience surrounding moral injury and expending the context outside the military population. Personal experience. When providing a rationale for a phenomenological study, the research topic should be relevant to the researcher’s own lived experiences – they should be drawn to a phenomenon which revealed itself to them, and which they chose to research as a way PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 42 to further uncover its meaning (van Manen, 2014). Moral injury had revealed itself to me within multiple contexts (war and intimate partner relationship). The phenomenon uncovered itself to me in a powerful and experiential way prior to me having any knowledge regarding the construct of MI. I began to note several unnerving dynamics within myself: I was changing, I was trapped and suffocating in intense anxiety and panic, I was dwelling in deep-emotional pain, I found very little purpose in life, and all of it was not acknowledged by others. It was triggered by my relationship, as I began to feel betrayed by my partner and the life we were living together. I began to feel betrayed by his unkindness and my reactions which did not resemble the person I thought I was. Slowly and almost inconspicuously, I was becoming a person that I swore I would never be, allowing myself to transgress what I believed was right – to sacrifice myself and my relationship with others – in an attempt to preserve my broken relationship out of a sense of religious obligation and not out of a desire for my well-being. I began to realize that although I was promising my partner a future and a repair of our fractured relationship, I knew, at my core, that it was a promise I would not be able to keep. I started to experience a deepening sense of guilt and shame for I began to face the reality that I was unable to and unwilling to stay in a relationship that although looked mundane in its normalcy, was toxic and forced a transformation of myself that would reflect who my partner wanted me to be and not who I was. As I began to feel broken, exhausted, and void of all life, I wanted to understand what was happening and if I was alone in this suffering. Likewise, as I began to heal and transform, I began to yearn to understand the unique and difficult process of becoming a more authentic self. It was my own lived experience with MI and the recognition of the suffering in others, which ignited my desire to conduct this research. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 43 Research gaps. In addition to the personal connection with the topic, while reviewing the literature on MI I noticed several important gaps. The current literature on MI successfully identified the complexity of the concept and its holistic impact. Unfortunately, the available literature does not clearly identify the subject and nature of harm (i.e. what or who is harmed in MI), the experience of MI, or propose a mechanism that has effectively and comprehensively explained the dire consequences of MI. Due to the aforementioned limitations, current interventions appear to be lacking an adequate and unique approach necessary for treating MI. These issues are to be expected and, indeed, welcomed, as the concept is evolving and being redefined on an ongoing basis. Although a comprehensive understanding of MI at this early stage is not anticipated, there are several research gaps worth noting and addressing. The literature proposes an impact that embodies spiritual/existential dynamics, yet, ironically, the current approaches for understanding MI are primarily cognitive and diagnostic, and thus reductionistic, in nature. To my knowledge, no research has yet implemented a phenomenological method of inquiry to try and understand the lived experience of MI in a more holistic manner. In addition, only two research studies on MI have been conducted outside the military context: (1) a study was conducted on MI and resilience among woman in a transitional living center (Chaplo, 2015), and (2) a study extending the construct of MI to interpersonal transgressions among emerging adults (Otte, 2015). Several researchers encouraged future studies to expand the context in which MI is being investigated to gain a more comprehensive insight into the construct (Bryan et all., 2014; Litz et al., 2009). PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 44 Aims of the Current Study This study aims to address two important limitations of extant research on MI: the context and the method. Specifically, this study expands the context of investigating MI to intimate partner relationships while focusing on exploring the lived experience using hermeneutic phenomenology as the research method. Context. MI has been researched and understood primarily within the realm of military experiences. However, it is very unlikely that the transgressions that lead to MI only occur within the military context. Bryan et al. (2014) and Litz et al. (2009) stated that MIEs are vast in their diversity and probably present in numerous circumstances. For instance, two recent studies have explored the construct of MI outside the military context. Chaplo (2015) studied MI with women exposed to homelessness, poverty, and IPV, and Otte (2015) conducted a first study within the youth populations. It is also probable that MI could occur in contexts such as: domestic violence, gang violence, divorce, death, intimate partner violence, first responders, etc. Therefore, in an effort to expand the scope of the current research on moral injury, this project sought to explore and understand the suffering of MI within the context of intimate partner relationships. ‘Intimate partner’ is defined as “a person with whom one has a close personal relationship that can be characterized by the following: emotional connectedness, regular contact, ongoing physical contact and/or sexual behaviour, identity as a couple, and familiarity and knowledge about each other’s lives” (Breiding et al., 2015). Rationale for studying MI in the context of intimate partner relationships. Even within the predominantly studied context of moral injury, the military, there are variety conceptualizations of why and how moral injury occurs. Shay (2014) stated that MI occurs when one experiences betrayal, in high-risk situations, by an authority figure. Litz et al. (2009) argued PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 45 that MI occurs following a transaction that severely contradicted one’s personal code of conduct, expectations, and rules. Jinkerson (2017) proposed that MI occurs when one’s moral beliefs are transgressed by themselves or someone he or she trusted. Due to a lack of theoretical cohesion within literature, it was important to find a population where all the hypothetical transgressions, or MIE, could occur. The current research explored intimate partner relationships as a suitable and likely context for such moral transgressions. Intimate relationships are where one practices beliefs and sets expectations, laying them on a perceived foundation of mutual trust. However, the unsettling and underreported statistics are that (a) emotional/physical/and sexual abuse affected roughly 97,500 victims of intimate partner relationships a year (Canadian Centre for Justice Statistics, 2015), and (b) more than 70, 226 divorces are processed a year (Statistics Canada, 2008). With various reasons provided for marital breakdown including adultery (3.7%-12.0%), mental cruelty (1.6%-5.6%) and physical cruelty (1.2%-3.6%) – it provided intimate partner relationships with a contextual complexity compatible for this research. Within such relationships many MIEs – where one encounters a transgression by self, transgressions by others, and/or betrayal (Wisco et al., 2017) – are possible. To ensure the potential for Shay’s (2014) proposed power dynamic within MI, it is important to note that research on abusive and non-abusive intimate partner relationships indicated a frequent presence of power discrepancy. Research on abusive relationships suggested one of the key factors to be an unhealthy power dynamic (Babcock, Waltz, Jacobson, & Gottman, 1993), and research among non-abusive relationships suggested a significant power discrepancy – with more than 50% of individuals reporting that he or she feels that the other partner has more power (Felmlee, 1994). PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 46 Overlapping consequences: MI and unhealthy intimate partner relationships. Shame and guilt have been discussed comprehensively within interpersonal trauma literature (Kubany, 1994; Lee, Scragg, & Turner, 2011), with particular samples such as IPV victims, combat veterans, and victims of sexual and physical abuse in childhood (Beck et al., 2015). All these samples are susceptible to numerous MIEs that could transgress one’s beliefs and morals about the world and oneself, evoke a sense of betrayal, and break an individual’s sense of trust in self and others. Given the strong emphasis on guilt and shame (Jinkerson, 2016; Litz et al., 2009) in the conceptualization of MI, it is not unexpected that MI was first studied in one of those populations, the military. However, there are a number of negative emotions reported as a consequence of such MIE in intimate partner relationships: shame, guilt, negative thoughts about the world, negative thoughts about the self, and self-blame (Beck et al., 2015), with a plethora of consequences which correspond to the symptoms of MI. These are: social withdrawal, suicide attempts, self-harming behaviour, negative thoughts about the world and self, and questioning self-worth. The overlapping consequences of MI and unhealthy intimate partner relationships can also be noted within individual accounts. The following quotes will assist in demonstrating the similarity of experience between individuals that have lived through wars and those who have suffered within various unhealthy or abusive intimate partner relationships. Without knowing the personal stories, I invite the reader to ponder the resemblances of such lived experiences: (a) “We are held hostages by our lives. We have no decent way out” (Tesanovic, 2000, p. 87). (b) “I am living in hell from one day to the next. But there is nothing I can do to escape. I don't know where I would go if I did. I feel utterly powerless, and that PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 47 feeling is my prison. I entered of my own free will, I locked the door, and I threw away the key” (Mirakami, 2011, p. 75). (c) “They’ll kill us eventually,” somebody said, “either psychologically or physically” (Tesanovic, 2000, p. 103). (d) “In situations of captivity the perpetrator becomes the most powerful person in the life of the victim, and the psychology of the victim is shaped by the actions and beliefs of the perpetrator” (Herman, 2011, p. 140). Method. Given the novelty of the concept of MI, to date, most empirical research studies conducted in this area are quantitative, with limited qualitative exploration, and no phenomenological exploration at all. To my knowledge, no research study has yet addressed the lived experience of MI, thus missing the subjective, personal, and experiential component of the struggle. A phenomenological exploration of the lived experience of MI may provide a richer and clearer understanding of how people suffering from MI experience their wounds. As a result, it could also aid the research in understanding the more experiential and spiritual components of MI. Research Question The purpose of this study is to examine the lived experience of MI by answering the following research question: what is the lived experience of moral injury in the context of intimate partner relationships? By using hermeneutic phenomenology, this study sought to explore the themes that encompassed the phenomenon of MI in an effort to uncover its essential characteristics, and to contribute to research literature on MI by being the first study, methodologically, and one of the first, contextually, of its kind within the area of MI research. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 48 CHAPTER 3: THE METHOD […] hermeneutics is a lesson in humility…it has wrestled with the angels of darkness and has not gotten the better of them […] now, it is not the function of […] hermeneutics to put an end to those games like a cold-blooded, demythologizing scientist who insists that the clouds are but random collections of particles of water […] its function is to keep the games in play, to awaken us to the play, to keep us on the alert that we draw forms in the sand, we read clouds in the sky, but we do not capture deep essences […] if there is anything that we learn in […] hermeneutics it is that we never get the better of the flux. (Caputo, 1987, p. 258) The primary purpose of this study was to gain a deeper understanding of moral injury (MI) by exploring the lived experience of individuals in the context of intimate partner relationships. To this end, hermeneutic phenomenology was employed to “attempt to accomplish the impossible: to construct a full interpretive description of some aspect of the lifeworld, and yet to remain aware that a lived life is always more complex than any explication for meaning can reveal” (van Manen, 1997, p. 18). Phenomenological analysis aims to bracket abstract and theoretical understanding of the phenomenon in an endeavor to identify essential and intrinsic properties of an experience (Wertz, 2005). Such an approach enabled an in-depth exploration of the individual’s experiences without interference. In the subsequent sections I will discuss the paradigmatic underpinning of hermeneutic phenomenology and the philosophical background and development of the method. Following, I will outline van Manen’s analytical strategies and describe the way each step was incorporated in this research project – data collection, data analysis, recruitment, sample size, and exclusion and PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 49 inclusion criteria. Next, I will address the methodological rigour and quality in this study. Finally, this chapter will conclude with a section on reflexivity. Research Paradigm It is difficult to place hermeneutic phenomenology within an existing research paradigm, as it is a method that pre-dated any scientific categorization. There are arguments that phenomenology research is pure description and that the interpretive phenomenology, such as hermeneutics, fits outside its limits (van Manen, 1990). Hermeneutic phenomenology is understood as “to the things themselves” (p. 184) – a paradigm cannot be found that captures hermeneutic phenomenology and its emphasis on uncovering meaning: it is only found within hermeneutic phenomenology itself. Ontological assumptions. Hermeneutic phenomenology positions itself in the basic premise that most truths are accessible only though inner subjectivity (Flood, 2010; Thome, 1991) and that the researcher is integral to the environment (Burns & Grove, 1999; Flood, 2010). Heidegger uses the term ‘life-world’ to express the notion that individuals’ realities are unvaryingly influenced by the world they live in. Interpretation and uncovering of meaning does not just enlighten one’s reality of what they have but of who they are (Flood, 2010; Heidegger, 1962/2004; Todres & Wheeler, 2001). One’s subjective reality is argued to be linked with social, cultural, and political contexts (Leonard, 1999). It can be concluded that one’s reality is fluid and continually in flux, however, one’s reality is constrained by the conditions of their daily lives (Flood, 2010). Epistemological assumptions. The epistemological assumption of hermeneutic phenomenology emphasizes on revealing meaning rather than than arguing points or developing an abstract theory (Flood, 2010). Knowledge is thought to be attained only by sharing and PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 50 uncovering common meanings of mutual history, culture, and languages of the world (Flood, 2010; van Manen, 1997). Phenomenological knowledge is argued to reform understanding (Grotty, 1998). Heidegger (1962/2004), argued that “all meaning, including research findings, are essentially interpretive. All knowledge, in this sense, is developed within a preexisting social milieu, ever interpreting and reinterpreting itself” (p. 26). An early student of Edmund Husserl and Martin Heidegger, Jan Patocka, stated that hermeneutic phenomenology needs to “…delve beneath the layer of the impersonal and bring out the originary personal experience. The experience of the way we live situationally, the way we are personal beings in space” (Patocka, 1998, p. 97). The Development of Hermeneutic Phenomenology J.H. Lambert, a German mathematician, coined the term phenomenology in the 18th century in an attempt to describe the science of appearances (Scruton, 1995). Despite the fact that the term phenomenology already existed, Edmund Husserl, a German philosopher and mathematician, is usually identified as the founder of phenomenology (Moran, 2000, p.1). For Husserl (1970), the phenomenological method represented a new science of the Being, a way of reaching meaning by transcending experiences, penetrating further and further, to discover the reality of the lived world (Bellefeulle, 2005; Valle, King, & Halling, 1989). Husserl saw phenomenology as a movement away from the Cartesian dualism of reality (Koch, 1995) and worked towards the development of pre-suppositional philosophy, which eliminates assumptions to the greatest extent possible, allowing the consciousness to be revealed in its essence (Bellefeulle, 2005; Koch, 1995). Hermeneutics is the “art of interpretation” (Inaba, 2006, p. 86). The term hermeneutics originated in the 17th century as a method of illuminating the meaning of texts, such as the Bible PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 51 and classical literature (Palmer, 1969). There are two assumptions underlying hermeneutics: 1) humans experience the world through language and 2) language provides both understanding and knowledge (Byrene, 2001). Hermeneutics strives neither to uncover understanding and meaning theoretically nor cognitively, but rather as a structure of “something as something” (Carr, 1987, p. 37). This means that the goal is to understand something as it is, not as it is perceived theoretically or cognitively; it can only be understood in the context of itself. The interpretation of hermeneutics is not a term of correctness; it is a means of uncovering hidden meanings, bringing what is concealed to the light (Palmer, 1969). Martin Heidegger (1962/2004), a student of Husserl, developed hermeneutic phenomenology and put forth an argument against Cartesian dualism by introducing the concept of Dasein, or “being-in-the-world”. This concept suggests that no subject is distinct from the external world, arguing that Dasein separates only when one attempts to theorize about oneself. Heidegger’s phenomenology argues that the world comes into existence by our participation in it (Heidegger, 1962/2004). Heidegger disputes Husserl’s beliefs regarding bracketing. Heidegger (1962) posits that in order to interpret experiences, one must participate in “being-in-the-world” (p.87). Heidegger’s philosophical focus, therefore, was fundamentally distinct from Husserl's. The latter focused on epistemology, while Heidegger’s concern was ontological in the sense that he strived to understand the essence of “Being” (p. 55). Heidegger maintains that to truly understand is the realization of Dasein (Gadamer, 1975), being aware and embodying being-inthe-world. The development of hermeneutic phenomenology was further supported by Paul Ricoeur (1995), who argued that the purpose of the approach is not to grasp the intentions of the PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 52 participants, but rather to find meaning in the text itself: to take the text as is, without any pollution of pre-conception. This concept is articulated concisely by Inaba (2006): […] we do not understand anything new until we understand it in a way that dramatically changes our perspective and new perspective is impossible unless we are able and willing to abandon our positions and risk our assumptions. With respect to this research, interpretation is not saying merely what the author intended, for to do so would be to stop short at the very point when true interpretation must begin. (p. 90) Ricoeur further argued that when the text is interpreted with no situation or intention, the interpreter can discover a possible mode of being-in-the-world. Hans Georg Gadamer (1975) elaborated on the topic of hermeneutic phenomenology as a research method by stating that its goal is for the researchers to place themselves in the situation so that they can better grasp the perspective of the individual. Gadamer argued that an interview is more than just a means of gathering data. Instead, it is a conversation that builds an alliance. The meaning is not presented directly, but is embedded and must be ‘wrestled’ with. Gadamer suggests that throughout the interview process, the questions serve two purposes: (1) to provide a sense of direction, and (2) to place that which is questionable into a particular perspective. Likewise, during the text analysis, the text is interpreted and questioned in order to gain deeper meaning. Gadamer (1975) states that the ultimate aim of hermeneutic phenomenology is to “reveal a totality of meaning in all its relations” (p. 471) and also emphasizes the importance of historical, cultural, and traditional understanding in all interpretation. Van Manen (2014) has developed a hermeneutic phenomenological research methodology that combines the phenomenological concern for describing the way-of-being-inthe-world with the hermeneutic concern for interpreting the social-symbolic world (Bellefeuille, PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 53 2005; Geelan & Taylor, 2001). Van Manen (2003) describes his method as inquiry that is “avowedly phenomenological, hermeneutic and somatic or language oriented” (p. 2). The following sections will describe van Manen’s method and the way it was utilized in this study. Hermeneutic Phenomenological Method To effectively utilize hermeneutic phenomenology, it is helpful to define some important terms. First, hermeneutic phenomenology is “a method of abstemious reflection on the basic structures of the lived experience of human existence” (van Manen, 2014, p. 26). The term “method” refers to the way or attitude of approaching a phenomenon. The term “abstemious” means that while reflecting on the experience the aim is to abstain from polemical, theoretical, emotional, and suppositional influences. To deconstruct its meaning etymologically, hermeneutic, on the one hand, means that “reflecting on experience must aim for discursive language and sensitive interpretive devices that make phenomenological analysis, explication, and description possible and intelligible” (van Manen, 2014, p. 26). Phenomenology, on the other, is separated into phenomenon which means “that which appears” and logos which means “word or study”. The key question posed in a phenomenological approach is “what is this or that kind of experience like?” (Inaba, 2006). Hermeneutic phenomenology differs from almost every other method, as its followers use it in an attempt to better understand the way people experience the world. Hermeneutic phenomenology aims to reflect on experiences while abstaining from theoretical, polemical, suppositional, and emotional intoxications (van Manen, 2014, p. 26). Phenomenology reflects on the pre-predictive or pre-reflective life of human existence. Hermeneutic phenomenology is driven by a pathos: “being swept up in a spell of wonder about phenomena as they appear, show, present, or give themselves to us” (van Manen, 2014, p. 26). As such, it is more a method of PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 54 questioning than answering – realizing that insight comes in the mode of musing, reflective questioning, and “being obsessed with the source and meanings of lived meaning” (van Manen, 2014, p. 27). Phenomenology is a search for the meaning of pre-reflective experience. To explain hermeneutic phenomenology, van Manen (2014) offered an explanation (p. 27): (1) phenomenological research begins with wonder at what gives itself and how something gives itself. It can only be pursued while surrendering to a state of wonder; (2) a phenomenological question explores what is given in moments of pre-reflective, pre-predictive experience - experience as we live through them; (3) phenomenology aims to grasp the exclusively singular aspects (identity/essence/otherness) of a phenomenon or event; (4) the epoche (bracketing) and the reduction proper are the two most critical components of the various forms of the reduction - though the reduction itself is understood quite differently, at times incommensurably, and sometimes contested by various leading philosophers and phenomenologists; and (5) phenomenological reflection and analysis occur primarily in the attitude of the epoche, the reduction, and the vocative2. In Being and Time (1962/2004), Heidegger explained phenomenology: […]to let what shows itself be seen from itself, just as it shows itself from itself. That is the formal meaning of the type of research that calls itself “phenomenology”. But this expresses nothing other than the maxim formulated above: “To the things themselves!” (p. 35) This study is not concerned with the questions of “how”, “why” or even a definite “what”. It focuses on encountering the complexity of the subjective experience itself. Due to the 2 “The vocative dimension of phenomenological method becomes especially active in the actual process of phenomenological writing. In the reflective process of writing, the research not only engages in analysis but also aims to express the noncognative, ineffable, and pathic aspects of meaning that belong to the phenomenon” (van Manen, 2014, p. 240). PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 55 structured nature of van Manen’s method of hermeneutic phenomenology, which will be further explored in this chapter, this approach will be utilized to conduct and analyze this study. Analytical Strategy: Steps of Hermeneutic Phenomenology For the purpose of this thesis, the phenomenological research followed the methodological structure provided by van Manen (2003). The thematic analysis proposed was not as a strict procedure that must be followed, rather “the method of phenomenology and hermeneutics is that there is no method” (van Manen, 2003, p. 30) and it is “pre-suppositionless” in its nature (van Manen, 2003, p.30). Van Manen offers a structure that is “a dynamic interplay among six research activities” (p. 30-31), which are the following: 1. turning to a phenomenon which seriously interests us and commits us to the world; 2. investigating the experience as it is lived, rather than by conceptualizing it; 3. reflecting on the essential themes which characterize the phenomenon; 4. describing the phenomenon through the art of writing and rewriting; 5. maintaining a strong, oriented stance towards the question; 6. balancing the research context by considering both the parts and the whole. These steps served as road posts for the way I conducted this research, which aimed to answer the question: “What is the lived experience of moral injury in the context of intimate partner relationships?” Step 1: Turning towards a phenomenon (Implicated researcher). Hermeneutic phenomenology is embedded in the idea that the researcher should “turn to a phenomenon which seriously interests us and commits us to the world” (van Manen, 2003, p. 30-31). And that is what I did. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 56 My encounter with moral injury started before I was even young enough to fully recognize my suffering. By the age of nine, I had lived through two wars – the NATO bombings of 1999 being the first tangible experience. I watched human beings transform into vessels of suffering, driven by desperation into an instinctual state of survival and blurring lines of humanity. It was a transformational experience that forced me to grow up and to change. It was the end of my childhood and of my sheltered naiveté. I became a survivor. I wish I could say that growing up in a war-zone was my only encounter with MI, but unfortunately, it was not. I experienced moral injury later in life in a much more abrasive, impactful, and painful way within the context of an intimate partner relationship. Feeling betrayed by my partner as well as betraying what I understood to be true about myself and relationships, I had to stare at this experience as an unavoidable truth of my reality. The encounter. The most recent and salient encounter occurred in the moment I woke up from my deeply desired denial of my suffering during a memorable visit to St. Martin-in-theFields Cathedral several years ago. It was quiet. The only things that filled the cathedral were occasional hush whispers, slow footsteps, and the smell of overpowering incense. People moved around with a deep sense of reverence and contemplation. I sat on the hard pew in the back, having just enough light illuminate from the candles to see my surroundings as the grey clouds blocked sunlight from penetrating the windows of the cathedral. It was dark, and within minutes, I was one of the only people there. I cannot seem to recall the interior of the cathedral, yet my experience of it has been imbedded in my being ever since. I just sat there, experiencing. It was as if the flood gates of my unconscious, of my whole being, started to speak to me. Or rather, it was as if for the first time, in a long time, I was still and willing enough to listen. I became mesmerized and alert; I was present and in a state of self- PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 57 transcendence. I began to experience glimpses of the grandeur of God and with it, in contrast, the Devil. They were both present and one made me deeply experience the other. Suddenly, I became aware of my sorrow and fear that I had been hiding for so long and with it joy that I did not know how to embrace in the presence of my suffering. I became aware of my purity, my sinfulness, my sacrifices and my transgressions; I became aware of myself. I felt compelled to hide, yet I craved to confess; confess to God, confess to myself. I was not sure what I wanted to say, but I wanted to apologize for the emptiness I was feeling because I deserved better. I wanted to cry out of despair for I suddenly noticed the abyss and brokenness within me. I wanted to beg for redemption and a way out of my life. This was the first time I became blatantly aware of the depth of my own distress; this was the first time I encountered the phenomenon of moral injury. It was not how I have pictured suffering; it was a lot subtler and refined. Perhaps not even always subtle, but it was presented in the way I did not initially acknowledge. I always thought I would know when I was suffering, but somehow, I was unaware for years. The experience transformed me into a helpless victim, without any signs of warning. I slowly started to perceive the restrictions, the oppression, the coercion committed by my partner. I realized that the way I dressed, the functions I attended, the people I was with, and the free time I had all belonged to him. I felt as if I was walking on eggs shells trying not to disrupt the fragile equilibrium that held the relationship. This fear evolved into becoming submissive to daily routines and predetermined future plans that were given to me. I began to feel suffocated and claustrophobic, but any attempt to break free was overpowered by intense feelings of guilty and manipulating words which made me question my very feelings, thoughts, and sanity. My voice was stifled and any attempt for agency was twisted into a form of perversion. Given my partner’s coercion and my insecurities, I felt like my desire to escape was wrong, sinful, immoral, and that such a desire was caused by PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 58 my weakness and immaturity. My Christian values held me chained, and my shame kept me from reaching out for help. I began to notice that it was difficult to even rely on myself for I became aware to the transgressions I have committed myself (self-betrayal, self-silencing, selfcompromise, etc.). I was lost, hurt, and isolated for such a pain was not easily explained or acknowledged by others. It haunted the way I made decisions, the way I encountered myself and the world. It desecrated my innocence and filled me with guilt, shame, and anger. It created a sense of fear and distrust towards humanity and myself and it trapped me in intense anxiety. This experience left me feeling shattered, forcing me to pick up the pieces and motivating me to reexamine who I was as a person. My experience of moral injury led to the genesis of this project, and although it is one of pain and suffering, it is also a journey of inspiration and transformation. I quickly recognized that this experience was not inimitable to me. It was difficult to name this experience, but I often found myself in conversation with individuals sharing my suffering. I began to wonder, how were others impacted by this shared suffering? How did others heal? What was the transformation like for them? And, how have they embodied the experience? I hoped that by answering these questions and uncovering the lived experience of MI my understanding would grow, I would be better able to help as a friend and therapist to the many hurting, and that I would be able to raise awareness to the reality and spectrum of human suffering. Step 2: Investigating the lived experience (Data collection). Data collection occurs by conducting in-depth interviews (Lopez & Willis, 2004). As the principle researcher, my role during the interviews was to maintain an openness to the individual experiences, and keep myself and the participants oriented towards the research question (van Manen, 1990). The semistructured interviews (Appendix E) were conducted face-to-face, allowing the client to determine PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 59 when he or she was done sharing his or story (with a limit of 2 hours). The interview started with a quick (10-15-minute) review of the informed consent form (Appendix A), which was then discussed and signed. Following the informed consent being signed, an audio-recording device was turned on. It is important to note that three of the participants engaged in two interviews, instead of one. This decision was made as a way to enhance my data collection because of the complexity of the topic, the vastness of the experience, and my novelty with the phenomenological method. According to van Manen (2014) “a phenomenological question may arise any time we have had a certain experience that brings us to pause and reflect” (p. 31). As such, significant flexibility was desirable for this process. The interview was meant to encourage an interactive, open, reflexive, and engaging discussion that is congruent with phenomenological inquiry (Kvale, 1996; van Manen, 2003). I sought to embody an “attitude or disposition of sensitivity and openness: it is a matter of openness to everyday, experienced meanings as opposed to theoretical ones” (van Manen, 2002, p. 1). The data collection was a co-creation between the participant and myself, bringing to life the experience being explored (Laverty, 2003). Therefore, flexibility was needed and desired; the participants were encouraged to reflect and take their time to explore experiences and meanings. The process was concluded with a debriefing session immediately following the interview (Appendix F). This was done for the purpose of ensuring that the individual felt comfortable with the information being used for the analysis, and to ensure that the participant felt grounded and well after the interview. This allowed me an opportunity to explore if any precautions/risk assessments needed to be conducted, and to remind the participant to make use of the counselling resources (Appendix B) provided to them if they felt distressed. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 60 Confidentiality. Many steps were taken to ensure confidentiality and anonymity of all the data. The pre-screening and screening material were made in hard copy. Immediately once the pre-screening and screening interviews were completed the material was shredded for such interviews contained a significant amount of identifiable information and because the assessments conducted were not done for a diagnostic reason, but rather for inclusion and exclusion purposes. Each semi-structured interview was audio-recorded, and all the transcripts were typed by the researcher by the assistance of the audio-recording, and electronically stored with all the files encrypted and password protected on a USB stick. The audio-recording files were encrypted and saved on a password protected USB that was locked in a house safe with the hard-copy informed consent forms. The identity of the volunteers was left anonymous; each participant was assigned an alias under which all information was filed, with all identifying information omitted as a way to further protect his or her identity. Complete records of the participant's interviews were preserved and secured for the duration of the project, and for five years following the project. All the data retention and privacy protocols will follow the ethical guidelines of the M.A. Counselling Psychology program at TWU. Steps 3-6: Data analysis overview. During the data analysis process, I followed van Manen’s (1997) hermeneutic phenomenological method – steps three to six. This was not a linear process, rather a cyclical one where each step was revisited multiple times and in no particular order. The interpretation revealed itself as the data was read and re-read, and as all the analyzers reflected on and considered the meaning. Upon completion of the data collection interviews, I transcribed all seven interviews by listening to the audio recordings. Each interview was transcribed verbatim, typing both what the researcher and the participant said. While transcribing, I would pause to insert any body PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 61 language that I remembered during the interview, any emotionality detected in the participants’ voice, and pauses. This process allowed me time to slowly and cautiously dwell on the words being spoken, evoking reflection which I began to note. Following the full transcription of an interview, I would listen to the audio-recording one more time to ensure the accuracy of the transcription. I transcribed one interview at a time, immediately following each encounter with the participant as it allowed me time to immerse myself in each lived experience without simultaneously being pulled into other accounts while transcribing. Step three: Isolating themes. In preparing for isolating themes, I began to ask myself, “What is going on here? What is this an example of? What is the essence of this experience and how can I capture it by way of thematic reflection?” (van Manen, 1990, p. 86). In order to isolate themes in the data, I followed van Manen’s (1990) methods: 1) Reading the text as a whole and identifying significant sections. 2) Selective or highlighting approach: Highlighting the words and phrases that are essential to the phenomenon being explored. 3) Reading each line individually and reflection on what it is saying about the phenomenon. I utilized all three thematic analysis approaches, and as a novice researcher, I engaged in a “collaborative analysis” (van Manen, 1990, p. 100) with my thesis supervisor whereby “hermeneutic conversations of the themes and thematic descriptions of phenomenon may also be conducted by a research group or seminal – these are too helpful in generating deeper insights and understandings” (p. 100). The themes uncovered assisted in approaching the core of the experienced and describing it. Van Manen (1990) states that: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 62 Themes are the stars that make up the universes of meaning we live through. By the light of these themes we can navigate and explore such universes. Themes have a phenomenological power when they allow us to proceed with phenomenological descriptions. (p. 90) The themes that I encountered served as a corner stone of my phenomenological writing process. Step four: Writing and rewriting. Writing is not merely the product of method, rather, it is the primary part of the research activity and reflection (van Manen, 1990). As a “method without techniques” (van Manen, 2014, p. 131), the analytical process involves a continuous immersion and seeking of the phenomenon, encompassing thinking and reflecting, writing and re-writing, the phenomenon being explored. After a highlight analytical process, the findings – the final themes – have been described in a form of phenomenological writing. The written text was intended to be rich, engaging, deep, transformative, and transparent (Palandra, 2015; van Manen, 1990). It is only within the process of writing and re-writing that the true description emerged and began to illuminate that meaning of the experience. Van Manen (1990) stated that “the purpose of phenomenological reflection is to try to grasp the essential meaning of something” (p. 77); although, van Manen (1990) also claims that no theme can ever capture the entirety of the whole lived experience. During this process, I began to engage in phenomenological writing as a way to grasp the essence, and the themes within the essence. Simultaneously, I used a journal to reflect my thoughts, experiences, and encounters with the participants in a way to gain a rich and engaging text. Step five: Remaining oriented towards the question. Van Manen (1997) stresses the importance of remaining a stance towards the question of inquiry. This is important as it PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 63 maintains a focus on the phenomenon that is being in question, rather than being sidetracked. In an attempt to remain oriented towards the phenomenon of moral injury, I would continually ask myself “what does this theme, or section of phenomenological writing, uncover regarding the essence of moral injury?” Journaling assisted the process, as it allowed me to express all the questions and reflections I had and narrow down the ones relevant and oriented towards the phenomenon. Step six: The parts and the whole. The final step of the hermeneutic phenomenology is to consider the parts and the whole (van Manen, 1997). The interpretive process of considering the parts and the whole can be achieved through a hermeneutic circle (Laverty, 2003). The Hermeneutic circle moves back and forth from the parts of the experience, to the whole of the experience to increase the depth of engagement with, and the understanding of the texts. The end of the spiraling motion through the hermeneutic circle is thought to occur when one reached a place of sensible meaning that is free of contradictions – for the time being (Kvale, 1996; Laverty, 2003). This process involved co-creation of meaning, as the researcher and participants worked together to bring life to the phenomenon being explored through the hermeneutic circle, imagination, and devotion to language and writing. During this process, I invited the research team (a group of 5 people), as well as the participants, to read over the phenomenological writing and provide feedback on how it resonated with them. The feedback received was than incorporated in my next process of writing and re-writing. Recruitment, Sample, and Participants Recruitment and sample. “A good talk happens between people who experience a special affinity of attainment to one other - and not only to each other, but also to their shared PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 64 world” (van Manen, 2014, p. 36). The shared experience/world enriched the phenomenological process of the inquiry, thereby, creating a unique opportunity to produce a deeper understanding of MI. As such, the participants for this study consisted of individuals who have encountered MI through the experience of intimate partner relationships. “An adequate sample size in qualitative research is one that permits […] the deep, caseoriented analysis that is a hallmark […] that results in new and richly textured understanding of experiences” (Sandelowski, 1995, p. 182). The validation of phenomenological inquiry is not gained by numbers, rather by the fullness, depth, and completeness by which the examination and interpretation extends understanding (Smith, 1991). The amount of data deemed to be sufficient is subjective; however, van Manen suggests a size between four to six (van Manen, 2014, p. 40). In phenomenology, it is not the quantity of people, rather the quality of the interview. Given the circumstances of this study, such as time, resources, and depth desired, the I deemed a sample size of four to be appropriate. Although four is a small sample size, the participants each have experienced environments and situations that helped further explore the concept of MI (Sandelowski, 1995; van Manen, 1990). Given the intimate nature of the study, and the small sample size needed to conduct an intensive qualitative research method (hermeneutic phenomenology), word-of-mouth and inperson recruitment strategies were used. The in-person recruitment strategies consisted of my contacting friends, family, and leaders in my church community, letting them know I was recruiting for a thesis project by briefly explaining what I was looking for. As a way to ensure the appropriateness of the volunteers for this study, the following inclusion and exclusion criteria were implemented. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 65 The duration of the recruitment phase was two weeks. All of the interested volunteers contacted me via email to set up a pre-screening interview date, which occurred within two weeks from the day of initial contact to ensure that recruitment and pre-screening phase did not surpass a one-month period. The willing volunteers (a maximum of four) were engaged in a 30minute pre-screening interview conducted via telephone (Appendix C) that was designed to ensure that the participants are appropriate candidates for the study of MI. During the prescreening interview, I introduced myself, the purpose of the study, and offered a quick overview of my own lived experience of MI. The screening interview was immediately conducted during a one-hour telephone interview upon the volunteers’ request. The following inclusion and exclusion criteria was used to guide the pre-screening and screening interviews. Inclusion criteria. For the purpose of the proposed research both genders were recruited to fit the following characteristics: (1) age 19 +; (2) currently living in Canada; (3) have been a part of an intimate partner relationship; (4) relationship occurred after age 19; (5) no longer in the relationship and feel safe (Appendix C); (6) report suffering consistent with MI. To ensure that the participants experiences consistent with MI, the participants underwent a pre-screening interview with identifying questions altered from the Moral Injury Events Scale (MIES) and from presently available research on MI (Appendix C). In Part I, the individuals answered negatively to the first two questions, and answered affirmatively to the last two questions. Furthermore, the participants answered affirmatively at least four out of the seven questions in Part II before being considered a suitable candidate for the study. Exclusion criteria. For the purpose of both conducting methodologically rigorous research and minimize potential risks to the participants, there were several key exclusion criteria: participants who were experiencing (1) severe acute anxiety, (2) suicidality, (3) major PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 66 depressive episode, or (4) dissociative identity disorder were excluded from the study. The assessment tools and the cut off scores used for the screening purposes are discussed below under “measures”. No diagnostic information was disclosed to the participants, for the prescreening process did not constitute as an official assessment/diagnosis. Rationale for the recruitment criteria. The employed inclusion criteria were motivated by the goal of gathering relevant and accurate data while minimizing additional variables and limiting potential risks for the participants. The inclusion criteria aimed to bypass any potential developmentally impactful experiences that could arise from the participants’ having encountered MI before age 19, as well as eliminating a possibility of addressing MI within child abuse. Moral injury has not yet been studied within a child population; thus, there is no data to identify how MI would manifest in children. Additionally, the participants were required to no longer be a part of the relationship in which they have experienced MI as a way to lower potential risks and promote safety for the participants. The individuals were required to live in Canada as a way to conduct face-to-face interviews, be able to provide relevant client resources (Appendix B), and be able to engage in a suicide protocol in case of emergencies (Appendix I). Lastly, both male and female participants were recruited for the purpose of diversity. The exclusion criteria were put in place to ensure that the researcher is exploring the concept of MI and not another psychological disorder/phenomenon. The exclusion criteria were also in place to protect the participants, as it aimed to ensure that only volunteers who had the capacity to encounter his or her lived experience without significant risk or harm were permitted to participate. Screening measures. The assessments being used in the study were conducted during the screening procedure (Appendix D). They include PC-PTSD, Columbia-Suicide Severity Rating PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 67 Scale – Screen Version, Generalized Anxiety Disorder 7 – item scale, and the DSM – 5 Diagnostic Criteria for Acute Stress Disorder (ASD), Dissociative Identity Disorder (DID), and Major Depressive Episode (American Psychological Association, 2013). Each measure had the following cut-off score used for the screening purposes of this study: 1. PC-PTSD - score of 3 2. Columbia-Suicide Severity Rating Scale- Screen Version - score of 1 3. Generalized Anxiety Disorder 7-item scale - score of 15 4. DSM- 5 Diagnostic Criteria for: 1. Acute Stress Disorder – meeting Criteria A: one or more, Criteria B: nine or more; 2. Dissociative Identity Disorder – meeting any criteria from A-E 3. Major Depressive Episode – meeting any criteria from A-E The screening interview assessed for Acute Stress Disorder and PTSD; however, this is neither part of the inclusion nor exclusion criteria. The purpose of distinguishing clients that meet the diagnostic criteria for ASD and PTSD was to inform the researcher about the vulnerabilities the client may have. The rationale for the screening tools mentioned above was to ensure that the participants were not vulnerable to experiencing negative reactions to the interview process. The cut-off scores presented are in place to screen for severe pre-dispositions that would indicate that the individual’s well-being should not be jeopardized by the interview process. Anxiety, depression, suicidality, and dissociation are all potential side effects for someone who has lived through MI. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 68 Participants In this study, three participants3 were interviewed. Participants’ ages ranged from 45 to 78. Two of the participants were male, and one female. Two of the individuals were Caucasian and one was Hispanic. The participants identified with varying worldviews; one individual selfidentified as Christian, one individual self-identified as an Atheist, and one person self-identified as spiritual. All the participants are currently employed, one being on a paid medical leave. The participants in this study self-identified as suffering from MI, which was confirmed during a prescreening interview. All the participants experienced MI in intimate partner relationships, primarily through emotional abuse and infidelity. Tom and James reported being victims of infidelity, James self-identified as a perpetrator of adultery, and Anne was part of an emotionally abusive intimate relationship. All participants reported that the intimate partner relationships were marital relationships, at least at some point during their experience. Lastly, all participants reported ending these relationships due to the suffering associated with moral injury. A more personalized and in-depth introduction of the participants and their stories will be provided in chapter four. Methodological Rigour According to de Witt and Ploeg, (2006), the application of a standard set of qualitative criteria of rigour for hermeneutic phenomenological studies is problematic because its philosophical underpinnings are inconsistent with the methodology. In an attempt to preserve the legitimacy and integrity of interpretive phenomenology expression of rigour, de Witt and Ploeg (2006), proposed a framework by drawing upon the works of van Manen and others. 3 For the purpose of this thesis three individuals were interviewed. However, one participant provided two interviews and two separate accounts of moral injury – of being a victim and a perpetrator. I used two different pseudonyms in an effort to protect their anonymity and confidentiality. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 69 Specifically, de Witt et al. (2006) suggested five expressions of rigour: (1) balanced integration, (2) openness, (3) concreteness, (4) actualization, and (5) resonance. In the following section I will define each expression of rigour and provide examples of how I have implemented such expressions to ensure the integrity of my research. Balancing integration. Balancing integration is characterized by (a) articulation of the general philosophical theme and its fit with the researcher and the research topic, (b) in-depth intertwining of philosophical concepts within the study methods and findings, and (c) a balance between the voices of the study participants and the philosophical explanations (de Witt & Ploeg, 2006). Therefore, during the research process I was mindful to integrate the voices/experience of the participants, my own responses, and works of authors to gain a fuller understanding of the experience of MI. Openness. Openness is characterized as orientation and attunement towards the phenomenon of inquiry that the researcher adopts and sustains throughout the research process (De Witt et al., 2016), a process congruent with step one of van Manen’s hermeneutic phenomenological method. It is an explicit process of accounting for the multiple decisions made throughout research procedure. For example, during the research process, I have made it explicit how I came to choose the topic, how and why I recruited the selected participants. In addition, I kept a journal of how each shared experience has changed or impacted my previous understanding of the phenomena. Concreteness. Concreteness relates to the practicality of the study findings. De Witt and Ploeg (2006), described concreteness as “findings [that] are written in such a way that examples are given that situate the reader concretely in the context of this phenomenon and also link with experience in their lifeworld” (p. 225). This concept corresponds with van Manen’s (1997) PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 70 expressions of lived thoroughness and contextuality. Lived thoroughness embodies the features of the phenomenological texts that connect the reader to a phenomenon in the context of everyday life. Likewise, contextuality refers to the historical and cultural context (or everyday life world) from which the reader will engage the author’s work. I offered rich, in-depth descriptions of the participants’ experiences and the context in which the phenomena unfolded as a means of enhancing the usefulness of my findings. Actualization. Finally, “actualization encompasses future realization of resonance of study findings” (De Witt & Ploeg, 2006, p. 226). Phenomenological interpretation does not cease once the study is completed, rather, it continues to be interpreted by the readers; therefore, the future holds the potential for an affirmation of the interpretation. In the light of this, my desire is to invite the readers to engage in their own interpretative process. Resonance. Resonance is understood as “the experiential of felt effect of reading the study findings upon the reader” (De Witt & Ploeg, 2006, p. 226). It is described as a moment when understanding meaning of the text is compared and contrasted with self-understanding. Van Manen (1997) further described the experience as an arresting, moving experience that is deeply apprehended. In an attempt to ensure such an experience, I allowed myself to be moved by the individual experiences, to dwell in the intensity of the phenomena, and to use my own lived experience and intuition to engage in the phenomenological writing process. It is my hope that when the findings are read, the reader will be able to experience the lifeworld of the participants by deeply connecting and being moved. Additionally, a resonance check has been conducted with all the participants as well as the research team members. The participants’ and research team members’ resonance checks will PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 71 further be elaborated in chapter five following the phenomenological writing which will first provide the reader with the necessary context for the feedback. Van Manen’s rigour criteria. In addition to the five expressions of rigour (de Witt & Ploeg, 2006), van Manen (2016) advises the utilization of the following criteria when evaluating the rigor and quality of a phenomenological writing: Heuristic questioning: Does the text induce a sense of contemplative wonder and questioning attentiveness? Descriptive richness: Does the text contain rich and recognizable experiential material? Interpretative depth: Does the text offer reflective insights that go beyond the taken-for-granted understandings of everyday life? Distinctive rigor: Does the text remain constantly guided by a self-critical question of distinct meaning of the phenomenon or event? Strong and addressive meaning: Does the text ‘speak’ to and address our sense of embodied being? Experiential awakening: Does the text awaken prereflective or primal experience through vocative and presentative language? Inceptual epiphany: Does the study offer us the possibility of deeper and original insight, and perhaps, an intuitive or inspirited grasp of the ethics and ethos of life commitments and practices? (pp. 355-356). The criteria described above was kept in mind at all times throughout the research study. The resonance checks also allowed for these expressions of rigour to be questioned and assessed. Reflexivity. Reflexivity is a critical component in conducting hermeneutic phenomenology (van Manen, 2014) because the researcher is always personally implicated in the journey of uncovering a phenomenon, and the phenomenon uncovers itself within the researcher. In the next few paragraphs, I will describe what this process was like for me, and how it shaped my research process. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 72 I grew up in a quaint town in former Yugoslavia known for its archeological digs of the Roman ruins. It was located on the river Sava, and for a small town, it was dense with marvelous architecture and Serbian-Orthodox cathedrals. Maybe this exposure was the reason why I grew up fascinated with the architecture of cathedrals and why as a child, I would seek out streets from the music academy that would cross the town square, giving me an opportunity to gaze at the town’s largest cathedral on my way home. This large building also served as my lighthouse, my sign post, to finding my way home. My house had a yellow exterior, big copper gate blocking any sight of our backyard, and large weeping willow tree that hung protectively over our garden. It was only two blocks away from town’s central cathedral, fading in its stark simplicity. As I passed the cathedral, I would often marvel at its high arches, its two large bell towers, and its tall fortified doors. I remember thinking it was the most grandiose thing I have ever seen, yet I often felt uncomfortable and threatened by its structure and its mystery. My parents never took me inside the cathedral as a kid for they did not believe there was anything particularly spiritual or inimitable about it. One Sunday afternoon, following a mass, as my family and I passed the cathedral its doors were open. I remember standing at the threshold as my eyes adjusted to the darkness and my body braced against the cold air. I became enveloped in eeriness and awe as the hypnotic chants of the priest filled the space and mesmerized me. That salient memory was since concealed by memories of war that shortly followed the experience. However, this was precisely the memory that emerged as I began to uncover the phenomenon and experienced the phenomenological process. I felt the familiar allure of vastness, its mesmerizing and incomprehensible depth, the eeriness that was interwoven in the experience of suffering, the threat of the unknown, and the sense that I was encountering something greater, more powerful, and more spiritual than myself. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 73 People enter the cathedral for many reasons, often with reverence seeking salvation, truth, and light. Many expect to encounter God without knowing what that experience would, or should, be like. Similarly, I entered the world of phenomenology blindly and humbly without knowing what the encounter with the phenomenon would be like. I willingly entered darkness to allow the light to illuminate something much greater than I, something that was potentially threatening and all-consuming in its darkness. As I took the first step I was unaware of how dark it could get nor what the phenomenon would ask of me. Just like many, all I knew was I was seeking an encounter; I wanted to encounter human suffering. It always takes time for my eyes to adjust to the darkness within the cathedral, and as my mind and spirit adjusted to the process of uncovering the phenomenon, I often felt lost and confused as to what I was looking for. It’s as if I saw too much at once but without any understanding of what it was or what it stood for. I initially encountered anger and self-loathing. Often facing the splendor of the cathedral made me quietly enraged for it made me feel insignificant and small, pointing out my inner darkness in comparisons to God’s glory, making God appear even more distant than before. Gradually, I began to discover the anger that was deeply rooted within me. I also began to note that the anger was no longer solely directed at others, but rather at myself and the role I have taken in my suffering. I began to recognize a sense of self-loathing for not looking after myself or being true to who I am, for coping with my suffering instead of walking away from the injustice. This awareness became unescapable as the experiences of others acted as a mirror to my own reality. In a cathedral, I would often be humbled by a sense of spirituality, yet be tortured by the reality that this strong sense of conviction in God was not everyone’s truth, or perhaps reality at PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 74 all. I would often watch faces of other tourists as they quietly walked around the cathedral, some with contemplation, some with reverence, and some with boredom. Similarly, I began to navigate the experience of my participants realizing that although a sense of morality was present in their journeys, it was unique for each individual. I began to question my morality, realizing that even for my ex-partner, the experience of “rightness” or “wrongness” within the relationship would be different. I grappled with what that means and began to notice how little I truly understood my own journey. Similarly, as the numerous themes uncovered themselves, I began to realize how little I understood the phenomenon of moral injury. Initially, the more I saw the more I realized how little I knew. As I navigated the dark waters of the phenomenon trying to stay afloat, I began to realize that the experience encompassed a suffering, a perception of death, and an experience of regaining vitality, a process that closely resembled that of Christ’s death and resurrection. This discovery evoked in me overwhelming feelings, for I began to experience something spiritual. I began to understand Christ as the architype of all suffering. Immersing myself in the phenomenon was like standing in front of the cross where Jesus died, like standing humbled in front of the crucifix at a cathedral. I marveled at numerous parts of the cathedral – architecture, paintings, statues, geometry – without understanding their connection to God. I eventually learned that to understand God I had to experience Him. Likewise, to see the phenomenon I had to experience it. As a child, I experienced the cathedral without trying, yet, as an adult I was resistant to being open. I soon recognized that it took willingness and a form of self-sacrifice to be attuned and surrender to the process. It was difficult to surrender to the process for I was searching in the dark for an object I have only seen glimpses of. It seemed absurd, scary, and at times, impossible. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 75 Ironically with deeper understanding came a new darkness. At times I felt discouraged, for the closer I got to the phenomenon the blurrier it became. I had to learn the dynamic process of approaching and distancing myself, a dance in which phenomenology led me. This was not a linear moment within my process, this was a cyclical occurrence. As if with the more hours I spent contemplating the cathedral the night would inevitably come removing me from the experience. The darkness triggered the very phenomenon of suffering, but with it, induced feelings of anxiety and panic. I was initially not comfortable with the darkness as it reminded me of the self-estrangement and helplessness that enveloped me during my suffering. The process of searching, searching with uncertainty and sense of failure, was too familiar and too triggering but it eventually became healing and transformational. Engaging in phenomenology was a much more impactful and difficult process than I have anticipated; it required of me to recall and dwell in the suffering and the darkness that was within me. By encountering my participants, I was moved in unexpected ways. I became aware of the things I suppressed or was still unaware of in my process. It pushed me towards vulnerability to be more honest with myself. I found anger, distrust, and conceptualizations of myself that I needed to let go. It allowed me time to be still in the pain and my darkness as a way to integrate it into who I am today. It was that process that opened my eyes to the richness of the dynamic of becoming, or forgiving, and of the reconciliation that evolved openness to the process. It was only when I was willing to face my own process that I was able to start seeing the essence. Abbe Suger wrote, “the pictures in the windows are there for the purpose of showing people who cannot read the Holy Scriptures what they must believe” (as cited in Stemp, 2010, p. 36). Just like the stories painted on the stained-glass windows, I believe that my life story and the story of each of my participants has shown me what I must believe regarding the phenomenon. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 76 They illuminated themes and poured light into the space that contained moral injury. It was hard to deny the truth of the phenomenon when it so deeply resonated with me. During my process of writing the results and putting words to the lived experience, I was travelling through France and visiting as many cathedrals as possible. I would sit there waiting for the cathedral to speak to me. Often while sitting in a cathedral my eyes would be drawn to the light penetrating the stained glass surrounding the architecture. Abbe Suger (1081-1151), known as the father of Gothic architecture, explained the intent behind stained glass windows as the use for the “most radiant windows to illumine men’s minds so they may travel through it to an apprehension of God’s light” (as cited in Rose, 2001, p. 76). Likewise, during the process of phenomenology I experienced an illumination of my own flaws, insecurities, wounds, strengths and self that ultimately paved my journey of phenomenology and apprehension of the phenomenon. Turning towards it was difficult and when I would try to impose myself on it, it became quiet – patiently waiting for me to settle down and quiet the ruckus of my mind. It was difficult to remain attuned to myself and conduct resonance checks. At times, I struggled to accept the experience as it was being presented, and in other instances, I had to be intentional about dwelling in the darkness for it was showing me things I did not want to see. With time, my own experience and focus changed towards healing, making it more difficult to remember and dwell in the darkness that I worked hard to leave behind. All the themes deeply resonated with my own suffering and experience of transformation. The most powerful resonance was felt as the beautiful symbolism of water emerged – representing the fluidity and power encompassed throughout the experience. It deeply describes the beauty and danger of the experience, for it could have led me to the all-consuming darkness and hopelessness, but instead, it empowered me to be the woman I am today. The journey was PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 77 truly one of confusion and threat for I did not know how to seek refuge – like being stranded in the stormy ocean I was beginning to give up hope that I would ever feel vitality and encounter the wonder of life again. Due to my own process of healing, the theme of reconnecting is still something I am exploring. This process has provided me with uncovering deeper meaning, yet I believe I am still gathering the lessons I have learned. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 78 CHAPTER FOUR: THEMATIC MEANINGS This chapter presents the thematic meanings emerging from the phenomenological exploration of the lived experience of moral injury in the context of intimate partner relationships. The chapter is structured in two parts corresponding to the process of phenomenological analysis: the elaboration of participants’ facticity (Heidegger, 1962/2004) and personal history (Koster, 2017), and the eidetic analytical process of distilling the thematic meanings of the lived experience of moral injury in order to explicate and un-conceal the essence of the phenomenon (Finlay, 2014; van Manen, 2014). First, I will invite the reader to get a felt sense of each participant’s experience of moral injury, and to engage with this phenomenon as it was experienced by each participant within the unique context of his or her life (van Manen, 2014). ‘Lifeworld fragments’ (Ashwort, 2003, 2006) from participants’ individual experiences will facilitate the reader’s phenomenological dwelling as these will articulate the existential lifeworld structures (i.e. embodiment, spatiality, temporality, selfhood, relationality) in each participant’s particular experience. Then, given that the aim of phenomenology is to uncover the essential characteristics of the phenomenon and not only individual or particular experiences, I will present and elaborate the thematic meanings of the lived experience of moral injury, which emerged from analysing participants’ transcripts. Each of these themes reflects meanings of the lived experience that illuminate the phenomenon of moral injury in the context of intimate relationships. Participants’ Lived Experiences of Moral Injury The four participants whom I interviewed for this study were Tom4, Annie, Aaron, and James. Although coming from different life venues and backgrounds, they all experienced 4 All the individuals in this thesis have been given pseudonyms as a means of maintaining anonymity. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 79 suffering consistent with moral injury in the context of their intimate relationships. Specifically, Tom’s suffering was connected with his partner’s sexual infidelity. Aaron’s suffering was primarily engendered by his indecisiveness about ending his unhealthy marriage that eventually dissolved following his wife’s infidelity. Anna experienced moral suffering in the context of a long lasting and emotionally abusive intimate relationship. James identified himself as the perpetrator of sexual infidelity and experienced moral suffering in the context of that experience. Tom. At the time of the interview, Tom was a single a 78-year old man, retired over a decade ago, and divorced for over 30 years. During the interview, Tom shared his experience of suffering after he discovered that his wife at that time, Sally, had an affair with another man. Tom recalled that he met Sally when he was about 40 years old and a successful businessman, a CEO of a major financial company. Tom was immediately smitten by Sally’s charm and energy, and felt drawn to her because of the life she evoked within him whenever he was around her. Before meeting Sally, Tom remembered his life as being mundane, dreadful, unfulfilling, and lonely. During that period in his life, Tom was dedicated to working long hours and was preoccupied with achieving his career goals and financial success. He was single, living alone, and estranged from his family. However, once he met Sally, he started feeling emotionally, spiritually, and mentally alive and connected. During one of their business trips, a couple of months after Sally began her internship, Tom and Sally started a romantic relationship. Not even a year later, they got married and remained married for almost two decades. They had three beautiful children together and lived a seemingly happy life together as a family. Reflecting on their marriage, Tom said: “I was happily married; she’s the love of my life. I thought she was the woman I was made for, and that she was made for me.” PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 80 At that time, his marriage with Sally fulfilled some of Tom’s longings stemming from his childhood. Due to the many traumatic events that occurred within his family of origin, including the death of his older sister, Tom longed to grow up and have a healthy and close family of his own. Although he had a lot of self-doubt, he longed to become a father, a provider, and a successful businessman. During his marriage with Sally, he felt that he had found the fulfillment of his longings: Um, and I thought we had a model, happy, loving marriage and relationship. Were happy with kids and um, I am, was successful at my professional career and was making good money. We travelled the world with the kids. I mean it was idyllic. However, a couple of years following the birth of their youngest child, Tom’s idyllic experience of his marriage and family was shattered when he accidentally discovered Sally in a close, intimate embrace with another man. Earlier that afternoon, Sally told Tom that she was going to a yoga class and that he should plan some activities with their children. Shortly after she left, Tom took their two children to the park near their house to play soccer. As he ran to fetch the ball from one of the bushes separating the soccer field from a hiking trail, he caught glimpses of his wife hugging another man on the trail a few meters away: Um, I can remember it like it happened yesterday […] It was a beautiful day […] the sun was shining; the buds were out. I can remember smelling the willows and the buds, which is a beautiful smell. Um, and the new growth in the forest, and the sedges […] I can remember the light flickering through the trees: and the shadow, light, shadow, light…it’s just vivid, like it happened yesterday […] I can remember looking to the left and seeing my wife […] in a passionate embrace with another person whom I recognized […] And, actually as I think about it, it wasn’t a passionate embrace, as opposed to intense, loving, PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 81 um, soulful embrace. Which immediately communicated to me that incredible intimacy has been shared between the two of them. And I immediately knew that they were having an affair from that one glace. They were clasping each other (sigh), their heads were laid on each other’s shoulders. Um, and my immediate thought was they are having an affair, and I was stunned into almost speechlessness but felt incredible, uh, first feeling was, feeling of shock… and…I was astounded. Cause I never expected it. Tom remembered that he initially tried to desperately keep everything under control as he smiled and joked around with his children while telling them it was time to go back home. His first instinct was to protect his kids in spite of the enormous pressure of the feelings that began to build him inside. After he ensured his kids were safe at home, he biked back to the park to see his wife and figure out what was happening. Tom confronted her about what he saw; however, she did not seem apologetic but rather was merely surprised that he has found out about her affair. And I went back to the path, and as I approached, by that time her ‘friend’ ran off to avoid confrontation. And the feeling was one of disappointment that he wasn’t there cause I wanted to vent my rage… [voice drops very low and shakes] I was going through very strong physical feelings of rage […] everything tunneled in so I wasn’t aware of my surroundings. So, the smells, the sights, and the beauty of the environment, and the park and the tress… I didn’t notice any of that. I was tunneled into this issue. Into this-this-this problem. I was, uh, rigidly tight and the muscles were hanging on the bicycle. And gripping the grip really hard and trying to restrain myself from doing something stupid. But I was, uh, intensely (long pause), well I was uptight… yah… it was… not nice […] um, but everything was… I couldn’t smell or (long pause) really notice what was going on around me. Sort of like everything tunneled in, and I was just seeing my wife there. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 82 Tom described how Sally refused to come home with him right away and instead insisted on taking time to think and be alone. Tom biked home alone, frozen in shock. The whole afternoon he sat around the house uncertain what to do. When Sally came home that evening, they had a brief talk and she promised to stop the affair immediately. Tom decided to stifle his pain and to focus on trying hard to keep the family together and to forgive Sally. He made his decision to forgive quickly, because at the time he was a devout Christian and believed that it was the right thing to do according to his Christian beliefs, for his children, and because he truly loved Sally. For the next three years, Tom was very intentional about pursuing his relationship with Sally by committing to attend family therapy, working fewer hours, taking fewer business trips, and organizing family vacations that would allow him, Sally, and the kids to spend quality time together and reconnect. He wanted to make her happy, and hoped that she would want to stay in their marriage. However, three years after the initial incident, Tom came upon Sally kissing the same man in a similar type of scenario like the first time he discovered them embracing in the park. Following the second discovery of Sally’s infidelity, Tom returned home and went into his bedroom: I can remember going upstairs and laying on the bed being in a, it wasn’t a tunnel, it was like being in a pit […] And I just laid on the bed and I was screaming to get it out of my system cause I knew my life was destroyed. Tom spoke how he never thought he could hurt as deeply as he did the first time he discovered his wife’s infidelity, but that the second time was even more painful: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 83 Because it was a re-lived betrayal… contrary to what she was telling me, and telling her parents, and telling the counsellor. About working and feeling sorry about it and trying to heal the family. She was perpetuating the affair. And it was a… well I didn’t think I could feel any worse than discovering them the first time. But that’s when I first realized how dead I was and how fruitless and wasted the effort was to try to keep the family together... the dishonesty and the continued lying and the double life she was leading, um, exacerbated my sense of betrayal because I was honestly committed to try and make it work and to reconcile and to forgive, and then I realized I was just being used as a doormat. Despite his efforts to forgive and reconcile with Sally even following her second affair, Tom sorrowfully remembered that one evening, as they were having a romantic dinner in their favorite restaurant, Sally announced to him that she has decided to end the relationship. She informed him that she had already rented an apartment, and made arrangements to take their kids with her. Sally also told Tom that over the last years of their marriage she has been storing money away and did not need his permission to leave: [It was] blunt, shocking, surprising, uh-uh... my reaction to it? Was… uh… (began to speak very quickly) shock and awe and disbelief and anger, intense anger at what a fool I have been made to be in view of the two and a half, three years of attempting to keep the family together. Tom articulated his story passionately, depicting the injustice and the resentment that he felt for his experience: I was the victim. Definitely the victim. Taken advantage of, abused… over protracted years, at significant financial expense, emotional expense, at significant expense of my PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 84 sense of well-being, my emotional stability, all of those things were significant costs associated with me continuing to turn the other cheek and continually to be slapped around and taken advantage of. Reflecting on these experiences, Tom shared that he felt that this experience had not only impacted him emotionally, but that it affected his whole being. He was not sure who he was outside his relationship with Sally as this relationship was the foundation on which he has built his life and future. He felt that after Sally’s infidelity and leaving, his world had crumbled. Tom felt forced to face his sorrow, as he did not know how to escape it. In the interview, Tom admitted that he was still struggling to leave the ‘whirlpool’ of intense negative emotions, and that he was still holding on to strong feelings of hurt and anger. He shared how he had tried to forgive Sally for years, but eventually came to the realization that he did not know what forgiveness would even mean in this circumstance and that he was unable to do so. He concluded by saying that ever since this experience he has lived with invisible scars. Annie. At the time of the interview, Annie was a 57-year-old single woman who spent the last 40 years working in numerous roles: sales representative, stay-at-home-mom, massage therapist, and writer. Annie has been married twice, and has a child, Alec, with her first husband, Ted. The context of Annie’s self-identified experience of moral injury was her tumultuous 20year long relationship with her second husband, Ron, whom she called the “love of her life.” Annie shared that she had initially started dating Ron when she was just a teenager. The night they met, Annie and her high school girlfriends snuck into a college party, using fake identity documents. From the moment they met, Annie remembered that she felt an immediate connection with Ron. The two started dating soon afterwards and moved in together after Annie’s high school graduation. Annie remembered that the relationship was initially filled with fun, PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 85 adventure, and passion as they explored life and adulthood together. However, with time, Annie began to have doubts about the relationship. Soon after, Annie and Ron had a fight over the phone regarding their future and decided to end their relationship. However, they were both left with uneasy feelings regarding the way they have spoken to each other for the last time. Following the break up, Annie lost all contact with Ron, and moved to Brazil to pursue her passion of art, travel, and exploring different cultures. In Brazil, she took two university classes, and in one of these, she met her future husband, Ted, whom she dated for almost a decade before getting married. Several years into their marriage, they had a son, Alec. Ted was a brilliant artist, an eccentric painter, and Annie was happy being his muse. The two had a fervent and intimate relationship that eventually ended 15 years later when Ted died in a tragic car accident. Following Ted’s death, Annie moved back to Canada to be closer to her family and to provide her son with a Canadian education. Annie recalled not having thought about Ron in years; however, one night after she moved back to Canada, she had a dream: I had a dream. And I hadn’t even thought about Ron, didn’t even feel connected anymore and one night I had a dream and it was Ron, and it was all kind of foggy. There was no background, no furniture or anything… he was just walking towards me, the age that he probably was, I haven’t seen him for years. And he walked up to me and said ‘do you want to get married?’ And I said ‘sure, why not’. Annie woke up quite surprised and shaken by the dream but eventually she told herself that, after all, it was just one of those weird dreams that everyone has once in a while. However, the next day as she was sitting with her son in the living room, cuddling on the couch, watching his favorite cartoon for the millionth time, the phone rang. Annie remembered letting the phone PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 86 ring and not answering because she did not feel like getting up and stopping the movie. That night before she went to bed, she checked her missed calls and as she looked at the phone she saw that “this number belongs to [Ron’s full name] I nearly had a heart attack. Cause the night before I dreamt that [he proposed].” Annie was nervous to call Ron back, but did, and the two had a three-hour conversation that ended with Ron saying to her: “I would love to see you again’. I said ‘oh sure, come out for dinner, see the family!” Annie recalled “totally not thinking anything would go anywhere. But it was so immediate [the connection they had when they saw each other again], just like it was the first time”. At the end of the dinner, Ron kissed her when they were saying goodbye: And um, and he, and I went to say goodbye at the door and he just grabbed me (motioned being pulled by the waist), planted a kiss on me and I went ‘oh my God! That was better than I thought it would be… and that is how the WHOLE thing started all up again… there was a very physical attraction, yah… and other things too. Annie pondered that it felt “like the Gods were looking down on us and said ‘what do you think, should we throw them back together and see what happens?’” Annie also thought that Ron could be a father figure for her son and a provider for the family and she hoped that the difficulties they encountered as young adults would not reoccur because she believed that they had both matured. Hence, once again, the two embarked on a journey together, and, at the start, Ron put “his best foot forward”. However, over time, the differences in how they saw the world, how they thought Alec should be raised, and the way they communicated made their relationship very difficult. Therefore, Annie often found herself in a position where she compromised on her beliefs and behaved in ways she perceived as “wrong”: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 87 Alec was having troubles at school and, that poor kid, Ron made him sit at his desk practically for the whole summer […] and it was a beautiful summer – all his friends playing outside- and he practically went through the whole summer [stuck inside], I was so tired of the battle. That he would start to convince me that maybe I am wrong. And I would get on board and it was so against my beliefs. Annie shared that she stayed in the relationship contrary to her values because she had hoped that things would change, and because Ron would periodically nurtured this hope. Annie depicted the relationship like riding a rollercoaster, with extreme highs of passion and love, and extreme lows of tension, verbal abuse, and hurt feelings. Often times, she felt that the way she and her son were treated was undeserved and harmful. Ron would often swear, yell, become controlling, or shut himself away for days from the two of them. Annie acknowledged that, over time, she also started to behave abusively towards Ron. She recalled swearing at him, trying to degrade and verbally belittle him as her frustration and exasperation grew every time his actions would take away her hope of having a happy, united family. As the result, Annie eventually came to the realization that she was becoming someone she did not want to be: “I realize that was abusive on my part. And thought… ‘oh my God what am I capable of ’? That’s certainly not the person I ever wanted to be”. Gradually, their relationship became quite taxing and Annie recalled experiencing a lot of stress trying to diffuse tension between her son and partner while staying true to who she was and what she believed in. She felt that she compromised a lot in the relationship in order to have peace and a sense of stability for her son to the point of not feeling free to be herself: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 88 We were willing to not be free in order to keep that semblance of peace […] That sacrifice of freedom to behave without restriction… just to be free in your own self, and home. Realizing that she was sacrificing her ability to be herself to preserve the relationship was a shocking discovery, because Annie always saw herself as strong: Me being the person that I am – pretty ballzie and in your face – I am a feminist, ‘how did I let that happen, or how I justified staying in that?’…this is still is a mystery to me. Although Annie initiated multiple separations from Ron over the time, she recalled a pivotal moment that marked the end of their romantic relationship when she realized that the relationship was truly over. Although making the decision to end the relationship was hard, Annie knew that she “had to do that, just for my own soul. To retake whatever, I had lost I guess. The freedom to be.” Annie concluded her story by sharing that overtime she has learned to forgive herself and her partner, and let go of the pain that enveloped her journey because she believed that holding onto the negativity could only harm her and imprison her in the past. She believed that recognizing one’s humanity, hers and her partner’s, was an important milestone for her: Aaron. At the time of the interview, Aaron was a 40-year divorced old male, who worked as a researcher in his early 20s, and later joined the military. He had recently retired due to medical reasons. Aaron got married young to Maia, a girl from his church community. He recalled that he met her about 20 years ago but, at the time, she had been in a relationship with someone else. Over time, Aaron and Maia became good friends and then started dating. When describing his initial attraction to Maia, Aaron recalled feeling drawn to her by her beauty, involvement, and PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 89 dedication to the church. Aaron shared that it was important for him to find a woman to share his life with, and that Maia had the same values, beliefs, and morals as him, which he appreciated. Eventually, Maia and Aaron got married when they were both in their early 20s and remained married for over a decade. Several years into their marriage, Aaron described that he felt that their relationship began to fade as each of them started to put less effort into their relationship, and to care less about each other. Reflecting on this, Aaron mentioned that he was struck by how gradually and almost imperceptibly this happened: It [the disconnect] happened very subtle, like, over time, little by little. [We fell] into something called a routine [and we stopped putting effort in]. And then, when you are leaving [the house, instead of a real kiss] there is a kiss in the air, and then you leave and there is not even a goodbye. Then you drop all these things [efforts]… no more flowers. Aaron recalled that, slowly, they began to disrespect one another, and ultimately themselves. He depicted how by disrespecting Maia, he began to lose sense of who he was and became unable to connect to his “inner peace” or happiness, losing touch with important aspects of himself. In an attempt to nurture their fading relationship, Aaron and Maia decided to move in order to be in a new environment and provide themselves with an opportunity to start over. Aaron decided to transport their belongings and set up the apartment while allowing Maia to finish her university studies. He shared that one of his friends told him that Maia was having an affair with a classmate from her university. Aaron shared that he decided to remain silent and not confront Maia regarding her possible affair, despite him feeling that his silence on this matter meant crossing his own personal boundaries and disrespecting himself. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 90 Several years after this discovery and their move Aaron and Maia had a baby girl, Olivia. In spite of their relocation and growing family, their relationship continued to deteriorate and the distance between them continued to grow. Aaron recalled how his Christian values, the love for his daughter, and both his and Maia’s unwillingness to deal with their relationship, prolonged the suffering in their marriage during this time. Aaron recalled that their relationship ended following Maia’s second affair with someone in their new neighborhood: Basically, it ended with her having an affair with someone that I knew really well [while I was deployed with the military]. And I didn't know about it. [A friend from work told me] I was needed at home. So, when I arrived home, I had a meeting with her and this person that she was having an affair with, my, what I thought was my friend. And then that's when I was told about [the affair]. Aaron shared that there was no remorse from his wife or his friend. Moreover, this friend was confrontational and tried to provoke a physical reaction. He remembered resisting the urge to fight for the sake of his daughter, and just feeling paralyzed by the shock of being betrayed by his wife and his friend. Following the disclosure of the affair, Maia acted as if she no longer wanted to be a part of the family, and yet, she continued living in the same house because it was financially convenient. Aaron thought that Olivia would be even more upset if Maia left altogether, so for a while, he did not say anything but finally came to an agreement with his wife that she should move out. Aaron shared that, during this time of transition, he did not have much time to focus on how he was feeling and tried hard to overlook his inner pain because he was focusing on being a good father. Later on, all of his attention and effort were devoted to winning custody of Olivia, a victory that finally made him feel vindicated in front of his in-laws and himself. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 91 Nevertheless, Aaron still wrestled with feelings of regret for not trying harder to save his marriage, shame for being mistreated by Maia, and guilt for the way he treated himself. Ultimately, Aaron articulated that his journey with Maia helped him to realize and learn that he needed to be more honest with himself, more accepting, and more intentional about prioritizing his needs if he was to be true to himself and a supportive parent and future partner. Although Aaron shared that he endured a lot of suffering (e.g., pain caused by not connecting to who he was, not standing up for himself in face of his wife’s infidelity, and behaving in ways that disrespected and misrepresented his true self), he highlighted a positive growth in understanding who he was and how to relate to others with healthier boundaries. James. At the time of the interview, James was a single, 50-year-old man who was married and divorced twice. James worked as an in-house physics consultant at an engineering firm James self-identified as having experienced moral injury because of him starting an affair during his first marriage with his first wife, Sofia. James described himself as the perpetrator of an immoral act and recounted the experiences connected with this. At the time of meeting Sofia, James was a graduate student. He met Sofia in one of the undergraduate classes where he was working as a teaching assistant. James thought that Sofia was beautiful, fun, and inexperienced. They both graduated the same year as he completed his graduate program and she completed her undergraduate degree. At this time, they have been dating for about a year, and James had planned for them to move in together and relocate. James recalled feeling blindsided when he was given an ultimatum by Sofia the night before they were supposed to relocate. Sofia told him that she yearned for greater commitment, and that he either had to commit to marrying her or that they should break up. Although unpleasantly surprised by the ultimatum, James decided to get engaged, and, within a year, the PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 92 two were married and remained married for almost two decades. Retrospectively, James commented that, while he enjoyed his time with Sofia, he was not ready for a committed relationship at that time and he got engaged out of a desire to keep his girlfriend in his life, rather than out of a desire for a lasting commitment such as marriage. Nevertheless, James shared that initially he found fulfillment and purpose within the marriage as he adopted the role of a provider and husband: I was the rock, I had to support her for everything, which at the beginning of the relationship I felt was fine… because it appealed to my male vanity, I think. And made me feel stronger, and wanted, and needed. My ability to solve problems and be supportive was an asset to the relationship. James recalled that several years into their marriage, they began their struggle to conceive a baby and start a family, which was something that both of them truly wanted. Eight years later, Sofia gave birth to a boy, Lucas, and Tom felt immensely happy for the birth of his son. However, feelings of hurt quickly intruded on his experience of joy, as James began to perceive Sofia’s actions as rejection of their son and of their plan to have a nuclear family because she refused to see, hold, and later stay home with their baby. James explained how he felt overwhelmed and confused, unsure what Sofia’s actions meant for their child and their marriage. He mentioned that Sofia was eventually diagnosed with postpartum depression, and that he began to perceive her in a different way, which led to a significant change for the worse in their relationship. James recalled feeling hurt, stuck, and hopeless once his ideals of a happy and ideal nuclear family were shattered by what he perceived as the unpleasant reality of his wife’s postpartum depression. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 93 For the next couple of months following Lucas’ birth, James struggled to cope with feelings of inadequacy and frustration as a husband, and, simultaneously, took on the new responsibilities of being a parent and needing to act as both parents. At that time, James also remembered feeling burdened by his financial responsibilities and found himself in a difficult situation when trying to do his duties at work while trying to appease his wife’s demands for his continuous presence. Although he felt burdened and worried, he was unable to express his distress within the relationship and consequently he stifled his voice. Gradually, James began to feel hopeless and scared about the relationship, experiencing it as an enveloping darkness that was consuming his life: It was like I was in the light and the relationship was a big bright tunnel, and then with these serial events and experiences the darkness started creeping in […] It got darker and darker and more uncomfortable and more scary. It was scary! Because it was not what I expected to experience in marriage. Over time, James recalled slowly feeling more trapped and burdened by what he felt as becoming a loveless marriage. He remembered one significant moment of encountering his buoyant neighbors and realizing that he and Sofia were not as happy as their neighbours and that he was not living the life he had always wanted: I looked at my life and thought about our relationship and there was no connection, no buoyancy, no happiness, no joy, no laughter, no joking. It was obligatory behaviour. It was like I was an automaton in a movie and that I sustained the relationship because it’s what you did. It’s what a husband did. And you make commitments, you had a young family and you put up because life isn’t perfect and relationships aren’t perfect. So, you PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 94 cope and you deal with it. What I didn't realize is that the coping and dealing was building up in me … and was actually harming me. However, James spoke of not taking any action either to improve his marriage or to end it, because he grew up with the belief that “you don’t…once you’re married, you’re married. You don’t get divorces.” Nevertheless, James remembered continually yearning for vitality, fulfillment, and freedom from the burden of being in an unsatisfying relationship. About two years following the birth of their son, Tom met Emma, the newly hired assistant of his wife, and he started an affair with her. He depicted his love affair with Emma as the following: It just opened the flood gates, and I just went with the flow. It was like being in a kayak in a river... just FLOWING down the river and being in command, and dangerous, and flowing water and everything… but exhilarating and exciting and very self-fulfilling! James remembered that most of the time he was with Emma he felt alive and fulfilled, but also noted that part of him occasionally felt burdened by the affair that contradicted his values: It was a burden, because my value system and moral code was not to deceit and lie and not to be unfaithful to my wife. So it was exceedingly difficult and a burden, I felt sick to the stomach at times by that. And the burden weighed down upon me in the quiet moments. But it was the minority of the time. And most of the time it was supplanted by the exhilaration of the joy and the wondrous experience of the affair. Several months into their affair, Emma decided to leave the city as a way to distance herself from the situation. After her departure, James realized that he wanted to follow Emma and be with her. This realization left him with the difficult task of telling his wife about the affair. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 95 “I felt guilty at the time because I knew it would hurt her […] I felt shameful at the time...[but] not enough to prevent me from doing it [ending the marriage in order to be with Emma].” James described his difficult conversation with Sofia when he told her about his affair and the inner dialogue that went on inside his head: I was sitting on the couch, looking out the window on a rainy day. Feeling very sad and despondent because [Emma] had left town the week before. And I missed her intensely. So, I was paining for what we had, for her presence. And every interaction with my wife was negative and shrouded in this lie, and shrouded in the shame of the affair that I had. And it was very debilitating, I felt empty and hollow. I felt ashamed, I felt bad… overall just bad. And as I sat there, and she came and sat down… it just dawned on me […] like a blinding flash of the obvious. That I couldn’t live my life like this, live the lie of the affair, and not have love for [Sofia] and not want to be intimate with her. And not wanting to commit myself to a sentence of dread and to an unloving, unhappy relationship for the rest of my life. No way. I felt anxious, and was very, very worried about how Sofia was going to the take it because she was a very emotional person. But I felt a strong commitment: this needs to be done. It’s for her best interest, and the kid’s best interest as well as mine […] James shared that although he had strong feelings and a moral code and value system that did not condone divorce and adultery, he found freedom and happiness pursuing his instincts and heart. He confessed that he was still perplexed by the fact that although his actions were considered “wrong”, he found fulfillment and a sense of authenticity that felt “right” in pursuing his affair with Emma. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 96 James shared that this experience shook him to his core by getting him to realize that he was not perfect, that he was in fact the “perpetrator”. He explained how it knocked him off a pedestal that everyone had put him on and that he became aware that he was able and willing to “violate fundamental moral values”. He spoke of this discovery as a shocking and painful one, because it made him aware that he was just like “everyone else”. Thematic Meanings of the Lived Experience of Moral Injury Whereas the individual experiences described before emphasized the unique life context in which each participant experienced moral injury, the thematic meanings presented here illuminate the trans-individual, essential features of the lived experience of moral injury. These themes point towards what was essential in the suffering that each participant encountered in his or her unique life circumstances. Thus, the thematic meanings are ‘concrete abstractions’ of what was essential in the experience of moral injury among the four participants. According to Van Manen (2011), thematic analysis is a “complex and creative process of insightful invention, discovery, and disclosure” (p. 1). He continued to say that the analytical process is not rule-bound, rather, it is a “free act of seeing meaning” (p. 2) Therefore, he stated that themes are not objective, nor can they be generalized – they are simply the “constellations that make up the universes of meaning we live through” (p. 2). The phenomenological analysis of the lived experience of moral injury uncovered six constellations of meanings, or core themes that shone through each participant’s unique experience: (1) self-estrangement, (2) transgressions and discord, (3) sudden awareness, (4) lostness and sorrow, (5) will to change, and (6) the aftermath. Within these core themes, 23 meanings (sub-themes) emerged adding richness and texture to the experience evoked by the core themes. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 97 Figure 4. Thematic Meanings of Moral Injury The following sections will explore each core theme and the accompanying sub-themes in an effort to depict the lived experience of moral injury. Self-estrangement. In reflecting upon their lived experience of moral injury, participants remembered experiencing a gradual yet persistent loss of connection with essential aspects of themselves (e.g., values, inner sense of peace, freedom, own voice). This almost imperceptible process of self-estrangement was accompanied by self-silencing while participants mechanically, yet dutifully, engaged in fulfilling societal duties and roles. Eventually, self-estrangement led to living a superficial life and narrowing one’s personal freedom. In the process of self-estrangement, participants intentionally disconnected from themselves and from their partners by giving up their expectations about their intimate relationships: The disconnect was coming to the realization that the only thing causing me pain was PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 98 having any kind of expectations from this person. And when I found myself thinking that something was an expectation, I would shut it down. It was really [me] shutting down, disconnecting. Feeling not good enough and self-criticism deepened participants’ experiences of selfestrangement, and weakened their acceptance of who they were: I thought there was something wrong with me, that I wasn’t whole. I would look at everyone else around me and they weren’t behaving as [emotionally as] I did […] So, I was thinking, ‘I am the one sticking out, I was the one that had to change, because there is something wrong with me’. Gradually, participants experienced an erosion of the felt sense of inner peace and happiness, followed by feeling deprived by essential aspects of one’s personal life: We all have some sense of …’I do enjoy this’, or happiness, personal happiness… certain Zen or peace or quiet zone kind of thing. And that pretty much got completely eroded away. You’re in this self-imposed thing […] so that access to that internal happiness, internal peace, internal stress free [...] I wasn’t being able to access that […] I didn’t have that […] depriving myself from that very important aspect of my personal life. Eventually, self-estrangement was experienced as a profound and irretrievable loss of self that went hand in hand with participants’ disconnection from their partners: “[T]hen the last drop was the loss of self […] and then once you lose that it’s really hard to get it back...” Over time, self-estrangement began to painfully restrict the freedom to be one’s self. This created an unspoken yet haunting feeling of fear or anxiety: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 99 …it was a subtle thing, this restriction [of not being able to behave and say things that were congruent with who I am]. It was out in the atmosphere thing that you could feel, that was not talked about. Although this experience of losing freedom and being worn down felt horrible, it eventually became the ‘new normal’: (Sigh) it felt horrible. But it became normal …that sacrifice of freedom to behave without restriction… just to be free in your own self, and home. To behave as you would like to be, like cuddling with my son while watching a movie. You know, that was pretty normal behaviour but that was restricted. Often, the process of self-estrangement was slow and lived in unawareness: “It’s such a slow process, and so incremental that you don’t realize it [the disconnect to my true self] as it’s happening”. It felt almost hypnotically slow: “It [the disconnect] happened very subtly, like, over time, little by little”, and it stemmed from seemingly insignificant actions within the relationship, which made this process seem even more innocuous: “It’s just like the book ‘A series of unfortunate events’. It’s just little ones. That's the thing, it wasn’t anything major – it was subtle, little things. And then they had a communal effect that was beyond, you know, the sum of the whole parts was – wow, it destroyed us … like a Colorado river that almost reaches the ocean in Mexico, but it doesn't really...it dies in the sand. But it doesn’t do that suddenly, the water diminishes and diminishes, diminishes.... Within the core theme of self-estrangement, four sub-thematic meanings emerged and elaborated this core experience (see Figure 2): longing, turning a blind eye, self-silencing, and performing life. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 100 Figure 5. Theme of Self-Estrangement Longing. Often, self-estrangement was propelled by longings or yearnings that felt like a painful measure of how far off participants’ relationships were from fulfillment and happiness. Most participants yearned to feel needed, wanted, loved or supported. Some desired an equal or stronger partner with whom to share the load of having a family and making decisions: I was the rock, I had to support her for everything, which at the beginning of the relationship I felt was fine…. But I quickly grew out of that and wanted someone who, in retrospect, was stronger (James). Others simply yearned for being with their chosen partner, and that longing for connecting and being with another person grew so strong that it overruled gut feelings and led participants to give into the pressure of circumstances: I didn’t want to abandon her. I wanted her to be in my life, I wasn’t sure I wanted to get married or to have that kind of commitment… but I overruled those feelings to get what I wanted. Which was to have her in my life. Deep-seated yearnings of love and happiness nurtured some participants’ hope that their relationships could provide relational fulfillment in spite of the scarce evidence that it was possible: I just kept hoping for change. I just kept saying, ‘well, I’ll get him to read that book and then he is going to get it! And we are going to be so happy’. And he seemed to know PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 101 when I was about to reach critical mass and then he would do something lovely. So, it would keep me, he would do things just to keep me…going. This hope for change often led to working hard towards fulfilling a need or expectation, even if the chances of success were slim: “And I tried so hard to make our little family work […] It was not a happy home. Should have been, we had everything we needed to have a happy home”. Feeling trapped in unbearable relationships and estranged from their own essence, some participants longed to feel alive, fulfilled, and free in spite of the risks or transgressions involved: It was like being in a kayak in a river… just FLOWING down the river and being in command, and dangerous, and flowing water and everything… but exhilarating and exciting and very self-fulfilling. Turning a blind eye. In the process of self-estrangement, participants turned a blind eye to their pain and to the reality of their relationships by not paying attention to what was going on or by dismissing how they were feeling. Sometimes participants refused to see certain red flags within the relationship: I can’t answer how does it feel because you don’t know it when it’s happening. Or you’re ignoring the little red flags as it’s going along, until it reaches critical mass. So, I don’t know how I felt. At times, the intensity of participants’ longings and hopes blindsided them: “And now in retrospect I go, ‘why didn’t I talk about this?’ Because I didn’t see it. You sometimes have to come away from it, to see it. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 102 Some participants turned a blind eye to one’s state of well-being, or to one’s physical needs: “I wasn’t paying attention to how sick I was, physically, that I was just totally devoted to caring for him”. Turning a blind eye meant that participants were not willing or ready to see the truth, thus, allowing themselves to make the same mistakes repeatedly: The only other surprise I guess would be the extent of my naivety, and readiness and willingness and ability to be a fool and continue to repeat the mistakes. I recognize that I am naïve and I am a fool and I am often reminded of-of the fact that […] Nobody wants to believe a lie, but we believe what we believe because we want what we want. At times, turning a blind eye was a deliberate action of turning away from problems within participants’ relationships, and that was justified by ideological or religious beliefs that prescribed unconditional commitment to relationships: And suddenly [I] realized all these problems [within the relationship] I was overcoming [by ignoring problems and feelings because] I thought during the marriage I [should be] turning a blind eye to [all the negative things] because you don’t…once you’re married, you’re married. You don’t get divorces. You don’t have affairs. Self-silencing. By continuously overriding their felt impulses and feelings, participants silenced themselves and their needs for the sake of preserving their relationship or the peace within the relationship. Self-silencing allowed the same relational conflicts to take place without participants saying or doing what needed to be said or done: “Why didn’t I just say whatever I needed or was thinking… we build this pattern over time that allowed this same thing to be playing out, the same fights with[in] different [contexts]”. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 103 In an attempt to silence their voice, participants avoided to confront their partners even in the face of blatant circumstances that violated deeply held personal values. For example, Aaron felt unable to confront his wife after she cheated on him the first time, and he silenced his impulses for the sake of not causing more trouble: So even to this day, she doesn't know that I know that she actually had something to do with one of her… school mates, I guess. In the same classroom. But someone else told me. Yah, but I let that one slide. I didn't say anything. Participants often experienced self-silencing as fulfilling an obligation to their significant others at their own expense, without realizing that, in so doing, they became further silenced and wounded: It was like I was an automaton in a movie and that I sustained the relationship because it’s what you did. It’s what a husband did […] So you cope and you deal with it. What I didn't realize is that the coping and dealing was building up in me … and was actually harming me. Participants silenced themselves by rationalizing their gut feelings and impulses, by deliberately looking for the good in their relationships, and by wanting to see more good than bad in order to maintain their relationships. They also accepted the cycle of pleasure and the pain brought up by abusive relational dynamics as a natural occurrence in life and relationships: I think most human beings will accept certain limitations or obstacles, or whatever you want to call it, if the scales they are weighing it by are … you convince yourself there are more good things than bad things, pain and pleasure…dichotomy if you will … and so, we went on this rollercoaster ride. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 104 Self-silencing was often done in the name of social or religious values that inhibited participants’ freedom to do what they wanted or needed to do: Yah, at a personal level what prevented me from doing that [leaving the relationship] … because I always kept telling myself, regardless of whether we had a daughter, (pause) it’s the right thing to do […] well, you know, separation… you’re supposed to…you know … divorce is not really… you know that whole older more conservative version of a Christian. Performing life. Self-estrangement manifested as obligatory, shallow, performing behaviour that replaced authentic engagement with life and relationships. All participants felt that they were performing life by carrying out societal roles, duties, and expectations while masking their inner pain and not attuning to themselves. Performing life did not allow individuals to attend to what was going on within themselves or to dwell on the pain they felt inside: “I didn’t recognize the amount of pain I was… (shaking voice). I was covering and hiding by trying to be a strong father, husband, male figure”. Performing multiple roles took away participants’ energy and focus, and thus, did not leave much space or time for their inner life, furthering their disconnect from their essence: “I had to pretty much perform the roles of mom and dad at the same time. And so that took most of my energy because all that focus, yah, and did not have much time to dwell on things”. While performing their roles, participants often felt misunderstood and taken for granted. They felt that they sacrificed a lot for their relationships or families, and that they were unappreciated or not enough: … emotional pain in that I wasn’t understood. I was taken for granted as the successful businessman and a successful husband, uh, the loving father. All those things and the PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 105 significant sacrifice that was put into those ‘roles’…um, was taken for granted, and was never enough. And that hurt. Because I was bending over backwards to be everything a husband and a man should be, and a father should be. And it still wasn’t enough. I still couldn’t do enough. At times, performing life was experienced as shutting down, being non-responsive or feeling like a zombie: I started to shut down, and so I started to consciously become unresponsive to the triggering experiences. And to be non-receptive, non-loving, non-supportive. All of these manifestations of the hurt, I was feeling […] And that the best way to deal with them was just to shut down […]the words that immediately popped to mind was deadness, and sort of like a zombie, sort of wandering around and going through the motions – and taking all the obligatory steps, and doing what is socially expected of you but being hollow. Being dead inside […] completely deflated. Transgressions and discord. A core experiential aspect of the lived experience of moral injury was participants’ engagement in transgressions against others and against one’s self. Transgressions were personal choices or actions that were against one’s own beliefs and values, even when they were directed at others. Paradoxically, at times, transgressions were experienced as a sense of passivity, resignation or inaction, in the sense of witnessing and not doing anything despite knowing that one should do something to correct the wrong. Transgressions were accompanied by inner tension or conflict marked by intense emotions of shame, guilt, and regret that encapsulated moments of clear intuitive knowing that what was happening was not right. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 106 Figure 6. Theme of Transgressions and Discord Transgressions against others. Participants felt that they contributed to the ugliness of the world whenever they engaged in acts of unkindness or harm against the people whom they intended to love, although many times these transgressive actions stemmed from participants’ exasperation, and were the last resort to break through and made their voice heard: Yes, because I hated unkindness. Had a personal mission statement that I wrote in 2002, that there is so much ugly in the world that my mission is to strive and not contribute. And I was contributing, hurting someone I was supposed to be loving […] I think it was out of exasperation. Nothing else works so let’s break through somehow. Often, participants transgressed against their partners because they felt hurt by them. For example, Annie spoke about her physical transgressions against her partner (e.g. slamming/kicking doors, throwing and breaking glasses) when he would hurt her by his withdrawing: Then he would shut himself away, which hurt, which is the worst thing he could do to me…is shut the door. And, um, I remember once, I was so sick of it that I kicked the door open […] I slammed the door on my bedroom so hard that I cracked the light switch. Some participants felt that they transgressed against their partners when they treated them with emotional withdrawal, intolerance and lack of compassion: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 107 I think that suppressing that emotion, and any negative emotion...they never go away and they start to brim over, to overflow. They make you intolerant, they make you less understanding. Intense feelings of shame and remorse accompanied participants’ transgressions. These emotions enveloped participants’ relational experiences and contributed to a personal sense of ‘badness’ or ‘wrongness’: Every interaction with my wife was negative and shrouded in this lie and shrouded in the shame of the affair that I had. And it was very debilitating, I felt empty and hollow. I felt ashamed, I felt bad… overall just bad. Transgressions against others sometimes resembled riding a “tension train of guilt” because participants felt that they acted against their values or were not being able to protect dependants in times of crises or chaos: I was always riding this tension train of guilt, and, um, guilt, guilt towards my son. But I would always find a way to, um, justify… ‘Yes, I think Ron is right’ and then do… it was chaos, stress, and tension. Constantly, constantly. Some participants felt intense remorse for acting violently against their partners, particularly when they felt that the hope for a good change was taken away by their partners’ actions: “And then he would do something that would take away any hope for the movement. Then I would just lose it”. This loss of control led to profound feelings of remorse: “I would get to the point where I would become a horrible person and just lose it, beat him up verbally so badly, and then, feel incredible remorse for it”. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 108 Transgressions against self. Participants’ transgressions did not harm only their partners but also participants themselves who felt that, through their actions, they cheated on themselves or let themselves down, sometimes wilfully and with full awareness: And so I felt cheated actually. I felt let down. Um, not necessarily by my wife but by myself. By my choices. I felt like I wasn’t getting out of life as much as I could be possible. Going along with things that were against one’s beliefs felt like betraying one’s values: “He would start to convince me that maybe I am wrong […] and I would get on board and it was so against my beliefs”. At times, participants’ awareness of acting against one’s self and one’s core values led to intense experiences of anger towards their partners and themselves, followed by an urge to destroy despite their inner voice saying not to do so: I remember being so filled with anger, that I, think I only felt that three times in my entire life. That level of anger, nobody was with me […] and I was standing there with this glass, it had a great thick base on it and I remember just, I had so much anger that I just, something said ‘don't throw it, don't throw it, you’ll just have to clean it up’. But I wanted to hear it go *shatter* I just remember wanting to hear that and to just let it go… . Gradually, acting against one’s self led to disrespecting self and others, and contributed to an ubiquitous feeling of self-loss: “When you are descended into the depths of disrespecting your partner […], you are disrespecting yourself. So by disrespecting yourself you are losing some of your self”. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 109 Even in the midst of self-transgressions, participants maintained an intuitive sense that what was happening was wrong. This felt moral sense was mainly expressed as regret, shame and guilt: …the regret came because it was so against my core values to do that[…]it was horrifying, absolutely horrifying to me. Regret that I did not either try harder or end the relationship when I should have. Um, shame… well anybody that goes through, that is on the receiving end of, obviously, an affair, is going to wish your friends didn't know about it. Guilty of not being honest with myself. Passivity. Sometimes transgressions were not the result of acting bur rather of not doing something that the individuals felt and were aware that they should. This passivity was essentially a deliberate overlooking of moral values and boundaries. Not speaking up, not confronting partners about violations of relational boundaries or simply letting partners get away with something wrong were instances experienced as harmful passivity: That [wife’s infidelity] definitely crossed my own boundaries. Because one of my boundaries would say [to myself]: ‘hey this is wrong, for your own sake you should bring this up, she shouldn’t just get away with it, right?’ But I didn't do that. Participants overlooked their sense of what was right in a given situation by not wanting to take initiative to clarify or even end a relationship that was already fraught with pain and lies: “no one wanted to take the initiative”. Instead of doing the right thing, participants waited for an external circumstance to make a change: “I will always kick myself in the butt for not doing the right thing when I had to do it, but it took something else for the thing to just end”. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 110 Because of this passivity, some participants began to feel imprisoned within the relationship, chained and shackled by the disheartening and unfulfilling reality of the relationship: “Ball and chain on both ankles, one hand shackled behind my back. Because, and I am not overstating it, that’s where it got to. Where day-to-day interaction was dreadful. And demoralizing. And unfulfilling. I had an albatross around my neck and I felt constrained. Although participants were aware of something being morally wrong in their conduct or in their relationships, they hoped that it would not be bad enough to have to do anything about it. Eventually, this passivity was lived as resignation and indifference: Yah yah, you’re conscious but you… that’s about it. You’re conscious, first you don’t think it’s going to go to too, too bad. Then you don't care…and then by the time you realize it… you’re like meh (shrugs shoulders). Inner discord and numbing. Perpetuating or passively witnessing moral transgressions was a profoundly conflicting situation that generated feelings of inner tension and discord, and made some participants experience themselves as being two different people: So, I felt, I felt like, actually as I think about it, I felt like I was sort of two people. One, was the rational, strong willed, iron disciplined, thinker. That was going through all these questions, that was the rat in my brain, that was the hamster on the wheel. But the other person (crying) was this raw, damaged, emotional blob, ha, and didn't know how to deal with it. Inner discord felt like an impossible mix of exhilaration and energy, on one hand, and guilt and fear, on the other: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 111 It was like I was schizophrenic. Half the time, perhaps more than […] it was exhilarating and dangerous and exciting and rewarding and fulfilling. All positive things. The great romantic adventure. 25% of the time I was feeling guilty, looking over my shoulder to see if anybody would recognize us. When the intensity of inner conflict overwhelmed participants, they turned to numbing or watching one’s life as someone else’s movie. They simply went through the daily life motions while feeling dead inside: “…and I was dead! It was like I was in someone else’s movie... and I was just going through the motions”. When the conflictual emotional experience was intensified by interactions with partners, some participants disconnected from them in an effort to numb their pain. Annie recalled how she felt so disconnected with her partner at one point, that even her partner’s attempt to shut her out did not affect her anymore: I think I was just so used to ridiculous behaviour… I am not sure that it was particularly hurtful… or painful… And um, I think I have arrived. I definitely arrived at not being as affected anymore, because I have disconnected. Sudden awareness. A very important theme of the lived experience of moral injury is that of sudden awareness: the moment when participants abruptly realized what was going on, often in a flash of realization that violently exposed the truth and the uncomfortable reality. This moment revealed to participants that what they had previously believed to be true about their relationships and themselves was not so. Initially, facing reality was met with shock and disbelief, followed by deeply felt pain. Ultimately, seeing reality for what it was, and realizing that they became foreign to themselves, led participants to experiencing the collapse of the foundation on which they have built their lives. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 112 Figure 7. Theme of Sudden Awareness Facing reality. The sudden awareness forced participants to face reality often in a blinding flash of realization that fully exposed the hidden truth they tried to avoid for so long: “And it [realization that his wife was cheating] came to me in a blinding flash of the obvious”. The flash of realization was experienced as encountering a foreign reality that did not fit with one’s previous understanding: “what I thought was a butterfly was a scorpion” but as the reality nonetheless: “It just is what it is”. Facing reality was accompanied by an immediate or instant knowing: “And I immediately knew that they were having an affair from that one glance”, and by a surge of raw, powerful emotions: “When this happened, um, I had no choice but to confront my emotions because they were so blatant – they were raw and there”. Facing reality was not only overwhelming but also humiliating, and some participants felt overwhelmingly enraged or anguished by the harsh discovery: The pain of being cookholded as a man raised in the 50s, the pain, and the insult, and the humiliation. And the rage of being repeatedly cookholded, and being lied to and deceived and betrayed… was the most intense, and rage inducing, intense white pain I could imagine. Often times, facing reality came as a sudden and disappointing realization that one was living an unfulfilled life: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 113 It struck me as an exceedingly disappointing realization that I wasn’t living as full of a life that I could or should or would want […] And so I felt my life was curtailed or diminished as a result of beginning to experience these realities. So, I was disappointed, unfulfilled, unfulfilled, very sad about it. Some participants felt stunned when they realized that they were the ones who allowed the painful reality to set in by not acting sooner: [W]hen I would take a moment to have some introspection about it, I could shake my head and go ‘wow, how could I let that many years go by without getting to the point where I would take action’? Shock and disbelief. The sudden exposure to an unforgiving reality was shocking and did not sink in right away: “… it’s like you win 10 million dollars, you know, you’re in shock. So, yah. That kind of sensation… it doesn't sink in right away”. Participants were stunned and speechless: “I was stunned into almost speechlessness but felt incredible, uh, first feeling was, feeling of shock… and…I was astounded because I never expected it”. Disbelief was often accompanied by feelings of hurt as one struggled to grasp the reality that one’s partner was not the person who one thought (s)he was: This is the woman I chose to be my wife, to be the mother of my young two children. So again, it was like… ‘what movie am I in? Who is this person? How could they behave and treat me this way? Treat my kids that way?’ Um, so it hurt, a lot […] because I still don’t fully understand. The inability to comprehend what was happening gave way to rapid and screaming questions of disbelief: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 114 ‘What the hell was I doing in that relationship for like 27 years?!’ I don't know! ‘What was I thinking?! […] this is mind blowing to me – what was I thinking?! Why did I think this was okay?!’ Well, I didn’t think it was okay – that was it. This is ridiculous – ‘how did [I] get here?’ [I was] willing to not be free … to keep the status quo…’what the fuck was I thinking?’ ‘Wow! How did I get there? Facing one’s unrecognizable self. In addition to facing a harsh reality, participants had to face themselves and their inability to recognize who they have become: who one thought oneself to be was no longer true. Participants became aware that they could no longer relate or connect to the way they were behaving, and that they have become foreign to themselves. For instance, Annie recalled feeling worn down to the point that she no longer represented the feminist, strong woman whom she always believed herself to be. She had become unrecognizable to herself as someone who has given up parts of herself to experience sporadic peace in her home: I was a feminist, opinionated, and never hesitated to say most things. So, to find that that wasn’t really true (sounds sad) … that somehow time had worn that down, to get me to the point where I conceded to give up something [parts of myself] in order to have peace […] how I let that happen, or how I justified staying in that still is a mystery to me… . At times, participants were terrified to identify themselves as somebody abusive, brutal and scary, someone whom they never wanted to be: “I sound like a monster […] I became a horrible person, someone I never wanted to be”. Some participants faced their unrecognizable self by coming to a clear and painful realization that they were the perpetrator in the relationship, which contravened everything they PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 115 imagined about themselves. They experienced themselves as foreign as they became aware that they had violated their moral principles and proper standards of behaviour: … because I was the perpetrator. And because I violated what I thought were proper standards of behaviour. And that I was brought up to respect, um, and because I did what anyone suggested I would do… two years before…I would have laughed in their face and said ‘no bloody way I would do that’. I fell off the pedestal, by my choice. Um, but it hurt, in that regard, it hurt. Facing one’s foreign self was triggered by witnessing the harm caused to others. Partners’ reactions forced participants to acknowledge that their behaviors were abusive: So, I remember seeing him almost physically cringing at my [stream] of, you know, ‘you’re a fucking asshole’ … things that I would never say to people! So, it was, I realize that that was abusive on my part. And um, made me think… ‘oh my God what am I capable of?’ And that’s certainly not the person I ever wanted to be (Annie). Collapse. All participants shared an experience where they felt that their entire life framework- what they believed to be true about their relationships, about themselves, and/or about the world, and their hopes- shattered or collapsed as a result of their awareness of what was going on: Well, I was lost because the entire framework for the plan of getting married and having a family and progressing with children, the rug was pulled under me. The framework was collapsing and I didn’t have an alternative to compensate for that loss. So, I was bewildered, annoyed, and angry at the betrayal. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 116 For most participants, the sudden awareness of partner’s betrayal was experienced as a collapse of their entire existence: “Everything was going so well for us, and then the entire house of cards came collapsing down because of her choices […] My entire world has been destroyed”. Some participants described the collapse as a cessation of forward motion, and as walking into a brick wall against which everything shattered: Walking into a brick wall is an immediate cessation of forward momentum, and so, in your life you are striving to accomplish […] you’re doing it with the best of intentions, it's a mutual plan, and you’re charging ahead and you’re gaining momentum and you’re on a plan. And suddenly you hit a brick wall. Everything shatters against the wall and you become completely debilitated to pursue that direction, that journey, or those goals is completely frustrated. Other participants experienced the collapse as walking into a tunnel and gradually facing more and more darkness creeping in, becoming worse and worse, uncomfortable, and eventually scary: I felt, it felt like… you know when you go […] into the tunnel and it’s all black, and as you walk through it the end of the tunnel gets bigger and bigger and bigger and bigger as you get close to the exit and where the light is. Well, I had the reverse experience. It was like I was in the light a […] tunnel, and then with these serial events and experiences the darkness started creeping in. The light became less and less and less and less and then […] It got worse and worse and worse and worse. It got darker and darker and more uncomfortable and more scary. It was scary! PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 117 These experiences of collapse often led to participants’ feeling anxiety and panic: “When I went through that period of time panic and anxiety…that totally destroyed my foundation of, about who I thought I was”. Moreover, the collapse hindered one’s ability to be and one’s resilience to pain. Thus, daily life stress and strain began to interfere with one’s sense of purpose: I think I knew every waking moment of my existence after discovering them together that it was harmful. That it was causing me significant stress and strain, um, was interfering with my sense of enjoyment in my life, was interfering with my ability to be […] um, and I felt like my life goals were being compromised. Lostness and sorrow. Participants recalled experiencing moments when they felt lost and consumed by sorrow amidst their relationships. Participants perceived their partners withdrawing from them, not acknowledging their pain, and not taking responsibility for the harm they have caused. Lostness felt like an amalgamation of losing trust in others and feeling disorientated by not being grounded in one’s self. Sorrow was lived as a surrender to the experience of sadness, inner death, and grief. Figure 8. Theme of Lostness and Sorrow Being unseen. Participants felt unseen by their partners who would withdraw in the midst of participants’ suffering. Sensing partners’ withdrawal was one of the most hurtful relational experiences: “… and we had this enormous fight and he would withdraw. Um, he would, was capable of closing himself away, on days on end not speak to me. Which was really hurtful”. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 118 Participants felt even more disconnected from themselves when their partners did not acknowledge the wrong they have committed in the relationship. Tom remembered feeling confused that his wife took no responsibility or expressed no repentance, sadness, or shame regarding her affair: She went all rational…but not apologetic. And so, I remember at the time going ‘this is absurd’ (starts crying) like how can this dialogue be happening, based upon what I just saw and what they were just doing. Like there was no shame on her part, or-or repentance, or sorrow expressed. Likewise, Aaron spoke of feeling unseen by his friend because his friend never acknowledged the suffering that he had caused and never apologized for sleeping with Aaron’s wife: From surreal it became very quickly confrontational because uh, my alleged friend… he wasn’t apologetic or anything like that. He was actually very confrontational. He told me that… you know, if you don’t like any of this, we can go outside [...] As if I was the one offending him […] I felt like it was when someone breaks into someone else’s house…in the middle of stealing stuff, and the owner shows up and then shoots the person in the leg. And then the injured thief [sues him]. Disorientation. Disorientation was experienced by participants as feeling lost and as a loss of implicit faith and trust in their partners and the world. Participants felt dazed and disoriented, no knowing what to do and how to continue living: My brain going on round, and round, and round, and around. Going, what does this mean? What does this mean for the family? (speech increases in speed) … what do I PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 119 think? What do I feel? What can I do about it? Just like in a hamster wheel, all this shit going around my mind. They felt lost and bewildered: “I was lost […] my entire existence collapsed […] I felt bewildered and overwhelmed”. Disorientation following betrayal shattered participants’ implicit trust and faith not only in their partners but in human beings in general: She was the last person I thought would ever do that to me with the history. I had such implicit trust and faith in her. To then be abused that way, just reinforced in my mind that the world is full of people with the propensity to betray. And that you have to be very very carefully whom (voice shakes) you open up to, who you trust…and whether or not to even open up and trust people. Sorrow. Eventually, a profound and intense sorrow overtook participants: “Sorrow for the loss. Intense sorrow”. A great sadness overwhelmed them when they realized that their romantic relationship has indeed failed and ended: That was so sad, that was really sad. I remember him moving out […] I was sitting in one of the bedrooms and saw the moving truck come for his stuff and I went down to say something. And we stood in the hallway just realizing that it had failed and he never cried, he was such a hard ass, but he was crying. And we both acknowledged that “you are the love of my life” (with sadness in her voice), but I can’t do it. Realizing that one’s hopes and expectations vanished and that one had to relinquish what one thought to be true caused great pain and sadness: “That, that uh, it didn't work and that what I thought was a butterfly was a scorpion. Um, and that uh, retirement years of my life with a healthy nuclear family is (long pause), has been trashed (deep sadness in his voice)”. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 120 Sometimes, sorrow was experienced as feeling leaden and stuck in a completely dark pit where surrendering to that darkness allowed grieving to begin: I can remember feeling (long pause) … completely leaden… just dead. I felt dead […] everything that I held dear has been snatched away by this betrayal. So that was […] like being in a pit. Everything was black and I was…I completely let go. For some participants, sorrow facilitated a forced time for introspection, slowing down and taking time off to be with one’s self: This sickness has allowed me to… have this time off from high tempo life […] and has forced me to have more time to think [about what was happening for me]. Will to change. After grieving the loss of relationship and of essential aspects of one’s self, participants began to feel the will to change as a sense of clarity of direction, decisiveness, and activation of personal agency. This awakening of the will to change compelled participants to pursue what felt right and to no longer accept the way they have engaged with life or their relationships. This led to a newly found freedom, and in all cases, this change was marked by the end of participants’ intimate partner relationships. Figure 9. Theme of Will to Change Clarity. Seeing and acknowledging clearly what was happening was a difficult process, not always experienced as a distinct or instant moment. For instance, Annie recalled her struggle of repeatedly ‘waking up’: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 121 Um, I guess it’s sort of like… they say to quit smoking you need four good attempts at it. So, to wake up doesn't always happen in a moment. I am sure it can, but I think that I tried to wake up, and we would split up. And then I would try to wake up and then, I don't remember a pivotal moment. For some participants, the clarity was experienced as taking off one’s blinders and ordering one’s self to wake up: “Once I have exhausted every avenue I can think of, that’s probably when the blinders started coming down: ‘You have really done it all, so wake up now’. Clarity was prompted by the realization that participants were worth more than how they were treated by their partners: “That probably was the wake-up call: ‘I think I am worth more than this’. Participants became certain that that they could not continue living the way they were, unless they were willing to live a lie or to commit to a life sentence of dread and unhappiness: I was sitting on the couch, looking out the window on a rainy day. Feeling very sad and despondent […] And as I sat there, and she came and sat down… it just dawned on me […] That I couldn’t live my life like this, live the lie of the affair, and that […I could not] commit myself to a sentence of dread and an unloving, unhappy relationship for the rest of my life. No way. When clarity set in, participants were able to see clearly and with certainty how the relationship truly was and how it was always going to be, which was in stark contrast with the desperate hoping that the relationship could change for the better: But I think after years and years and years... the recognition, the light bulb coming on that this is going to be it. ‘This is how it’s always going to be’. This awful up and down, good and bad, but recognizing that […] I think instinctively that it was something I felt. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 122 Clarity made participants realize that wanting to keep the harmony within the relationship and family at all costs by silencing one’s voice or need for justice was not worth it. They realized that compromising their sense of self to maintain the peace and stability was no longer worth the pain and they no longer wanted to live that way: “You don’t feel like keeping the peace anymore. Yah, so I guess that understanding that this was an injustice to myself was probably what finally ended it”. For some participants, clarity was lived as a desire to set new boundaries to protect one’s self from feeling overwhelmed, hurt, and frustrated. Participants began to consciously distance themselves from the lack of respect and acknowledgment received from their partners: I didn't want to deal with that pain anymore… that frustration, that anxiety, and that anger and that lack of respect and acknowledgment, and all of that discomfort and pain it caused with those interactions and the attitude she had towards me is what contributed to killing the marriage. So, I wanted out of it. Agency. Personal agency was experienced as the capacity to decide and do what one knew was right for one’s true self. Agency led to regaining the freedom to be: “It was devastating [ending the relationship]. But I knew I had to do that, just for my own soul. To retake whatever, I had lost. The freedom to be”. All participants decided that they no longer wanted to stay in the relationship: I was getting to the place where I would no longer be willing. That there is too much, I probably framed it, as there is too much tension. It’s not ok to live this way. This is harmful, it’s starting to really wear us down. And so that that’s where the not willing, the can’t, came in. When I all of a sudden, I went: ‘I am not going to do this anymore!’ PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 123 Agency meant following one’s essence and experiencing the feeling of resonance with one’s true self, even when it appeared to violate the established moral codes: I know what I decided to do was to follow my instinct, to follow my heart, and pursue that. Rather than being true to the moral code that I was raised with. [When] I was violating my own moral code […] was in the happiest time of my life. Happiest, most incredible experiences in my life […] although I knew what I did was wrong, it reinforced what I did was right. Paradoxically, at times, agency involved doing something that was thought of as wrong, but that felt as the right thing: I would say I hardly felt the pain […] I was pursuing, what I felt in my entire being, was the right thing to do. Even though it was wrong. Morally. It was the right thing for me as a human being. And it caused a lot of…hm…quite a paradox. Participants’ agency was strengthened by feeling fed up with the unfair treatment, feelings of imprisonment, sacrificing too much, and being taken advantage of. Being fed up was experienced as burdensome, debilitating, angering, and hurtful, and led participants to take action to change the status quo: It came to the point of being debilitating for me and caused anger and hurt. Because it was an unfair burden, and it was building through the years. It was like an albatross around my neck. It was excessive. And it was way too much sacrifice. To the point where I felt I was being taken advantage of and where I finally felt fed up with it. Freedom. Freedom was experienced as a release from the heaviness or imprisonment experienced in the relationship. For some participants, freedom meant feeling released from the lie that engrossed their relationship: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 124 It was very liberating to come under the lie. And to accept accountability […] whatever they may be, it’s very liberating. Back to freedom. ‘Cause living in a lie is constraining in many ways, it suppresses who you are. And I think it is damaging to who you are, to live a lie and to perpetuate lies. And so, coming clean as it were […] released me. So, I felt rejuvenated as a human being…in my essence, to my core! Relieved, rejuvenated, free! So, it was healthy, I felt great. Freedom allowed participants to find a way out from a harmful relationship: “Because he [the friend who betrayed him] catalysed this whole thing, because the affair then was a way out for the two of us”, and it was experienced as excitement and liberty to move and engage in new adventures: Even with the shame factor, and the embarrassment factor, that wasn’t enough to overcome the newer and excited and adventure and the freedom of the affair. The freedom. That's what it was. It was freedom. Capital F. In every possible way. Intellectual, emotional, physical. It was freedom. So shame came secondary, freedom came primary. All participants felt lighter and relieved once they reconnected with their inner freedom: But in this case it wasn’t …the relationship was so bad that it way it was almost like… oh my God, this happened… but, thank you!! AH! So, you almost felt like the weight has been lifted! […] YES! Even after all these years. Yes, there was a relief. For some participants, freedom meant the beginning of forgiving and accepting themselves despite the mistakes they made: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 125 Yes, definitely, you create your own prison that you can’t get out of, until you let it go […] I forgive myself. I know my intentions always were coming from the right place, but they were wrong choice though sometimes. The aftermath. Some participants felt that their experience has left them with painful scars and wounds. Others felt that their experience eventually led to a reconnection with themselves and others, to feelings of gratitude for the journey and growth they experienced, and to appreciating this process as a valuable learning experience about nurturing their connection with themselves. Figure 10. Theme of the Aftermath The scars. One of the participants identified his scars as pain that was still present because he continued to have a hard time facing and dwelling in the agony long enough to understand and integrate what has happened. The scars are the wounds that still bleed occasionally: And all of the things that hurts so much, they've never gone away. I feel scarred. And not all the scars are healed yet. There are still wounds there, that start to bleed every once in a while. Many participants shared that they still had moments that take them right back to the pain and the experience itself: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 126 I am quite emotional and it takes me right back to the day… I’m, um, choked […] clearly there is some damage that was done, and I know there was. Cause I don’t feel good thinking about it. I feel hot and flushed, and distraught. Some participants revealed that because of their relational experiences they continued to struggle to trust others: Um, well the main change, or changes that I noticed are… Number one, having a hard time trusting people… I really. It’s hard for me to trust people. I still do, and I still get stabbed in the back a little bit … so that has made it very difficult for me to trust people. Often, participants were aware that, because of their experience, they began to lack the ability to recognize and share emotions, and, thus, truly connect with people: Emotionally, I think is where the costs were. I think it affected my ability to truly connect with people and be emotionally honest with people...I [lost] out on, I think, the wonder of being able to sharing emotions as effectively as a person who doesn't suppress their emotions. I would have loved to be a person that could honestly recognize, acknowledge, express, manage and communicate emotions. In the aftermath, some participants still felt regret for not having acted to end or fix the relationship. “I did not either try harder or end the relationship when I should have”, or regret of ever meeting one’s partner: “Uh, there are times when I regret ever having met her. Um, I seriously question if she ever really loved me at all”. Reconnection with self and others. Participants began reconnecting with themselves and others by taking responsibility for their actions and inactions, and by committing to a different course of action: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 127 I would say I was a willing agent that contributed to it. As I look back, if I made different choices at different times and was more true to myself. I would have made different decisions, rather making decisions out of concern and affection for my wife. For some participants, reconnection with self was experienced as tuning in to one’s self: Because I would, I would tune in, tune in with how much it was hurting me. Instead of pushing through… how ill I was, and how tired I was, and how much I needed SOMETHING from someone else! Anyone just for some support, a sister or a friend. For others, reconnection with self was experienced as feeling good in one’s own skin and opening up to a whole new chapter in one’s life: [I realized all the] positive effects of achieving self-realization, of being true to myself, of the atoning process. [It] all contributed to opening up a whole new and wonderful chapter in my life. It was invigorating, and perhaps most interesting [part was that] my guilt passed away! I feel good in my own skin, with no disabling black emotions or wounds that I can detect. At times, participants experienced the reconnection with others as vindication. It was lived as having others reaffirm one’s goodness: It was vindication...it felt, good, felt very good. It was like a reaffirmation that what I have been doing was good and that I wasn’t really a horrible person, not necessarily the horrible person that she described me to be. Finally, reconnection with self was experienced as remembering the truth: “But it’s good to remember what was the truth. In its good and its bad. It’s a good thing to face facts about the journey. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 128 Gratitude and self-forgiveness. Some participants looked back on their experience and were grateful: “Grateful, gratitude [...] we humans tend to run on the spectrum of emotions and gratitude comes only when you can take the moment to find it”. Gratitude was lived with happiness and relief: Whenever I think about it, I am still very glad it happened. And you can tell by the big smile (laughs)…oh God. So, yah that's one relief […] um, you know, I am happy that, you know, it took too long, but I am happy that it eventually ended. Some of the participants expressed gratitude as a wish to repeat the journey with the knowledge that they accumulated during this experience: “Yah so I think, I realize, I recognize that I wish I could do that again, I wish I could do that journey again, knowing what I know now”. At times, gratitude was experienced as believing the journey of moral injury was the best thing that has happened. “Even though it was the most negative of circumstances, it was the best thing that could have happened to me. And it doesn’t justify the behaviour but that’s the consequence”. Self-forgiveness meant distancing one’s self from the situation and acknowledging one’s humanity and one’s imperfections. It was experienced as a wise understanding and acceptance that one did the best one could given the circumstances. Annie spoke of forgiveness setting her free from hurting: I have accumulated enough knowledge in my life to be able to go up a thousand feet in the air and look down, and that takes out the ego and whatever and say…and look at it from a human perspective. And say ‘you did the best you could’. You really did, more than most people would […] I have also learned in my life that if you carry any of that negative PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 129 energy forward with you, like if you can’t forgive somebody or yourself, it’s just going to keep hurting you. You are a prisoner to it. Gradually, most participants were able to let go of the hurt and to open themselves to new experiences: But I don’t dwell on it a lot anymore it's a waste of time and energy and I am in the twilight years of my life and I don't want the rest of my life to be tainted by this, and I am not going to let it taint me anymore than is obvious. I want some new experiences, and do new things and different things. Lessons learned. All of the participants shared that they have learned valuable lessons along the way. Annie spoke of the lessons she has learned as an ongoing process that she was not always aware of, “well (long pause) I think that’s another thing that is multi layered. Because on the day to day basis you’re learning things, you’re learning without knowing you are while going through it”. Aaron experienced the lessons he had learned as opening a dialogue with oneself, being free, and becoming more intentional about big decisions, no longer making decisions on the fly and looking at multiple angles to determine if he is doing the right thing: [I]t makes me not be so…makes me, forces me to, second and triple guess big decisions. So, yah…I am not so…you know, deciding things on the fly like that. I do little tests… and look at more angles, am I really doing the right thing. One important lesson that participants learned was to look after themselves first in order to be there for others: And I worked really hard to realize, a really simple concept, to realize that ‘hey! you come first’ if you don't look after yourself first, you cannot be there for others. Being a PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 130 good friend or family or a relationship or whatever. So, I’ve learned that. I learned that saying no is ok, if it means I am looking after myself first. It feels awesome! In this chapter, I have depicted the participants’ journeys of moral injury by engaging in thematic analysis and offering a description of the six themes that have emerged as the lived experience of moral injury. In the next chapter, I will ask the readers to immerse themselves within the phenomenological writing as a way to gain further insight into the phenomenon. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 131 CHAPTER FIVE: PHENOMENOLOGICAL WRITING This chapter elaborates the phenomenological writing of the lived experience of moral injury. Phenomenological writing cannot be separated from the phenomenological research because “for phenomenological work, writing is closely fused into the research activity and reflection itself (van Manen, 2014, p. 364). Phenomenological writing acts both as a method and as findings. It is required for a process of deep immersion into “the space of the text” (p. 371) in a hope of grasping the lived experience. “The object of radically qualitative research is essentially a linguistic project: to make some aspect of our lived world, of our lived experience, reflectively understandable and intelligible” (van Manen, 2014, p. 364). In the following pages, I have written about the lived experience of moral injury in a way that reflects how participants, my research team members, and I have experienced it. “Phenomenological text succeeds when it lets us see that which shines through, that which tends to hide itself” (van Manen, 2014, p. 373), and my hope is that which is hidden in the experience of moral injury will be illuminated in the following pages. However, the understanding of the phenomenological writing is not determined by the writer, but it reflects a dialogical engagement with the reader: The reader must be prepared to be attentive to what is said in and through the words. While a text possesses literal content or lexical meaning, there is also meaning in the form or rhetorical structure of a text. Certain meaning is better expressed through how one writes than in what one writes (p. 373). PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 132 The writing here follows the flow of the experience of moral injury, the convoluted process of unravelling, becoming, and transforming5. It follows the symbolism of the water (e.g., erosion, submersion, emersion) as the metaphor for the lived experience in an attempt to preserve the fluid, ungraspable, and cyclical nature of the experience. If things were clear to you, the reader, or overly simplified, it would devoid you of entering the world of someone who has encountered moral injury, someone who even years later is still uncovering its meaning and is still dwelling within that experience. The repetitiveness of the text is intentional, to evoke the returning, and at times, the overwhelming nature of the experience. The journey of moral injury is one filled with emotionality and desire, and such humanness could not have been depicted another way. Moral Injury as Transformative Experience: The Water Symbol They both listened silently to the water, which to them was not just water, but the voice of life, the voice of Being, the voice of perpetual Becoming. ―Hermann Hesse, Siddhartha (1922/2012, p. 134) Water emerged as a powerful symbol for the experience of suffering in moral injury. Water symbolizes the transformative potential of human existence by submerging us in the tomb of our darkness, re-orienting us, and allowing us to emerge atoned, transformed, and whole, like a baptism. Water represents both our innermost darkness, and our source of agency, freedom, and vitality. Thus, water embodies a dual symbolism: it holds both a destructive and a generative, creative and transformative power. Water evokes a movement that is, at times, slow, insidious, 5 The process of moral injury was not experienced as linear. Despite the temptation to make this assumption based on the verbal limitations of depicting the experience in a cohesive way, it is important to note that the process was at times cyclical and even chaotic. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 133 yet tenaciously destructive, transformative, and unapologetically molding, carving paths even in the most powerful rocks. The experience of moral injury transformed us in a similar way: we experienced the power of water in the imperceptible yet tenacious erosion of our foundation, in drowning and submersing under water to surrender to our sorrow, and in emerging anew from the water in a symbolic, metaphorical act of atonement. The phenomenological writing of the lived experience of moral injury elaborated this symbol as it imbued the thematic meanings of this phenomenon. Eroding Our Foundation: Self-Estrangement Our6 story was often left untold, as it was concealed by the tragedy of the relational context in which it unfolded. Our suffering became apparent to those around us, but its source was often mistaken and amalgamated with the chaos of our intimate relationships. Our relationships contained the story of what happened between us and our partners, but also of the dynamic that occurred within ourselves. Our relationship with the other was an unhealthy and a painful one; however, a parallel dynamic occurred within our self and impacted us on a fundamental level. In many ways, our inner journey began before our relationships with the others, and continued to unfold after the relationships ended. Our experience is that of becoming through suffering, a dynamic process of transformation by losing and finding our self. We did not always understand ourselves or what was unfolding. An intricate veil was woven over our hearts and minds, by our longings and wants. Although we were in the eye of a hurricane sensing its alluring stillness, we remained ignorant to the suffering slowly enclosing on us. It took endurance to feel the force of the wind, note the darkness of the sky, and yet refute its 6 Our, us, and we were used with the intent of presenting a unified voice of the participants, research team members, and me. This language was also used to depict the lived experience of moral injury in a more personal and poetic manner, endeavouring to nurture the reader’s connection to the phenomenological writing. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 134 ominous presence. It would have been difficult for us to comprehend a storm in the middle of our soul’s drought, and maybe we ignored it because we were fearful of drowning, and dismissing its possibility was all we felt able to do. Therefore, we made a choice, albeit unconsciously, to ignore it and lie to ourselves: Nobody wants to believe a lie, but we believe what we believe because we want what we want. A deeper want awaken within us was stronger than our grounding in reality. We yearned to feel happy, loved, supported and connected, and we began to engage blindly in a struggle to attain these. The external promises of fulfillment through our intimate relationships seduced our ego and our will followed our wants. Our will became a powerful instrument submitting to our wants, and combined with our blindness and unwillingness to see the truth, it proved harmful. It robbed us of our ability and desire to notice our estrangement from our self, from our being. We convinced ourselves that our unrealistic expectations and misplaced idealism were causing our disgruntlement with existence. We learned to silence the voice within that kept signaling our pain, our fear, and our longing: When I found myself thinking something that was an expectation, I would shut it down. It was really [me] shutting down, disconnecting. We did not realize that we were silencing something greater than human idealism; we were silencing our self. Eventually, self-silencing evolved into not wanting to see the reality in which we lived. We missed the outcries of our suffering because we were too preoccupied to face the feelings that we so desperately tried not to have. We dismissed and rationalized the undercurrent of emotions, and by doing so we deepened our self-estrangement. We concealed our self-abandonment behind so-called maturity and reason: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 135 I have the perspective of, there is nothing perfect in this world […]. You get sweet fruit and pits. So, you got to learn how to deal with the pits. You can’t expect to have a bowl full of cherries without pits in them… and life isn’t that way… and so, it’s just being mature… looking at it. Going ‘okay, there were good times and there were bad times’. We nurtured the disconnect we had with our essence, with our being, self-inflicting suffering by assuming that this was the way we should be living. We convinced ourselves that there was no way out, and perhaps no alternative state in which to exist that would not contribute to our suffering. We chose to ignore our distress, believing that our decision to remain in suffering was driven by our sense of morality and nobility. In those moments, it did not occur to us that, aside from our sense of duty and morality, the self-sacrifice was committed out of our fear to lose the hope of fulfilling our longings and the fright that without the other we cannot achieve our wants: I hadn’t realized while [we were still together] how much I depended on him for so many things. We could sense that our state of existence was balancing on a wire, that any alteration of the status quo would plunge us into discomfort or chaos because there was no foundation within to safely ground us. Blindly, we engaged in self-rejection often by mistaking our uniqueness for a flaw: I thought there was something wrong with me, that I wasn’t whole. I would look at everyone else around me and they weren’t behaving as [emotionally as] I did […] nobody was as stupid as me when it came to being so emotionally fragile. So, I was thinking, I am the one sticking out, I was the one that had to change, because there is something wrong with me. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 136 We disengaged as a way to coerce ourselves into roles that were prescribed to us or that we convinced ourselves that we should embody. Along the way, we began to value these roles more than our self and our lives became mechanical and devitalized: I looked at my life and thought about our relationship […] it was obligatory behaviour. It was like I was an automaton in a movie. I sustained the relationship because it’s what you did. It’s what a husband does. Our roles gave us a sense of false ground. At times, they anchored us into a false sense of security and they were a welcomed distraction from engaging in the introspection towards which the gradually intensifying pain was beckoning us: I had to pretty much perform the roles of mom and dad at the same time. And so that took most of my energy because all that focus, yah, and not so much to dwell [on the impact it had on me]. I did not have much time to dwell on things. Slowly, over time, we acted as if our roles replaced our true identity, and the stakes of our performance grew. To keep up the pretense, we could not fail in our roles. Failure threatened to expose our fragile state – a state of disconnection from our essence, from who we truly were. We desperately wanted our role to satisfy those around us. And we wanted it to satisfy us, hoping that it could aid our capacity to ignore the aching we felt inside. Despite the attempted roles, the façade was challenged by the rejection we experienced: I was taken for granted as the successful businessman and a successful husband, uh, the loving father. All those things and the significant sacrifice that was put into those ‘roles’…um, was taken for granted, and was never enough. And that hurt. Because I was bending over backwards to be everything a husband and a man should be, and a father should be. And it still wasn’t enough. I still couldn’t do enough. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 137 Because the roles became our way of identifying ourselves, once they were undermined our pain enveloped us without us fully understanding why. We were so preoccupied with the ‘should’ of our roles that we lost touch with who we were. We did not notice when our role and duty to others started to restrict our freedom to be: …that sacrifice of freedom to behave without restriction… just to be free in your own self, and home. To behave as you would like to be. It was like becoming hypnotized by the calmness of the waves breaking onto the shore and not noticing the rising tide. We only noticed it once the icy water penetrated the boundary of our personal space and unexpectedly touched us with a wave that appeared larger than the rest, but was actually just the same. Existing within this ‘sameness’ eventually eroded us, like waves wearing down a rock: It was a song that came out around that time, and when I drove to work I use to scream it at the top of my lungs and it was ‘wore me down like the road’. The normality of the restrictions and self-deceit became the most dangerous part, like being inured to be tossed between the waves, not realizing that the toss would inevitably drown us. It was with unacknowledged intent that we allowed this erosion of our foundation and of our inner peace: We all have some sense of …I do enjoy this, or happiness, personal happiness… certain Zen or peace or quiet zone kind of thing. And that pretty much got completely eroded away. We engaged in self-deceit, inadvertently, yet repeatedly, betraying ourselves: … feeling guilty of not being honest with myself. We were willing to overlook all the sacrifices we were making: I wasn’t paying attention to how sick I was, physically […] I was just totally devoted to caring for him. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 138 Once we offered all that we knew, we started to offer the thing that was of the greatest worth: our self. Often this appeared merely as a compromise, leading us to underestimate its impact. We deliberately surrendered parts of our self in the hope of gaining something that we really longed for. But we later learned that nothing was worth more: Maybe I should have stood my ground and said ‘well no’. I am not going to have conditions dictated to me. That’s sure as hell what I would do now. And I wish I would have done it then. We did not intend to contribute to the destruction of the very connection we so desperately needed. We did not intend to stop swimming while so desperately trying to stay afloat, yet we found no immediate danger in taking breaks. The little self-compromises were crimes that we committed against our self. They were the only cornerstones to which we can point that led to our deep disconnection and ultimate self-loss: Not a particular one, it is just like the book ‘A series of unfortunate events’. It’s just little ones. That's the thing, it wasn’t anything major – it was subtle little things. And then they had a communal effect that was beyond, you know, the sum of the whole parts was – wow, it destroyed us. The danger was the subtlety and the intensity with which the process of self-estrangement occurred. It did not happen all at once. As a result, we did not realize that it had occurred until much later: …like a Colorado river that almost reaches the ocean in Mexico, but it doesn't really...it dies in the sand. But it doesn’t do that suddenly, the water diminishes and diminishes, diminishes... PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 139 Riding the Waves: Transgressions and Discord After a while, the self-estrangement became disorienting. We were not sure anymore of who we were. We stopped being adamant about standing up for ourselves. Perhaps we were not always sure what we were standing up for or maybe we had lost too much ground. We were unable to act even when we knew that we should: …one of my boundaries would say “hey this is wrong, for your own sake you should bring this up, she shouldn’t just get away with it, right?” But I didn't do that. We succumbed to the beliefs and opinions of others: He would start to convince me that maybe I am wrong […].And I would get on board with it and it was so against my beliefs. Boundaries became unclear and, therefore, transgressions became easier. We began to do things that no longer resembled who we thought we were: ‘Oh my God, what am I capable of?’ That’s certainly not the person I ever wanted to be. However, our self-estrangement stopped us form declaring with utter certainty that this was not us. Instead, we were left with unsettling self-doubt. With every inauthentic act, with every incongruent and unjustifiable demeanor, our desperation grew: I hated unkindness. And I was hurting someone I was supposed to be loving […] I think it was out of exasperation. Nothing else works so let’s break through somehow. But the regret came because it was so against my core values to do that. We felt like we needed to be aggressive to be heard. We wanted to be heard by others, but, more importantly, to be heard by our own self. We wanted our voice and our actions to penetrate through and draw attention to our pain: [I] slammed the door on my bedroom so hard that I cracked the light switch. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 140 Denying our emotions became a catalyst for aggression. Since we could not make our pain disappear, it surfaced as hostility and anger: I think that suppressing that emotion, and any negative emotion...they never go away and they start to brim over, to overflow. They make you intolerant, they make you less understanding and angry. However, when we committed acts that we deemed to be wrong against the others, we simultaneously harmed our self. Our desperate actions did not vindicate us; they further condemned us: When you go to that point [of fighting aggressively], you are descended into the depths of disrespecting your partner. By doing that, you are disrespecting yourself. Therefore, by disrespecting yourself you are losing some of your [self]. Our self became unrecognizable and we felt horrified by our actions: I would get to the point where I would become a horrible person and just lose it, beat him up verbally. So badly, and then, um, feel incredible remorse for it. It is truly within those moments that we felt our authentic self rebuke us for the inauthentic actions. It is within those moments that we were discouraged by how far we had wandered off. Such moments provided fleeting glimpses of the loss to which we were still blind. Throughout these transgressions, the focus was frequently on the act or on the other. However, the greatest impact was often experienced by us. The impact came from the creeping realization that perhaps something was wrong, but not knowing what it was or how to orient ourselves out of it. It felt like being underwater and swimming up to the surface, expecting to break free of the water and gasp for air at any moment. We started to swim faster towards the surface, but no matter how fast we swam all we reached was more water. We began to worry that perhaps we were swimming in the wrong direction and that a breath would not come in time. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 141 Out of fear, we continue to perpetuate the cycle of aggression. We conducted more futile attempts at being heard and being seen, hoping to prevent us from drowning: And I remember once, I was so sick of it that I kicked the door open. The harder we tried, the more transgressions we committed and the further the distance grew between us and our being. We felt so overwhelmed that we had a difficult time controlling our actions: And I remember being so filled with anger. And I was standing there with this glass, it had a great thick base on it and I remember just, I had so much anger that I just, something said ‘don't throw it, don't throw it, you’ll just have to clean it up’. But I wanted to hear it go *shatter* I just remember wanting to hear that and to just let go. We came to a point where we felt inherently foreign and scary to ourselves: I sound like a monster […] horrifying, absolutely horrifying. Although our actions were incongruent with our deeply held values, we did not recognize the disconnect they represented. Our pain deepened and we felt less and less certain of the way we were conducting ourselves: It was like I was schizophrenic. Half the time, perhaps more than […] it was exhilarating and dangerous and exciting and rewarding and fulfilling. All positive things. The great romantic adventure. 25% of the time I was feeling guilty, looking over my shoulder to see if anybody would recognize us. The discord and dichotomy soon became more obvious: I felt like I was sort of two people. One, was the rational, strong willed, iron disciplined, thinker. That was going through all these questions, that was the rat in my brain, that was the hamster on the wheel. But the other person (crying ) was this raw, damaged, emotional blob, ha, and didn't know how to deal with it. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 142 The discord intensified when our sense of right and wrong opposed our faint inner voice beckoning us towards our self. At times, the discord even prevented us from listening to the voice of our moral conscience: What prevented me from doing the right thing [leaving a harmful relationship] …is …because I always kept telling me…telling myself […] that [staying in an unhappy marriage] it’s the right thing to do. At times, it was our inaction that weighed us down and contributed to our drowning: Ball and chain on both ankles, one hand shackled behind my back. Guilt, shame and regret eventually began to envelope our experiences, as we slowly noticed that we were letting down ourselves and the people around us: Then, you feel guilty because you can’t even look at yourself in the eyes. Because you’re consciously failing yourself. That kind of guilt. Struck by Lightning: Sudden Awareness We could not initially embrace the reality when it dawned upon us like a bolt of lightning and struck us in the midst of our struggle. The reality was too much, too sudden, and too foreign for us to grasp. We guarded against it with shock and disbelief: It’s like you win 10 million dollars, you know, you’re in shock. That kind of sensation… it doesn't sink in right away. It was difficult to understand what was happening, the truth was unfathomable, as it would imply a state of brokenness that appeared all consuming and existentially threatening. The shock was a big part of the incomprehension that encompassed our initial experience of reality: I was stunned into almost speechlessness but felt incredible, uh, first feeling was, feeling of shock… and…I was astounded because I never expected it. At first, the shock helped us to distance ourselves from the experience: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 143 What movie am I in? Who is this person? How could they behave and treat me this way? Treat my kids that way? The pain was very real and threatening. To disconnect from it, we stopped trying to understand it. In a bizarre way, we found comfort in our incomprehension and in the absurdity of the reality: I think I was just so used to ridiculous behaviour… I am not sure that it was particularly hurtful… or painful… [when he barricaded us out]. I just think, one of my first thoughts was ‘how am I going to do my laundry?’ The laundry room was in there. Slowly, we started to grasp the state that we have been living in. It seemed utterly impossible that we lived such an existence: What the hell was I doing in that relationship for like 27 years?! I don't know! “what was I thinking?! […] this is mind blowing to me – what was I thinking?! Why did I think this was okay?! Well, I didn’t think it was okay – that was it. This is ridiculous – how did [I] get here? We struggled with the reality that we were the ones who cultivated this state and self-inflicted so much pain: It struck me as an exceedingly disappointing realization that I wasn’t living as full of a life that I could or should or would want. And so I felt, I felt cheated actually. I felt let down. Um, not necessarily by my wife but by myself. By my choices. So I was disappointed, unfulfilled, unfulfilled, very sad about it. This invasion of reality acted as a mirror that reflected a stranger, a foreign self, someone we did not recognize: I was the perpetrator. Because I violated what I thought were proper standards of behaviour. And that I was brought up to respect, um, and because I did what anyone suggested I would do… two years before…I would have laughed in their face and said ‘no PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 144 bloody way I would do that’. I fell off the pedestal, by my choice. Um, but it hurt, in that regard, it hurt. Um, thinking of myself, in my 20s I was a feminist, opinionated, and never hesitated to say most things. So, to find that that wasn’t really true (sounds sad) … that somehow time had worn that down, to get me to the point where I conceded to give up something in order to have peace. The unraveling reality swept over us in a wave of panic, and all our regular coping patterns were insufficient. As our foundation collapsed, we panicked: I went though that period of time panic and anxiety…that totally destroyed my foundation about who I thought I was. We could no longer cope. Our bodies did not allow it, and we had to become still in our suffering: But um, this sickness has allowed me to…[take] this time off from high tempo life […] and has forced me to have more time to think. We each experienced a moment of meaningful encounter with existence. It stripped away our self-deceit, our blindness, and our disbelief. We felt almost violated by an unfathomable truth, and by a very harsh reality: I was emotionally distraught and completely devastated. And um, in private, um, vented a lot of emotion and tears and distraught, um, exclamations and, because my entire world has been destroyed. Almost against our will, our eyes were opened to the reality we have been living in. These moments merely uncovered the truth that was there all along. Nonetheless, it felt like jumping off a cliff into the clear blue water and experiencing that moment when your body submerges. And PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 145 we felt that shock that robs us of our breath because we could not even imagine just how cold the water would feel against our body. It was in that moment that the illusions we had created were shattered and we saw the full catastrophe and the emptiness that was within us. We no longer could hide behind our roles. Once the façade of the relationship was cracked, we were felt lost and without a foundation to ground or support us: I was lost because the entire framework for the plan of getting married and having a family and progressing with children was gone, the rug was pulled from under me. The framework was collapsing and I didn’t have an alternative to compensate for that loss. So I was bewildered, annoyed, and angry at the betrayal. We felt that the world stopped. We experienced uncertainty regarding our ability and will to keep going. We were left without a roadmap and the unknown looked daunting: And suddenly you hit a brick wall. Everything shatters against the wall and you become completely debilitated to pursue that direction, that journey, or those goals are completely frustrated. The paradox was that the more light crept in through our awareness, the more darkness we experienced because of our self-estrangement. Dwelling in that darkness was overwhelming, suffocating, and terrifying: The light became less and less and less and less and then […] It got worse and worse and worse and worse. It got darker and darker and more uncomfortable and more scary. It was scary! We lived in a reality where nothing made sense except the threat of non-existence and the intense pain that accompanied it. It was in those moments that we tested our limits of suffering. This PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 146 awareness of our non-being frightened us and compelled us to turn to others to validate our existence. Left to Drown: Lostness and Sorrow We wanted someone to tell us that it was going to be okay. We wanted our partners to acknowledge our suffering and to confirm our reality. But the difficult encounter with reality was only made more arduous and harmful by not being seen by our partners and being left alone in our suffering. We felt our partners’ indifference or rejection as a personal attack against the already fading sense of who we were, fueling the sense of instability that we have been already experiencing. It hurt not to be seen. It was harmful to be dismissed and to feel that those closest to us refused to turn towards us, to encounter us, and to validate our pain. Being unseen in such painful moments made us feel as if we were losing touch with reality. Having our pain disregarded or minimized made us question it and, therefore, we further questioned our own experience: She went all rational but not apologetic. And so I remember at the time going ‘this is absurd’ (starts crying) like how can this dialogue be happening, based upon what I just saw and what they were just doing. Like there was no shame on her part, um, I think there was shock and awe that she was discovered. But there was no shame, or-or repentance, or sorrow expressed […] So um, (long pause, starts crying), I just felt dead. We felt robbed by the other and robbed of our experience of reality: From surreal it became very quickly confrontational because my alleged friend… he wasn’t apologetic or anything like that. He was actually very confrontational. He told me that… you know, if you don’t like any of this, we can go outside [...] As if I was the one offending him […] I felt like it was when someone breaks into someone else’s house…in the middle of PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 147 stealing stuff, and the owner shows up and then shoots the person in the leg. And then the injured thief [sues him]. Our partners turned away, refusing to acknowledge our pain or desires: We had this enormous fight and he would withdraw. He was capable of closing himself away, on days on end not speak to me. Which was really hurtful. It was the rejection of our experience by the people who were the closest to us that further disoriented us. It was their lack of acknowledgment that made us perceive ourselves as crazy and out of touch with a reality that we used to share with the other: I didn’t have a strong sense of self when I was a kid. And if I did it was the wrong self because it was perceived as weak when I was raised. So I changed that, so to have that [new sense of self] undermined, to have that ego undermined [by my ex-wife]. It affected more than just my feelings, it affected my entire being! We understood our partners’ betrayal as turning away and disregarding us as human beings. It not only shook the foundation on which we stood, but it challenged our trust in humanity: She was the last person I thought would ever do that to me in the history. I had such implicit trust and faith in her. To then to be abused that way, just reinforced in my mind that the world is full of people with the propensity to betray. And that you have to be very, very careful whom (voice shakes) you open up to, who you trust…and whether or not to even open up and trust people. We suffered greatly and sorrow pierced our hearts: Sorrow for the loss. Intense sorrow. That it didn't work out and that what I thought was a butterfly was a scorpion. Um, and that uh, retirement years of my life with a healthy nuclear family is (long pause), has been trashed. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 148 For a while, we hoped that our experience was a mere nightmare from which we would wake up, and that we would eventually be released from the grip of dread and agony. We did not want to accept that what was happening could be true. We hoped that someone would swoop in and save us, but as people turned away, it slowly stripped away our last glimmer of light, our last glimmer of hope, and our last defense before being consumed by the darkness: [A]nd then he would do something that would take away, probably when it took away any hope for the movement. Then I would just lose it. In our despair and despondency, we started to experience further inner death – the very state from which we were so desperately asking others to save us: I started to shut down, and so I started to consciously become unresponsive to the triggering experiences. And to be non-receptive, non-loving, non-supportive. All of these manifestations of the hurt, I was feeling […] And that the best way to deal with them was just to shut down. But, but the emotion…the feelings of the injury were […] um, well its interesting because the words that immediately popped to mind was deadness, and sort of like a zombie, sort of wondering around and going through the motion – and taking all the obligatory steps, and doing what is socially expected of you but being hollow. Being dead inside. As we were pulled under dark waters, we watched the light dance on the surface, until eventually all we could see was darkness all around us. It was hard to imagine that we would see light again. It was hard to envision living and breathing again as our lungs submerged. We recognized this moment as the end. Not the end in the literal existence, but an end of existence as we knew it: an end to our bearable existence: I can remember feeling (long pause) … completely leaden… just dead (crying)…I felt like it was all over. I felt dead […] Everything was black and I completely let it go. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 149 At times, we still wanted to swim as hard as we could, relentlessly pushing our bodies towards the surface. But then a moment came, where the last bit of air from our lungs was used up, and our body could not keep going anymore. We started to sink, slowly disappearing in the tomb of the dark waters. ‘It’s Time, Wake Up Now’: Will to Change Dwelling in the submersed darkness had its purpose. There was a reason why we resided there for as long as we did. We faced our fear of nothingness and our painful meaninglessness. We learned to surrender to darkness to uncover our truth. It was a time to be still, to mourn, to encounter our self, and to gather strength for what was to come. Although it felt like death, it was just a deep sleep. Paradoxically, our suffering fueled our sense of vitality, so we recognized that we were still alive, still present, and fully aware of our pain. Encountering the reality, although painful and threatening, was initially insufficient to compel us towards change or agency. Awakening was difficult. It took many attempts before we could wake up, before we could emerge from the waters: Waking up doesn't always happen in a moment. I am sure it can, but I think that I tried to wake up, and we would split up. And then I would try to wake up and then, I don't remember a pivotal moment. Waking up was not a cognitive process. It was our personal truth that we sensed within our self and decided to follow: But I think after years and years and years... the recognition, the light bulb coming on that this is going to be it. This is how it’s always going to be. This awful up and down, good and bad, but recognizing that […] I think instinctively that it was something I felt. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 150 The awakening helped us find our position by orienting us to our being. As a result, it compelled us to take a stand. The change was painful but necessary. We had to fight back for what was rightfully ours, for our lives. We had to stand up to others: Devastating [ending the relationship]. But I knew I had to do that, just for my own soul. To retake whatever I had lost I guess. The freedom to be. It was a time when we went through the process of re-establishing our sense of self. We started to act authentically based on our inner resonance and intuition, rather than following abstract knowledge or social expectations: I know what I decided to do was to follow my instinct, to follow my heart, and pursue that. Um, rather than be true to the moral code that I was raised with. The moment of clarity about our situation and letting go of our stubborn hopes that change was possible catalyzed our awakening: Once I have exhausted every avenue I can think of, that’s probably when the blinders started coming down. You have really done it all, so wake up now. Waking up came with a strong sense of relief and congruency. It was like a breath of air that we had desired for so long. Our relationships ended during our awakening, but it allowed for regaining our freedom: I didn't want to deal with that pain anymore…that frustration, that anxiety, and that anger and that lack of respect and acknowledgment, and all of that discomfort and pain it caused with those interactions and the attitude she had towards me is what contributed to killing the marriage. So I wanted out of it, I didn’t want anything to do with it. We desperately yearned to be free, to shed the burden of our roles: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 151 It was an unfair burden, and it was building through the years. It was like an albatross around my neck. It was excessive. And it was way too much sacrifice. To the point where I felt I was being taken advantage of and where I finally felt fed up with it. We wanted to be released from the incongruent identity that has been imposed on us: It was vindication...it felt good, felt very good. It was like a reaffirmation that what I have been doing was good and that I wasn’t really a horrible person, not necessarily the horrible person that she described me to be. Our craving for freedom came organically, authentically, and once again, gradually. We became aware of the harm to which we were exposed, and how staying in such a relationship was incompatible with the freedom we needed: The freedom. That's what it was. It was freedom. Capital F. In every possible way. Intellectual, emotional, physical. It was freedom. So, I felt, you know, straightjacketed in my first marriage. I felt constrained. [...] So shame came secondary, freedom came primary. The search for freedom was also an attempt to recover our lost sense of vitality, the zest for life: It just opened the flood gates, and I just went with the flow. It was like being in a kayak in a river...just flowing down the river and being in command, and dangerous, and flowing water and everything…but exhilarating and exciting and very self-fulfilling! Once we were able to see clearly and stay connected with our deep sense of personal truth, our will and agency were activated: I, all of a sudden, I went, I am not going to do this anymore! […] And when you are willing to take the blinders off, and really look. Instead of […] always trying to look for the good and you can find that, you know? And when you finally start to take the blinders off and go this is going to be my life! PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 152 It just dawned on me that I couldn’t live my life like this, live the lie of the affair, and that […I could not] commit myself to a sentence of dread and an unloving, unhappy relationship for the rest of my life. No way. Although our renewed sense of freedom sometimes contradicted our worldview, we embraced it as a growing and learning experience. We no longer understood it as a restriction: I was pursuing, what I felt in my entire being, was the right thing to do. Even though it was wrong. Morally. It was the right thing for me as a human being. And it caused a lot of…hm…quite a paradox. Although the process of awakening was mainly centered around freedom and agency, we still had to address the many transgressions we have committed throughout the process of becoming. We had to face our atonement. Baptized by Water: The Aftermath The process of transformation through suffering is not immediate or easy. It takes time, self-acceptance, and integration. We are continually in the process of learning to nurture the connection with our self. For some of us, this process is still challenging. We may encounter difficulty in connecting to the pain that is still there if the suffering is too raw and threatening. This does not mean that we have somehow failed the process; it means that we are in the process of becoming through suffering: And all of the things that hurt so much, they've never gone away. I feel scarred. And not all the scars are healed yet. There are still wounds there that start to bleed every once in a while. We may be tempted to believe that we should reach a point where we will have no scars or traces of our suffering. But, on the contrary, it was through and within our suffering that we underwent a beautiful transformation, like clay is transformed by fire. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 153 We experienced times when it was difficult to let go of the pain. Yet, our transformation was likewise aided by not letting go right away. Sometimes, holding onto the pain was the only validation we had for the arduous journey we were on. This process helped connect us to our vitality, by uniting us with our purest form of emotionality. Consequently, consciously or not, we were not always willing to let go of the suffering because we worried that by letting it go, we would further lose parts of our experience and of our self. Hence, we let the pain affect us and we embraced the suffering: I am quite emotional and it takes me right back to the day… I’m, um, choked […] clearly there is some damage that was done, and I know there was. Cause I don’t feel good thinking about it. I feel hot and flushed, and distraught. We may still mourn our reality and inability to be the way we always wanted to be. It took time to understand and reformulate the meaning of our new reality, our new way of being, and parts of this process are still enveloped in suffering: Emotionally, I think is where the costs were. I think it affected my ability to truly connect with people and be emotionally honest with people...I [lost] out on, I think, the wonder of being able to sharing emotions as effectively as a person who doesn't suppress their emotions. We learned to find value and meaning in our becoming, but this process required intentionality, humility, and forgiveness. We came to a place where we recognized our humanity and offered ourselves grace and understanding. Self-forgiveness felt like a reunion between a lost child and her parent: full of relief, regret, and conviction that it will never happen again: I have accumulated enough knowledge in my life to be able to go up a thousand feet in the air and look down, and that takes out the ego and whatever …and look at it from a human perspective. And say ‘you did the best you could’. You really did, more than most people would PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 154 […] I have also learned in my life that if you carry any of that negative energy forward with you, like if you can’t forgive somebody or yourself, it’s just going to keep hurting you. You are a prisoner to it. Sometimes, we had to decide to let go of the hurt. Letting go was an intentional process that required us to move on from our injury: Yes, definitely, you create your own prison that you can’t get out of, until you let go [of pain]. It is not something someone else could do for us; it is something that we decided: But I don’t dwell on it a lot anymore it's a waste of time and energy and I am in the twilight years of my life and I don't want the rest of my life to be tainted by this, and I am not going to let it taint me anymore than is obvious. I want some new experiences, and do new things and different things. It was a choice to feel empowered over broken, to find our voice and to let it inspire us. It gave us the ability to stand with our self in confidence, love, and understanding of our being. It was a transformative act: And I worked really hard to realize, a really simple concept, to realize that ‘hey! you come first’ if you don't look after yourself first, you cannot be there for others. Being a good friend or family or a relationship or whatever. So, I’ve learned that. I learned that saying no is ok, if it means I am looking after myself first. It feels awesome! We learned that it is okay to ask for help. We do not have to do this alone, and shutting down our suffering is not a solution as it does not make it go away: Instead of pushing through… how ill I was, and how tired I was, and how much I needed SOMETHING from someone else! Anyone just for some support…a sister or friend. Our experience encouraged us to keep checking in with our self, making sure we are respecting and listening to our inner self as we re-engaged with life: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 155 [I]t makes me not be so…makes me, forces me to, second and triple guess big decisions. So, yah…I am not so…you know, deciding things on the fly like that. I do little tests… and look at more angles, am I really doing the right thing. Our story holds space for both gratitude and despair. The movement across the continuum was slow, and perhaps cyclical, but an important lesson that we learned was that we can allow ourselves to be grateful for the suffering, intentionally holding a stance of gratefulness within our process: It was almost like… oh my God, this happened… but, thank you!! AH! So, you almost felt like the weight has been lifted! Grateful, gratitude and despair, they certainly are on the opposite ends of the spectrum. I don't know for sure […] except that we humans tend to run on the spectrum of emotions and gratitude comes only when you can take the moment to find it. Slowly, we began to see the bigger picture, to distance ourselves from the pain and recognize the journey that led to freedom and healing: Whenever I think about it, I am still very glad it happened. And you can tell by the big smile (laughs)…oh God. So, yah that's one relief […] um, you know, I am happy that, you know, it took too long, but I am happy that it eventually ended. That allowed everyone involved to pick up pieces and try to move on instead of carry on indefinitely, years, and harming all the involved even more. Even though it was the most negative of circumstances, it was the best thing that could have happened to me. In the end, although we may not have appreciated the suffering itself, the atonement, the transformation, and who we became are now of greater value: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 156 Yah so I think, I realize, I recognize that I wish I could do that again, I wish I could do that journey again, knowing what I know now. I felt rejuvenated as a human being…in my essence, to my core! Relieved, rejuvenated, free! And most of us do keep going, maybe not in the same way, but the process of becoming never stops. It is when it ceases that it hurts. All that we have learned, all that we have embodied, and all that we have become, can now enrich the experience of our present and our future. We can now float on water, aware of the depth that supports us, while remaining anchored within ourselves. Resonance or Iconic Checks An important component of ensuring rigour in this study was by conducting resonance or iconic checks with participants and research team members alike. The resonance check was conducted by sending the participants and research team members this chapter (the phenomenological writing), and asking the following questions (Appendix G): (a) do you feel the findings resonate with your lived experience of your suffering in the context of your intimate partner relationship? (if willing, please elaborate on how so); (b) do you feel as if there are aspects of the finding that do not resonate with your experience? (if so, could you please provide me with further insight as to what would be truer to your journey?); (c) do you feel there is something missing that would be important to incorporate as a way to offer a more accurate picture of the experience. Participants. All the participants partook in the resonance check and reported feeling a profound sense of resonance. Specifically, all the participants deeply resonated with the way the findings were written, bringing the phenomenon to life: “I believe that if it had been written any differently, it would have lost a great deal in describing the depth of feeling and, “humanness” that this theme required” (Annie). PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 157 Tom. Tom reported resonating with the findings “amazingly and painfully so”. He narrated that the feelings of “intense anger, deep regret, and aching sorrow” surged back, as the phenomenological writing walked him though his darkness. Tom stated that it was a little more difficult for him to resonate with the themes of will to change and the positive aspects of theme of aftermath. He believed that the reason he may be encountering difficulty with these two themes is the fact that he is still suffering and has not fully let go of his pain. He claimed that the resonance check was an amazing experience, and although helpful to bring further insight, it was also painful given the nature of the topic. James. The participant claimed that the findings fully embodied his lived experience, particularly the suffering that was captured by the damage caused by the process of selfrejection. He reported feeling a strong resonance with the theme of performing life and the damage that living out of expectations, rather than authenticity, possesses. He wrote how the themes of will to change and the aftermath reinforced his own experience of moral injury – as ultimately a transformative healing process. James resonated, and emphasized, that despite the suffering, the experience resulted in wonder, joy, beauty, and happiness. He recalled feeling the release from guilt, and the encounter with authenticity and agency. He resonated with moral injury as an experience or re-birth brought on by the awareness of self-harm. He emphasized how participating helped him further make meaning of his experience. Annie. Annie reported that the finding resonated and that some themes resonated more than others. Annie deeply resonated with the way the findings were written, claiming it described her experience exactly how she lived it. Annie highlighted several sub-themes that particularly resonated: the self-estrangement as a slow and hypnotic movement, turning a blind eye, longing, self-silencing, transgressions against self, and the will to change. Annie reported not fully PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 158 resonating with the sub-theme of being unseen because she was the one that decided it was time to end the relationship and was confident regarding her decision. However, there are other complicating factors that Annie claimed probably led to her lack of resonance with that subtheme but suggested that the sub-theme of sorrow very accurately reflected that time in her life. Aaron. Aaron expressed deep resonance with all of the material – loving how and what was written. He offered only a brief, overall comment about the phenomenological writing without pointing out whether certain themes resonated more than others. Research team. The research team was comprised of five individuals, four women and one man. The team members were individuals who have expressed resonance with the construct of moral injury within the context of their own intimate partner relationships. The feedback suggested that all of the research team members deeply resonated with the findings of this study. There was a strong resonance in the way the writing followed the stream of consciousness of someone who experienced moral injury. One team member said “it was like reading my story, like reading through my mind.” More specifically, the research team reported that the findings captured the themes and the process in a fashion that was identical to their lived experience. The team members resonated with the internal suffering and the way it manifested in the external context (i.e., relational context), and appreciated that the writing simultaneously presented the complexity within the relationship while remaining focused on the inner dynamic. Selfestrangement deeply resonated as the beginning of the participants’ journey of moral injury. One member of the research team said that “my experience of that time was truly as if I was living someone else’s life instead of my own. I had no grasp of who I was.” Likewise, the sub-theme of freedom evoked many emotions for the members of the research team as they all reflected how they had the key to their freedom all along, but did not use it for years. One of the research team PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 159 members explained that reading the phenomenological writing induced a sense of anxiety and feelings of being overwhelmed because the suffering described reflected his own. Another individual spoke about how the themes of lostness and sorrow deeply resonated and recognized how in her numbness that she sought refuge and strength to survive another day. This person spoke about how this experience was difficult but provided her with the agency she needed to fight for herself. Research team members and participants alike thought that the themes of selfestrangement, self-silencing and performing life should be emphasized in research on moral injury, because they felt that the suffering experienced was a consequence of being dishonest with one’s self, which led them to sacrifice not only their mental state but also their physical health for the sake of maintaining their relationships. Finally, two of the research team members spoke about how the findings provided them with closure as it reinforced the healing aspect of the experience, and provided them with deeper meaning. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 160 CHAPTER SIX: DISCUSSION The purpose of this research study was to understand the lived experience of moral injury in the context of intimate partner relationships by using the method of hermeneutic phenomenology (van Manen, 2014). Although research on moral injury has been almost exclusively focused on military personnel, researchers have recognized the need to explore moral injury in other contexts that have a high potential of experiencing morally injurious events (Bryan et al., 2014; Litz et al., 2009). To this end, this study sought to expand the contextual understanding of moral injury from military to intimate partner relationship context, and to uncover the lived experience of this phenomenon within this novel context. For this research project, I interviewed adult participants who have self-identified as having experienced consequences congruent with the current conceptualization of moral injury in the context of the transgressions (e.g., infidelity and/or emotional abuse) suffered or perpetrated in their intimate partner relationships. Although each participant shared a journey that was unique in its struggle and transformation, the movement of unraveling and becoming in each person’s experience uncovered meaningful glimpses into the phenomenon of moral injury in the context of intimate relationships. The phenomenological analysis of participants’ interviews following the guidelines suggested by van Manen (2014), uncovered six core thematic meanings, referred to as themes: (1) self-estrangement, experienced as a slow and hypnotic erosion of connection with one’s true self; (2) transgressions and discord, experienced as violating one’s own morals and beliefs by hurting others and oneself; (3) sudden awareness, experienced as a painful realization that what one believed to be true about self and others was not true; (4) lostness and sorrow, experienced as being unseen and disregarded by others, disorientation, and sorrow; (5) will to change, experienced as awakening to one’s reality and PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 161 activating one’s agency as a means to gain freedom to be who one truly is; and (6) the aftermath, experienced by some participants as a process of learning, reconnecting with one’s true self and others, and gratitude, and by others, as a wound that has not healed yet. Within these six core themes, 23 sub-themes were further identified to elaborate the lived experience of the core six themes (see Figure 4, 97). This chapter will begin by situating the findings of this study within the extant research literature on the topic of moral injury. Next, the new findings of this study will be discussed and the main theoretical contributions of the study as well as its clinical implications will be outlined. Finally, future research directions will be explored, and the strengths and weaknesses of this research study will be addressed. Findings that Fit with Previous Research Studies To my knowledge, this study is the first phenomenological exploration of moral injury, as well as one of the very few studies (i.e. two studies) on moral injury conducted outside of the military context. This means that some of this study findings are unique to this new context and may diverge from those obtained in other research contexts (e.g., military). Yet, there are still significant overlaps and similarities between some of the findings of this study and those reported in the previous research literature on moral injury. These similarities may point towards possible common features of this experience, which are shared among various contexts. The following sections will discuss these similarities with respect to: (a) transgressive acts and moral injury, (b) experiential features of moral injury, sometimes referred to as symptoms (Jinkerson, 2016) or consequences of moral injury (Drescher et al., 2011; Litz et al., 2009; Nash & Litz, 2013), (c) the role of awareness in moral injury, and (d) the role of self-forgiveness in one’s journey of healing from moral injury. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 162 Transgressive acts and moral injury. The concept of “transgressive acts” or “transgressions” has been highly debated in the moral injury research literature, and Frankfurt and Frazier (2016) suggested that a “systemic inquiry that bridges psychology, philosophy, and military studies is needed to resolve what should be considered transgressive acts and how they should be defined” (p. 2). There are currently several proposed conceptualizations of “transgressions” in the research literature on moral injury. Frankfurt and Frazier (2016) attempted to summarize the current available understandings of “transgressions” within the context of moral injury, starting with Litz et al. (2009), and offered further insight into the ambiguous construct. They suggested that transgressive acts “identify and describe experiences that involve the violation or transgression of accepted boundaries of behaviour” (p. 2). However, the authors go on to explain that there is no consensus within literature on what “acts” are considered transgressions but allude that boundaries in this context are understood as a “behaviour that falls outside the rules of engagement (e.g., atrocities, war crimes)” (p. 2). Frankfurt and Frazier acknowledged transgressive acts as “potentially traumatic experiences distinct from the fear-based traumas” (p. 1), meaning that transgressive acts can be accompanied by a traumatic experience, but unlike PTSD, the experience of moral injury is not rooted in transgressions which evoked a fear-based reaction, but rather a moral violation. Most recently, Wisco (2017) simplified the conceptualization of transgressions in the context of moral injury by suggesting that there are three such common moral transgressions, or potentially morally injurious events: (1) transgressions that have been committed by oneself, commonly referred to as “transgressions by self” and corresponding to Litz et al.’s (2009) understanding of MI as “perpetrating or failing to prevent” (p. 695) ; (2) transgressions that have PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 163 been committed by others, commonly referred to as “transgressions by others”, which correspond to Litz et al.’s (2009) construct of “bearing witness to” (p. 695); and (3) the experience of betrayal, understood by Shay (2014) as a transgression of what is right, and by Nash and Litz (2013) as loss of trust as a consequence of a transgression. For the purpose of this discussion, I will use Wisco’s (2017) list of the three primary transgressions (i.e., transgression by self, transgression by others, and betrayal) to understand the findings of this current study within the extant literature on moral injury. Transgressions committed by self. In this study, transgressions by self or transgressionsself were experienced as: (a) acting out aggression against partners in a physical manner, (b) verbally abusing intimate partners, and (c) engaging in acts of sexual infidelity. Some participants described how transgressing their partners felt like they were hurting the very person they were meant to love. In some instances, participants acted in a physically aggressive manner (e.g. kicking doors, breaking things) in an exasperated attempt to be heard and seen by their partners. Participants understood their aggressive actions as a desperate attempt to hold onto the relationship and to what they believed it represented. For some of the participants, transgressions perpetrated by self were experienced as being verbally abusive towards their partners. A few participants recalled degrading their partners by name calling, and addressing them with a level of disrespect with which they would never speak to other people. For others, transgressions meant engaging in sexual infidelity as a way to escape the pain they were feeling in their broken relationships. One of the participants described feeling like he was never enough and could never do enough in his relationship, and eventually escaping the anger and hurt by having an affair with another woman who made him feel alive and fulfilled. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 164 Regardless of the type of transgression, these actions were experienced by participants as violating important “moral beliefs and expectations” (Litz et al., 2009), which led to experiences of shame, guilt, and remorse. Transgressions committed by others. Litz et al. (2009), Drescher (2011), and Jinkerson (2016) proposed that moral injury entails witnessing or failing to stop transgressions committed by others. In the context of intimate partner relationships, transgressions committed by others were experienced as being committed against the participants, thus making the participants victims of these transgressions. Specifically, transgressions committed by others against the participants were often experienced or witnessed as instances of (a) sexual infidelity, (b) direct emotional abuse, and/or (c) indirect emotional abuse as a result of participants’ partners mistreating their children (e.g., one of the participants had to witness his or her partner mistreating their son without being able to intervene). With respect to the sexual infidelity, both Aaron and Tom recounted that they felt harmed and hurt by their partners’ affairs. Tom recalled his experience of intuitively knowing that his wife was having an affair from seeing her embracing another man, and feeling stunned and speechless as a response to such a betrayal. All of the participants experienced direct emotional abuse within their relationships. For example, James felt emotionally abused by his wife for always making him feel as if he was not doing enough, and that he was not enough. He described doing everything in his power to fulfill his duties as a man, a husband, and a father, but constantly feeling inadequate because of the way his wife treated him. Similarly, Tom identified himself as a victim of emotional abuse by sharing how he was taken advantage of financially and emotionally as he continued to forgive his wife’s PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 165 transgressions and attempted to keep the family together despite the significant costs to his wellbeing and emotional stability. Both James and Annie had experiences where they felt emotionally abused due to the powerlessness they experienced while their partners rejected or mistreated their children. James shared that he started feeling this way after the birth of his child as he watched his wife reject their newborn baby. He felt angry, confused, and hurt that his wife was preoccupied with coping with her own emotions that she wanted nothing to do with their beautiful and innocent child who deserved nothing but her love. Betrayal. Nash et al. (2013), Shay (2014), Bryan et al., (2014), and Wisco (2017) suggested that moral injury may entail betrayal. Although Wisco (2017) listed betrayal and transgressions committed by others separately, the results of this study suggest that, in the context of intimate partner relationships, it is hard to distinguish between the two because transgressions committed by participants’ partners were almost always experienced as betrayal. Although the findings of this study suggest that they are experienced as one and the same, it is important to note that this should not be generalized to other contexts such as the military. In the current study, participants’ experience suggests that betrayal was lived in response to a transgressive act done by their partner (e.g. infidelity, stonewalling, verbal abuse). For instance, Tom stated that his wife’s continued affair was experienced as betrayal. He described that under the pretense of trying to make their relationship work, she continued lying and living a double life with him and another man. Tom shared feeling used, worthless, and betrayed because while he continued to be committed to healing and uniting their family, she continued to be dishonest. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 166 Participants often experienced transgressions done by their partners towards their children or themselves as betrayal. James spoke of feeling betrayed by his wife as she rejected their baby post-delivery. James spoke of feeling rejected by her as she rejected the child, for he felt that she had betrayed him and the plan they had for their life together. As a result of betrayal, some participants experienced significant loss of trust in others. Tom spoke of becoming more guarded and suspicious when relating to people as a result of his experience with his wife. Likewise, Aaron shared how being betrayed by his ex-wife induced some similar changes, and that after that experience, he had a hard time trusting people. In addition to betrayal by others, Nash and Litz (2013) suggested that the “most powerful of all wartime betrayals may be those which persons accuse themselves of committing, whether rightly or wrongly” (p. 7). Likewise, the current findings suggest that, for most participants, the greatest pain of betrayal was experienced when the participants perceived their actions or inaction within the relationship as self-betrayal. The findings of the study suggest that the experience of self-betrayal would occur when the participants realized that their actions, regardless of whom they were directed towards, violated their own sense of right and wrong. Self-betrayal was also experienced as restricting or depriving oneself from being authentic and true to one’s core aspect of being. Aaron shared that he felt that he betrayed himself as he slowly and gradually deprived himself of essential aspects of his personal life, such as internal happiness and peace. Similarly, James depicted self-betrayal as not being true to who he was by stifling his voice and supressing a component of his personality within the relationship. He further described his self-betrayal as having had a negative impact on his ability to connect to other people, in romantic and non-romantic relationships. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 167 Experiential features of moral injury. In the current literature, the manifestations associated with moral injury are labelled as “consequences” (Drescher et al., 2011; Litz et al., 2009; Nash & Litz, 2013) and “symptoms” (Jinkerson, 2016). Some of the most notable and typical symptoms or experiential features of MI reported in research studies are guilt, shame, spiritual/existential conflict, and loss of trust in others, deities, and the self, self-condemnation, and remorse (Drescher et al., 2011; Jinkerson, 2016; Litz et al., 2009; Nash & Litz, 2013; Shay, 2014). In addition, there are secondary psychological manifestations that seem to be associated with moral injury: anhedonia, dysphoria, depression, anxiety, anger, and intrusive thoughts and images (Bryan et al., 2014; Drescher et al., 2011; Maguen et al., 2011; Nash et al., 2013; Stein et al., 2012). The term “consequences” has often been used to speak about these negative manifestations of moral injury (Drescher et al., 2011; Litz et al., 2009; Nash & Litz, 2013), yet, it is also important to note that Litz and colleagues (2009) identified some of the same consequences, such as guilt and shame, as part of the causal mechanism of moral injury. Most recently, Jinkerson proposed a syndrome perspective and identified what were previously understood as “consequences” as core symptoms of moral injury (Jinkerson, 2016). For the purpose of this discussion, I will refer to the often-identified symptoms/consequences, as experiential features or manifestations associated with moral injury. The findings of this study suggest that participants experienced many of the moral injury features found in previous research studies. For the participants of this study, the most salient manifestations of moral injury were shame, guilt, self-condemnation, remorse, and anger. Moral emotions and moral injury. In the literature on moral injury, there is a significant focus on moral emotions, and their presence is used as an indicator to show that the injury is PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 168 moral in nature. Litz et al. (2009) suggested that “moral emotions, self-focused and otherfocused, serve to maintain a moral code” (p. 699) Further, the authors proposed that moral emotions are unique emotions related to the experience of moral beliefs. Haidt (2003) has mentioned four subtypes of moral emotions: (1) emotions concerning others (i.e., contempt, rage, displeasure); (2) self-conscious emotions (i.e., shame, embarrassment, guilt); (3) emotions related to the suffering of others, such as empathy; and (4) emotions related to praising others (i.e., gratitude, fear, evaluation). The current research literature on moral injury identified shame and guilt as the primary moral emotions involved in the subjective experience of moral injury (Jinkerson, 2016; Litz et al., 2009; Powers, 2017). However, the understanding of the role of moral emotions in the experience of moral injury varies among researchers. Litz et al. (2009) discussed moral emotions as part of the causal mechanism of moral injury, stating that if dissonance (or a conflict between what has occurred and the individual’s intact moral belief system) was not reconciled, moral emotions would emerge and could eventually lead to moral injury by evoking withdrawal and difficulty to forgive, nurturing self-condemnation (see Figure 2). Jinkerson (2016) proposed that moral emotions may be a distinctive symptom of moral injury. He suggested that “loss of trust and spiritual/existential issues are core moral injury symptoms, and psychological and social problems also merit syndrome inclusion” (p. 3). And lastly, Powers (2017) suggested that moral emotions accompany the affective experience of moral injury and are experiential markers signaling to individuals that a transgression was committed. Since a phenomenological study does not seek to answer questions of how or why, this study cannot clarify whether moral emotions have a causal or simply symptomatic role in moral injury. Rather, the following sections on moral emotions will depict the participants’ lived experience of shame, guilt, anger, PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 169 self-condemnation, and remorse as depicted during the phenomenological exploration of their moral injury. Shame. Understood as the negative evaluation of the “core self” (Lewis, 1971; Tangney et al., 2007), shame was omnipresent in participants’ lived experience. Participants experienced shame as a result of: (a) something they have done to their partners, (b) something they have done to hurt themselves, and/or (c) what their partners have done to hurt them. For one of the participants, shame was an experience that was evoked by doing something they deemed wrong. James recalled feeling “bad” and ashamed for secretly having an affair with another woman. He spoke of shame as something that encapsulated his interactions with his wife at the time, leaving him feeling debilitated, empty, and hollow. For another participant, shame was directed towards himself and his lack of willingness and ability to protect himself. Tom spoke of feeling ashamed of his foolishness and gullibility that allowed him to stay in a relationship that was abusive and riddled with betrayal. Shame also appeared as a natural reaction accompanying a degrading circumstance, such as being a victim of infidelity. This diverse appearance of shame suggests that the context of intimate partner relationships offers many circumstances that may evoke shame, and therefore, a negative evaluation of the core or true self of the participant. Such a finding appears to suggest that regardless of one’s role within the emotional abuse (perpetrator, victim, or both), it seems likely that an individual will experience shame, and therefore a global, stable negative evaluation of self. Guilt. Tangney, Stuewig, and Hafez (2011) suggested that “shame is the more “public” emotion arising from exposure to disapproving others, whereas guilt is the more “private” PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 170 experience represented by internally-generated pangs of conscience” (p. 2). Guilt has been suggested to be an emotion focused on “a particular action as being bad or immoral” (Fisher & Exline, 2006, p. 129). Many researchers, including Litz and colleagues (2009), Jinkerson (2016), and Powers (2017) proposed that guilt was a salient moral emotion in moral injury. Consistent with these existing research findings on moral injury, guilt was also experienced by the participants of the current study. Specifically, participants experienced guilt when they hurt their partners. For James, guilt occurred when he cheated on his wife and then told her that he no longer wanted to be married to her. James shared feeling guilty ending the marriage because he knew it would hurt his partner. The current study also highlighted that participants experienced guilt when they did not prevent harm to their children. Annie spoke of experiencing guilt towards her son because she allowed her partner to treat her son the way she believed went against her beliefs. In addition to the participants feeling guilty for hurting their partners, some of the participants shared feeling guilty because their children were exposed to unstable, inconsistent, and at times, unhealthy family environment. Lastly, Aaron recalled feeling guilty for not being honest with himself. He described not being able to look at himself in the mirror because he knew that he was consciously failing himself by the way he was behaving in the relationship, and by the fact he was staying in it. Self-condemnation and remorse. Studies conducted by Fisher and Exline (2006) and Litz et al. (2009) suggested that the tendency to experience shame was associated with feelings of self-condemnation and remorse, “variables germane to moral injury” (Litz et al., 2009, p. 702). Although Litz et al. (2009) do not define these two terms, a common definition and distinction between remorse and self-condemnation is that remorse is often used “to refer to PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 171 offense-related responses that are guilt-related (e.g., sorrow; regret), and self-condemnation to refer to offense-related responses that are shame-related (e.g., self-hatred; seeing oneself as a bad person) (Fisher & Exline, 2006, p. 129). Fisher and Exline’s (2006) study suggested that remorse was connected with one’s willingness to “humble the self and to repent for one’s misdeeds” (p. 141), while self-condemnation embodies a more global, negative, and severe stance towards oneself. The current findings fit with the suggestion that both these emotions are experienced during moral injury (Fisher & Exline, 2006; Litz et al., 2009) and that remorse was never felt by the participants solely as an outcome of the pain inflicted on their partners, but was always combined with the pain of recognizing self-estrangement through their transgressions against their partners. For example, Annie recalled becoming aware of the disconnect she had with her true self by the way she would mistreat her partner. She described losing control and verbally attacking her husband, and as a result perceiving herself as a horrible person. Annie explained that immediately following her “abusive” actions she felt incredible remorse. Self-condemnation frequently appeared following remorse, particularly when participants became aware of one’s participation and contribution to the suffering. Tom remembered feeling angry and labeling himself as “stupid” and a “fool” for thinking that his dreams of a happy and unified family could come true. He recognized that his self-perpetuated blindness regarding the problems in the relationship led to some of the pain he was experiencing. The awareness that one was contributing to the unbearable situation was often painful, for it was not always immediately reconciled with the realization that such actions were committed out of a misguided attempt to fulfill significant longings. Annie recalled being willing to sacrifice her freedom as a way to keep PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 172 a sense of peace and stability in her family. In the interview, she recalled this sacrifice with shock and self-directed anger for letting herself be in such a position. The findings suggest that it was easy for the participants to start questioning or blaming oneself for the part played, increasing the potential of entering a cyclical trap of remorse and self-condemnation. Anger. Aside from the shame and guilt as the moral emotions described in the research literature on moral injury, anger, disgust, and contempt have also been proposed as emotional experiences that accompany moral injury (Farnsworth et al., 2014). Anger is commonly speculated as a moral emotion (Haidt, 2003), although not as widely accepted as shame and guilt. In this study, participants often described anger as an emotion being directed at their partners as a result of an unjust treatment they were receiving from their partners. James shared feeling angry that his partner was not helping him or their children and was relying solely on him. He recalled how his partner’s lack of willingness and ability to share the burden of the relationship and of having a family eventually became debilitating, leaving him feeling angry and hurt. Annie recalled getting so angry at one point in her relationship that she would get verbally aggressive. She recalled yelling, swearing, and even threatening her husband to take down the door of the study so that he could no longer lock himself away and ignore her. In the current findings, anger was also described as being directed towards oneself. Tom shared that even now he is still angry with himself for being a fool within his relationship. Summary. The findings of this research study provide support to the central role of moral emotions in the experience of moral injury. The participants’ experience of guilt, shame, remorse, self-condemnation, and anger emphasize the experience of moral injury as a consequence of moral violations (Frankfurt & Frazier, 2016), rather than a fear-based response to trauma, such as PTSD (i.e. hypervigilance and avoidance behaviours). PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 173 Role of awareness in moral injury. Litz and al. (2009) stated that moral injury may entail one’s “engaging in subtle acts or experiencing reactions that, upon reflection, transgress a moral code” (Litz et al. 2009, p. 697). This emphasizes the key role that reflection and awareness play in experiencing moral injury. Consistent with Litz and colleagues’ (2009) conceptualization of the role of awareness, participants in this study described their reflection and awareness of transgressions as painful moments of sudden realization that brutally exposed that what they previously believed to be true about the self and their partners was not true. Annie explained that she always thought of herself as a feminist, confident and opinionated. However, there came a moment within the relationship when she realized that that was no longer true, and that time in the relationship has worn her down to the point where she conceded to give up a part of herself to experience peace. The current findings suggest that awareness was often experienced as deepening of one’s pain. Simply put it, for all of the participants it was only after they became aware of the transgressions (e.g., actions of infidelity, verbal aggression/abuse, moral violations) and selfestrangement (e.g. ‘who have I become’?) that they began to feel lost and sorrowful. In addition, for many participants, the experience of anxiety or depression shortly followed the awareness of their partner’s infidelity or their own transgressions within the relationship. Powers (2017) suggested that moral injury can be framed as “the realization one’s moral orientation, to which one commits his or her willing, is aligned toward a “good” that is ultimately false” (p. 327). The findings of this research also suggest that awareness is a significant theme of the moral injury process, and that the transgression per se has very little explicit impact on the individual until he or she becomes aware of the meaning and impact of transgression. By becoming aware of the transgressive acts (committed by themselves or their partners), the PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 174 participants either realized that they were behaving in a manner did not represent the way they saw themselves, or, that their partners were acting in a way that the participants deemed incongruent with their understanding of them. For the participants, this meant that what they believed to be true about themselves, their partners, and their marriage was not. In other words, what they “aligned toward as good” (p. 327), turned out to be “false”. Self-forgiveness. The literature on protective factors and healing of individuals suffering with moral injury in the context of military has emphasized the significance of self-forgiveness and meaning-making of the morally injurious experience as key to the healing process (Hall & Fitnchan, 2005; Harris et al., 2015; Litz et al., 2009; Yan, 2016). Litz et al. (2009) suggested that self-forgiveness is a “means of obviating self-condemnation and shame and a vehicle for corrective action” (p. 699). Hall and Fincham (2005) define self-forgiveness as: a set of motivational changes whereby one becomes decreasingly motivated to avoid stimuli associated with the offense, decreasingly motivated to retaliate against the self (e.g., punish the self, engage in self-destructive behaviors, etc.), and increasingly motivated to act benevolently toward the self. (p. 622) Self-forgiveness entails acknowledging the event, accepting responsibility for it, experiencing the negative emotions associated with it, devoting sufficient energy to heal, and committing to living differently in the future (Litz et al., 2009). Likewise, in the current study, self-forgiveness was experienced as an important experience of healing. Annie spoke of finally letting go of the pain of moral injury by gaining distance from the experience and looking at her actions with understanding and compassion. She realized that she did the best she could, and that it was time to let go by forgiving herself and others. The participants of this study shared that letting go was an important part of forgiveness. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 175 Tom recalled making a decision not to dwell on the pain of his failed relationship, and not to allow his past to define his future. He recalled wanting to have new experiences that would not be tainted by his previous ones. Conclusion. So far, this chapter has focused on the similarities between current literature and the lived experience of moral injury found in this study. Specifically, the findings of this study are consistent with those indicating that: (a) transgressive acts are essential for experiencing moral injury, (b) moral injury is lived through the negative moral emotions and secondary psychological distress, (c) awareness and reflection represent catalysts for a full experience of moral injury, and (d) self-forgiveness plays a central role in the process of healing from moral injury. For the purpose of gaining further insight into the phenomenon of moral injury, the next section will highlight the new findings that emerged in the current study. New Findings The phenomenological approach adopted by the current study allowed to uncover the lived experience of the phenomenon of moral injury, rather than provide an understanding of it from the perspective of a detached observer. Thereby, the current findings offer unique and novel glimpses into the lived experience of moral injury, thus complementing the previous research findings on moral injury. This section will address the following new findings that emerged from the current study: (a) self-transgressions as morally injurious acts, (b) the role of self-estrangement in moral injury; (c) moral injury as holistic experience, (d) moral injury as human response to transgressions; (e) lack of awareness and perpetration of moral injury; (f) the experience of moral injury as process, and (g) the transformational potential of moral injury. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 176 Self-transgressions as morally injurious acts. Although transgression by self is mentioned within the research literature on moral injury (Bryan et al., 2017; Drescher et al., 2011; Litz et al., 2009; Wisco, 2017), transgression against one’s self or self-transgression is not. However, the experience of transgressing against one’s self has clearly emerged as an important finding of this study: participants often experienced the transgressions committed by themselves as self-transgressions or transgressions against one’s self. Specifically, by violating another human being, participants became aware that they were violating their own sense of self. Annie recalled that by swearing at her partner and seeing his reaction, she became aware that her words were abusive. She remembered coming to a point where she questioned what she was capable of (i.e., hurting her husband) and realizing that she was not the person that she wanted to be. Likewise, Aaron explained that when he would do or say things that disrespected his partner, he felt as if he was disrespecting his true self. He elaborated by sharing that such behaviour made him feel as if he was disconnection or losing himself. Self-transgressions were also lived as engaging in inauthentic actions that contradicted one’s beliefs. Annie recalled that her partner convinced her to act a certain way towards her son (e.g. not letting him express his more creative or emotional side) and that she would do it even though it violated her beliefs. The presence of self-transgressions in the lived experience of moral injury represents an important finding to note because, in the existing research literature on MI, the subject and object of transgressive acts have not been explicitly identified, and, typically, the object of transgressions was assumed to be the other person, not one’s self. Nonetheless, the findings of this study suggest that whenever someone is inflicting moral harm against another person, one is also self-inflicting harm against oneself, although one may not be aware of this at the time of PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 177 transgression. For instance, James shared that he felt cheated and let down by his own choices because they led to an unfulfilling life. The role of self-estrangement in moral injury. In the existing research studies on moral injury, the theme of self-estrangement has not been identified or explored. Yet, in the current study self-estrangement emerged as one of the six core themes within the lived experience of moral injury in the context of intimate partner relationships. For some of the participants in this study, self-estrangement was experienced, in part, as loss of self. Aaron shared feeling like his experience within the relationship narrowed down to one very important point, the last drop, a moment where he felt like he had lost himself. For others, such as Annie, self-estrangement was lived as shutting down her true self or disconnecting from her true self as a way to cope with the pain of the relationship while her true self was alarming her that something was wrong. Later on, Annie recalled behaving in such an unauthentic, and at times, abusive way that she said began to question what she was capable of. The experience of the participants in this study suggest that the dire impact of moral injury may be partly due to one’s lack of connection to one’ self. That disconnection from self led participants to not seeing or not wanting to see the reality for what it was, and, thus, to a progressive weakening of the grounding in what was true for both self and other. Without being anchored within themselves, when the reality set in, participants were left feeling shocked and dead inside. Tom shared feeling dead in the moment he became aware of his wife’s transgression, because he did not have a remaining sense of self to anchor himself in. James recalled being unable to cope with the betrayal, and feeling like his life was over. Although self-estrangement clearly deepened within participants’ intimate relationships, for some participants self-estrangement might have begun prior to their intimate relationship. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 178 This observation may evoke questions regarding the role of self-estrangement in the experience of moral injury, specifically with respect to individual’s vulnerability towards moral injury or in the genesis of moral injury. In other words, some of the current findings suggest that disconnection from one’s self or self-estrangement may pre-date the actual experience of moral injury, and may constitute a significant vulnerability to experiencing moral injury. This hypothesis is consistent with research studies on complex relational trauma that suggest that early traumatic experiences that led to misalignment within one’s sense of self predispose one to experiencing moral injury (van der Kolk, 2005). In the current study, Tom’s experience offered a glimpse into this dynamic and illuminated the impact that transgressive acts may have on an individual who does not have a solid connection to one’s true self. Tom shared that as a child he did not have a strong sense of self, and what he perceived to be his authentic self was socially unaccepted and rejected as weak. He described how in time he managed to build a new sense of self, identifying as a successful business and family man. However, he recalled that his wife’s infidelity undermined his new self (his “ego” ) and that her transgression impacted his entire being by shattering the only sense of self he had left. Moral injury as holistic experience. Although some researchers suggested that moral injury is centered around the experience of cognitive dissonance (Litz et al., 2009; Nash et al., 2013), and even proposed that cognitive dissonance is the explanatory mechanism of moral injury (Litz et al., 2009), the findings of this study suggest that moral injury encompasses far more than one’s cognitive dissonance and represents an experience that encompasses one’s entire being, including one’s dignity and sense of self. In this study, two participants used the phrase “entire being” as they described their journey of moral injury. One participant used this phrase as PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 179 a way to depict what was being transgressed as a consequence of a moral violation (infidelity): “It affected more than just my feelings, it effected my entire being!” Tom described his partner’s violation to have affected the way he thought and felt, characterizing its impact as a ceasing of any forward motion or comprehendible future for him as a whole. Another participant, James, used the phrase “entire being” as a reference to what he was reconnecting to through activating his agency. James shared that in the process of reconnecting to his true self, he pursued things that felt authentic and that eventually he began to feel joy and a new sense of comfort in his “own skin”. The current findings suggest that the impact of moral injury clearly transcends the cognitive aspects highlighted in the current research on moral injury. Moral injury as human response to transgressions. Rather than understanding the experiential features of moral injury as symptoms indicative of psychopathology, or moral injury as a traumatic syndrome (Jinkerson, 2016), the findings of this study suggest that the distressing experiences that accompany moral injury (e.g., anxiety, depression) often represent warning signs that communicated to participants that something was wrong and that they were suffering, even if they turned a blind eye to what was going on. Depression and anxiety were not merely experienced as negative manifestations of moral injury; rather, they were also experienced as wake-up calls that participants needed to pay attention and to attend to self-estrangement and disconnection with reality. These experiences forced the participants to face reality and be more attuned to their emotionality and their true self. Aaron spoke of how his experience of depression made him slow down and take time off, forcing him to have more time to connect to what was happening for him. For many, these “negative” experiences provided insight and motivated them to begin their journeys towards healing. This suggests that the suffering experienced when someone PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 180 transgresses others or one’s self represents a human response that encapsulates the potential for healing, not just symptomatic behaviour that needs to be reduced or eliminated. That being said, it is also possible that this moral suffering left unattended may lead to more severe psychopathological symptoms such as severe depression, substance abuse, and/or suicidality. Lack of awareness and perpetration of moral injury. Awareness has been previously discussed as a necessary step, a moment where the participants realized he or she did something wrong, in order for them to experience moral injury and the suffering that accompanies it. It was during the theme of sudden awareness that all the participants faced their reality, their transgressions, and their pain. However, the current findings go beyond stating that awareness is necessary for an individual to experience the pain associated with moral injury, suggesting that, in addition, lack of awareness may actually lead to perpetuation of transgressive acts and harm to self. Similar to one being unaware that smoking is deadly, an individual may be perpetuating unhealthy habits by smoking multiple cigarettes a day while being completely unaware they may be increasing their risk of lung cancer or death. Although, at times, the participants of this study were not fully aware of the harm they were causing themselves by being in the romantic relationship, such actions contributed to greater chances of transgressive acts and further selfestrangement. The current findings suggest that insufficient awareness by the participants regarding what was happening for them (performing life, slow and hypnotic self-estrangement, transgressions, self-silencing, etc.) within their relationship may be the reason why transgressions often reoccurred. Annie shared how in retrospect she ponders and criticizes herself for not voicing her pain and unhappiness, yet understands that at the time she did not see it. She PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 181 elaborates by saying that she had to distance herself from the relationship to be able to see the pain and transgressions within it. James spoke of this lack of awareness as being something he was inflicting on himself by turning a blind eye to the dysfunctional relationship he was in. He recalled being naïve, ready, and willing to fool himself so he could repeat the mistake of staying in the abusive relationship. He depicted this experience by stating that although no one wants to believe a lie, people still do if it means they get to fool themselves into thinking they are getting what they wanted. Annie shared how being unaware and not attuned to herself eventually contributed to her staying in the relationship for 27 years. She shared this in disbelief, asking herself what the “hell” she was thinking. The experience of moral injury as process. The results of this study indicate that the lived experience of moral injury represents a process of becoming that unfolds over time, and is not one strictly localized event like a physical injury (e.g., spraining one’s ankle). Hence, the term “injury” may be misleading when one encounters moral injury through a phenomenological lens. This further suggests that the lived experience of moral injury in the context of intimate partner relationships represents an intrinsically temporal phenomenon and that time is quintessential in understanding of moral injury phenomenon. Heidegger (1962/2004) states that “because Being cannot be grasped except by taking time into consideration, the answer to the question of Being cannot lie in an proposition that is blind and isolated” (p. 40). Likewise, the findings of this study suggest that the understanding of moral injury in the context of intimate relationships should not be constrained by an incomplete or rudimentary notion of a linear sequence of triggering events and consequences. Applying the physical concept of injury to the PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 182 experience of moral injury would misguide the understanding by experientially and linguistically restricting the phenomenon. The extant literature based exclusively from moral injury in military contexts has not adequately captured the temporal nature of moral injury found within the intimate partner relationships, namely the unraveling and becoming through suffering. The current conceptualization of moral injury stemming from research in military context appears to overlook the existential and noetic dimensions of this human experience (Frankl, 1986), by not acknowledging the temporal, fluid, and transformational essence of the human being or Dasein (Heidegger, 1962/2004). These characteristics were apparent in how participants in this study experienced moral injury. This emphasis on the process aspects of moral injury in the context of intimate relationships may be due to the fact that participants had a longer time period in which they experienced all the transgressions (e.g., it may have taken a longer time for transgressions to occur), and perhaps had more time to process all the manifestations associated with moral injury without simultaneously battling survival instincts or psychological disorders associated with the war context. In addition, it is possible that transgressions are more subtle and less salient in the context of intimate partner relationships, making time an essential component in experiencing moral injury. In this sense, Aaron depicted his process of moral injury as: “It happened very subtle, like, over time, little by little” (Aaron). Likewise, Annie suggested that the process was gradual but that it had a dire impact of restricting her ability to be and behave the way that felt true to who she is. The transformational potential of moral injury. Although there are many negative consequences associated with moral injury, the lived experience of this phenomenon has PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 183 highlighted that such an outlook does not encompass the whole truth. Specifically, the phenomenological analysis of the experience of moral injury within the context of intimate partner relationships suggested that this experience often possesses an inherently transformational and healing movement that nurtures an individual’s journey towards restoration of a connection with self and others. Aaron shared working hard towards understanding that he should come first, and that he has to in order to be there for the people in his life. Similarly, Tom recalled his journey by sharing that through it he became more aware of who he is and has begun to feel good in his own skin. He elaborated by saying that he has gone through a process of atonement, and that the guilt and the “black emotions” has dissipated leaving him excited and open for new experiences in his life. However, not all participants experienced moral injury as a positively transformational experience, rather, some experienced it as everlasting wounds. James spoke of feeling scarred, sharing that his wounds still bleed from time to time. He elaborated by saying that the unhealed wounds are the consequence of not being attuned to himself and processing the pain. Theoretical Contributions of the Study The following sections will highlight the theoretical contributions of this study. More specifically, in this section I will discuss: (a) the meaning of “moral” within the phenomenon of moral injury, (b) the role of one’s self in moral injury, and (c) a newly proposed term and description of the phenomenon currently identified as “moral injury”. The moral in moral injury. It is important to note that the term “moral” has not been defined by any of the current moral injury theories or definitions. Hence, the term “moral injury” is itself ambiguous regarding the object of harm (what is being harmed) and the nature of PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 184 suffering (i.e. spiritual, existential, cognitive). The findings of this study illuminated two different ways in which the term “moral” was understood and experienced by the participants. The first meaning of ‘moral’ pointed towards an external understanding of morality, described as socially, familial, and religiously ascribed morals, values, expectations, and norms. One participant shared how he did not believe that ending his unhealthy relationship was an acceptable thing to do because it would not be true to the moral code he was raised with. He elaborated by saying that he used to believe that once a person got married they remain married, there was no space for divorce or affairs. However, he added that the negative emotions he was not addressing brought up by his relationship continued to build overtime regardless of him following the values he was raised with and doing the “right” thing. Likewise, Aaron shared the pressure he felt from his religious community to remain in his unhealthy marital relationship and not get divorced. He explained how for a long time he did not believe divorce was an option for a Christian, for he was exposed to the beliefs of the older and more “conservative version of a Christian”. Both examples illustrate the external moral codes that the participants abided by, despite wanting to do the contrary, or knowing that they should do the contrary (i.e., get a divorce). The second meaning of ‘moral’ pointed towards an internal experience of morality lived by the participants as their unique sense of what was right for their true self (i.e. essence), even if, at times, what they believed to be right for their true self contradicted the externally prescribed morality. In many instances, participants of this study described transgressions, such as cheating on their spouse or ending a marital relationship, as actions that they anticipated would cause feelings of guilt or shame because they were violating the moral codes they grew up with. However, participants noted that they did not experience significant guilt or shame when they PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 185 transgressed those, but rather, they felt liberated and fulfilled. These findings suggest that the experiences of feeling liberated and fulfilled were lived when participants’ actions or inactions transgressed their external sense of moral (e.g. community expectations, family values) but did not transgress their internal sense of moral (i.e., what they believed was the “right” thing for them as a unique human being). James speaks about feeling ashamed that he cheated on his wife, but that this sense of shame was not enough to stop him from doing it. He recalled pursing what he felt was right for him as a human being, his true self, even though the moral codes of society deemed it as wrong. The recognition of what felt morally right in terms of their essence was often accompanied by the participants’ will to make decisions and take actions that were congruent with their core sense of self. For all of the participants in this study, this recognition and actions manifested in the ending of their intimate partner relationships despite the unchanging external pressures (e.g. church community, children, family). Moreover, current findings suggest that when the participants’ actions were congruent with their true sense of self, such actions may have aided the participants’ process of feeling more fulfilled and more connected to themselves and others (less self-estranged). Thus, the findings of this study suggest that transgressions of internally and externally defined morality, at times, carry profoundly different consequences. Although the findings indicate that these transgressions often occur simultaneously – given the relational nature of humans – the suffering encountered within the lived experience of moral injury appears to primarily emerge from the awareness that one has transgressed their internal sense of morality. The lived experience suggests that the object of violation is not merely beliefs, expectations, values, ethics, and morals independent of one’s unique and authentic self (Heidegger, PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 186 1962/2004); rather, it is a suffering stemming from transgressing one’s core self. This current finding infers that morality is an inherent part of one’s essence, of one’s true self; thus, violating one’s morality is experienced as self-transgression. Comparably, the moral polarity of the internal and external experience of morality suggested in this study is similar to the Existential Analysis (EA) theory of the moral conscience. In EA, the moral conscience is understood as personal and refers to the selfhood of the person on the “internal pole, to self-loyalty, and on the outer pole, to intrinsic value of the other – and then more generally, to “what is right” (Längle, 2013, p. 1). Moral conscience is thought to “indicate to me what corresponds to my essence and how I correspond to the essence of the other” (Längle, 2015, p. 1, emphasis in the original). In EA theory, however, the moral conscience creates justice for both one’s self and the other at the same time. Although the findings of this study are not always clear regarding the participants’ desire to “create” justice for their partners, most described the ending of their relationship as being positive for both individuals. Aaron spoke about how the end of the relationship “allowed everyone involved to pick up pieces and try to move on instead of carry on indefinitely, years, and harming all the involved even more.” Understanding the object of injury is important for gaining further insight into the individual’s role in the process of moral injury. The findings of this study suggest that the object of harm is one’s essence, and in the next section, I will elaborate what that means in terms of one’s involvement in experiencing moral injury. The role of self in moral injury. To begin, it is important to note that one’s role in morally injurious events may be different than one’s role in the intimate partner relationship, even if the morally injurious events happen within the context of intimate partner relationships. In traumatic contexts, such as in unhealthy or abusive relationships, an individual may be PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 187 identified as a victim, a perpetrator, or, in some instances, both. However, even if an individual perpetrated moral transgression, such a transgression does not infer that the individual was a perpetrator within an abusive relationship. For example, one of the participants felt as if they have transgressed themselves because they did not stop their partner from mistreating their child and staying quiet was an act against their beliefs. Although in this situation the individual may have perpetrated self-transgression, they were also a victim of an emotionally abusive relationship. Current literature on moral injury states that one can experience moral injury as a consequence of actions, inactions, bearing witness to, or learning about events that may violate one’s morals, expectations, beliefs, and ethics (Drescher et al., 2011; Jinkerson, 2016; Litz et al., 2009; Shay, 2014). It suggests that one can develop moral injury as a result of being a witness, a perpetrator, and or a victim of learning about events of morally injurious actions. It is important to note that these authors do not explain the reasoning behind such an expansive criterion; however, given moral injury’s conceptual overlap with PTSD and its focus on the military context, one might infer that such variables influenced this conclusion. The findings of this study suggest that the individual experiencing moral injury is always directly involved within a morally injurious event (by their actions or inactions). The participants in this study experienced transgressions by acting against their beliefs or by violating their values by not acting. As previously discussed, the findings of this research suggest that the concept of morality in the context of moral injury within intimate partner relationships is lived as a transgression of internally experienced morality which correlates to one’s essence, or core self. Thus, a violation of one’s internal morals implies a self-transgression, or a violation of one’s true self. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 188 The current findings acknowledge that individuals experiencing moral injury are victims of the suffering which accompanies such an experience; however, the current study also identifies someone suffering from moral injury as an individual who has taken part in the perpetration of their moral injury. Simply, the findings of this study suggest that an individual suffering from moral injury is both a victim and a perpetrator, for moral injury requires for one to have an internal sense of morality and actions/inactions (that the participant could have altered) that transgress them. I state this with extreme caution, and would like to clarify that the participants in this study did not choose to harm themselves. On the contrary, the participants were dwelling in toxic, oppressive, and potentially traumatic environments which would have made it incredibly difficult to be attuned to oneself and act congruently with their internal sense of morality. The current findings suggest that given the identified self-estrangement, the deep sense of longing that each participant hoped to fulfill within their romantic relationship, and external pressures or promises from their partners, transgressions appeared as a natural consequence of such a situation. The current findings do not infer that the transgressions are indicative of participants poor sense of morality or character. The term “moral injury.” As noted in the literature review, there are currently several conceptualizations and definitions of the phenomenon referred to as “moral injury”. The term itself has not been unanimously well-received by military personnel, with some members suggesting that it evokes negative emotions and judgments (McCloskey, 2011). The feedback has often indicated that the term “moral injury” does not fully characterize the experience of the afflicted and it is perceived to be a pejorative term (Marine Corps Development Command, 2010). Although the current study was not conducted within a military context, participants PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 189 found the term relevant, but suggested that the term does not fully embody the lived experience. One participant stated: I am not sure…moral injury is definitely… I think an appropriate way to label it. Um, I would also look at it, for example, um (pause) I don't know how you would label it... but degradation of your own principles. Not only, um, relating to your Christian principles, but how you treat others in relationship context, and how you treat yourself in the relationship context. It is also the erosion of your own moral principles, and I guess, would go parallel with moral injury (Aaron). This quote illustrates a need for a term, and a corresponding description, that captures the impact on the intra-relational dynamics of the experience, while acknowledging the interrelational dynamics. It would be important for the term to capture the experience of transgressing one’s internal morals, not simply identify that they have occurred. The existing term – and definitions thereof – does not seem to reflect the lived experience revealed in the findings of this study, thereby excluding the core, or the essence, of participants’ experience. Particularly, it overlooks and excludes the transformational and becoming aspects of the phenomenon. Based on the findings of this study, I propose that the phenomenon may be better represented by the term moral suffering than moral injury. The term “suffering” would highlight an ongoing nature of hardship. The revision of the term would allow the ongoing process of the suffering to be emphasized, rather than indicating a singular outcome and static pain. Moral suffering implies an inner conflict, a movement and a grappling within. The term embodies an interaction – a dialogue – between the ego and the true self, rather than emphasizing transgressions of externally imposed morals. Lastly, moral injury has a negative connotation, implying an irreparable damage or perhaps a condition of immorality. By contrast, moral PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 190 suffering does not imply a lack of morality. It embodies the suffering that is present in all the themes of moral injury. Even within the theme of restoration, the journey is not devoid of suffering, difficulty, or pain. Proposed description. Given that the newly proposed term (moral suffering) emerged from studying the lived experience, I would like to suggest the following description in an attempt to capture the experiential aspect of the phenomenon: Moral suffering is a lived experience grounded within a painful process of losing one’s connection with one’s authentic self and struggling to regain it. It embodies a journey of living transgressions that violate one’s personal morals, and collapsing under the violent and shattering reality of oneself and the world. Moral suffering is a painful part of the human condition; its suffering often manifests in feelings of guilt, shame, betrayal, isolation, remorse, imprisonment, and anger. However, it is also a potentially (positive) transformative experience that can foster empowerment, forgiveness, growth, authenticity, and reconnection with oneself and the world. Inherently, it is a journey of one’s unraveling and becoming through existential suffering. Clinical Implications7 The participants’ journeys explored in this study could provide clinicians with further insight into how to honour and help clients who are experiencing moral injury. The phenomenological process illuminated several themes that could assist the therapeutic process. The findings revealed that during the healing experience, clients deepened their awareness, activated their agency, and engaged in acceptance, forgiveness, and integration of lessons and meanings. Specifically, Annie spoke of distancing herself from the situation and 7 It is important to remember the context of these findings and clinical implications – intimate partner relationships –and not assume generalizability to other contexts of moral injury. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 191 looking at herself with compassion and understanding that she did the best she could. She elaborated by stating that she learned that it was important to not carry any negativity with her, and the importance of forgiving others and herself so that she is not imprisoned by the hurt or her past. The participants described a pivotal moment that evoked change and a movement towards healing and becoming more aware of their situation or, as Annie depicted it, taking the “blinders” off. The findings suggest that in this moment of awareness the participants faced their reality, acknowledging their worth and the injustice being experienced as the result of remaining in the relationships. Annie recalled that recognizing that she was worth more than how she was being treated to have contributed to her “waking-up”. She elaborated by stating that understanding the injustice she has endured within the relationship was what helped her finally end it. Other participants described this moment as an unwillingness to commit to living a life that was unhappy and filled with dread. Therefore, assisting clients in re-establishing and growing in their self-worth may help them activate their agency and empower them to make necessary changes as a way to regain their freedom to be. Nurturing self-worth within the therapeutic process can also assist them in re-establish a loving relationship with themselves and, consequently, in establishing boundaries for healthier relationships with others. The participants described the importance of their journey of forgiveness, letting go, findings gratitude, and integrating the lessons they have learned. The findings suggest that the individuals that did not engage in this theme of restoration, but stopped their journey with implementing change, continued to suffer. Tom shared that he feels that his experience has caused him damage, for he feels hot, flushed, and distraught every time he thinks about it. He continued to share his struggle with forgiving his ex-partner and forgiving himself. Tom PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 192 elaborated that he does not believe that he can ever truly forgive his ex-wife for treating him the way she did. He shared that he had tried to forgive her but that he cannot, being unsure what that would even mean for him. He also explained that not only is he struggling to forgive his ex-wife, but that he cannot forgive himself for the transgressions he has committed within the relationship. Differing, Annie spoke of the burden that she has let go of as she empathized with and forgave herself. She recalled distancing herself from the situation and accepting her imperfections (her humanity) and forgiving herself because she knew that her intentions were coming from a right place, even if her actions were wrong. This finding would suggest that engaging in meaningful conversation regarding what forgiveness would mean in the context of moral injury could be beneficial in helping the individual let go of the hurt. Therefore, I propose that opening up a dialogue regarding forgiveness and the meaning of the experience is critical, even if the individuals, as in this case, have left the context in which they were experiencing moral injury. It could be beneficial to allow participants space to re-encounter and restore a loving relationship with one’s self and with others. The participants’ descriptions reveal moral emotions as encompassing experiences of moral injury, primarily emotions of guilt, shame, anger, regret, and remorse. The lived experience of the participants suggests that while working with clients that have suffered moral injury, it would be important to identify and explore these emotions as a way for the individual to gain deeper meaning and understanding into their experience. This would mean that, alongside addressing the emotions regarding the social or religious sense of morality that may have been violated, it may be beneficial to explore a potential disturbance of the being and, consequently, one’s relationship to the self. In therapy, I have often noted that it can be difficult for clients to PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 193 take ownership of their own suffering without feeling blamed or judged. It is, therefore, important to provide a safe space where such realizations can be encountered with selfcompassion and understanding. Additionally, the findings seem to suggest that the experience of pain related to moral injury was lived as an inability to recognize one’s self because of the transgressions committed, and it shattered their perception of who they thought they were. James recalled realizing that he was the perpetrator within his intimate partner relationship, violating what he believed to be proper standards of behaviour. He described how he fell of “the pedestal” by his own choices and action, but that if anyone would have told him two years prior that he would have cheated on his wife he would have not believed them. Therefore, it may be beneficial to guide the clients towards self-discovery and deeper growth of authenticity. The findings suggest that having the participants’ “goodness” recognized and acknowledged by others helped in their healing journey. Aaron recalled feeling good as a result of experiencing vindication when his in-laws began to acknowledge and appreciate the kind of father he was and that their daughter’s story surrounding the divorce was not all true. He shared that this affirmation helped him understand that he was not the horrible person that his ex-wife has portrayed him to be. Lastly, the findings of this study suggest that the experience of moral injury encompasses the potential for transformation. As a clinician, it would be important to emphasize this hope of becoming to one’s client as a way to help reduce feelings of imprisonment and hopelessness. The participants described moral suffering not as a singular event that causes static pain, but rather as an ongoing and evolving process in which each theme presents a new difficulty and unique experience. It is difficult to treat moral suffering if one does not understand the breadth of the PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 194 process and where in the journey the client is found. Therefore, it would be important to allow sufficient time for the narrative and hesitate before engaging in a more directive approach. Directions for Future Research As mentioned previously, this is the first phenomenological study of moral injury and, thus, an understanding of its lived experience has just begun. In an effort to uncover the phenomenon, it would be helpful for future research to conduct phenomenological studies in various contexts to further explore the essence of moral suffering. Such an investigation could enhance and expand qualitative research on the topic, and aid the potential integration of the existing quantitative and qualitative research, providing a more holistic approach to understanding moral injury. “Morally injurious events” (Litz et al., 2009) is a construct within the literature that has been used to spur many scales that are utilized as assessment tools for determining the presence of moral injury. Future phenomenological studies of the lived experience may assist in developing a scale or questionnaire that addresses the experience of moral injury, allowing therapists to recognize it within a client’s suffering. More importantly, it may help identify where within the process the client might be – potentially increasing treatment efficacy. Moreover, given the findings of this thesis – that moral suffering impacts one’s relationship with the self, with others, and with meaning and purpose – it would be valuable for future research to assess the efficacy of various existential therapies with clients that are encountering moral suffering in various contexts. Next, the findings of this study highlight moral injury as being lived as a process. The participants’ experiences illuminated eroding connection with one’s self as the beginning of this experience; however, the genesis of self-estrangement is unclear. Most of the participants have PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 195 encountered childhood or war trauma that predated the context of the studied moral suffering, making it imperative to speculate if the self-estrangement may have begun with another traumatic experience or if it is rooted within the natural process of growth and embodiment of one’s identity. It could be beneficial for future research to explore the vulnerability and/or genesis of moral suffering as a way to further clarify its potential relationship with trauma. In addition, examining a correlation between severity of moral suffering and various trauma may illuminate the nature of the relationship. The prevalence of exposure to trauma appears to be an inevitable part of humanity and, if so, could this be the vulnerability to developing moral suffering that is rooted within the natural human condition? Lastly, much of the current literature on moral injury approaches the phenomenon as a psychopathology similar to PTSD (Jinkerson, 2016). This understanding is reflected not only within the numerous conceptualizations of the phenomenon, but also – and even more clearly – within the current interventions that are available to treat moral injury. Moral injury treatments have been adapted from PTSD interventions (Harris et al., 2015; Litz et al., 2009; Koenig et al., 2017; Resick, Monson, & Chard, 2014; Shay, 2011). The findings of this research suggest that moral injury appears as a human response to complex contexts and hurtful experiences. The lived experience of moral injury and the themes that have emerged span a wide spectrum of suffering, loss, transformation, and growth. The findings propose that moral injury may represent a healthy indicator that something is wrong, just as pain sensors, albeit unpleasant, can protect an individual by alarming him or her to the danger through suffering. This assertion is presented with caution, as this suffering can often cooccur or contribute to psychopathological suffering (such as PTSD, anxiety, or depression) that needs to be addressed accordingly. The results indicate that it is when the individual appeared to PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 196 be overwhelmed by the process of unraveling and becoming – or fully rejected it – that psychopathological conditions such as anxiety and depression emerged. Therefore, it would be beneficial for future research to further explore one’s movement throughout the themes as a way to explore the nature of moral injury, and identify it as either a human condition or pathology. Strengths and Limitations of the Research I would like to begin this section by emphasizing the strengths of this study. This is the first study that has investigated moral injury using hermeneutic phenomenology. Moreover, this study is one of the very few studies that have expanded the research context of moral injury by conducting research outside the military context. The methodological variation of this study offers a new insight regarding moral injury by depicting the lived experience of the phenomenon. The use of hermeneutic phenomenology offers glimpses of the phenomenon from within the experience, highlighting themes and meaning of an intimate suffering. The contextual distinction allows this study to not only deepen understanding of the complexities embedded within the phenomenon, but also to illuminate the presence of moral suffering within intimate partner relationships. Another strength of this study is the rigour implemented during the research process. I utilized a rigorous approach to hermeneutic phenomenology, conducting a thematic analysis, engaging in phenomenological writing, and incorporating resonance feedback from participants and research team members into the findings. In addition, I was mindful and intentional about journaling as part of the reflexivity process to ensure that I was engaging with the participants’ experiences (and not my own) and that I remained oriented towards the phenomenon (van Manen, 2014). Every precaution was taken in an attempt to honour and illuminate the voice of the participants as they shared their lived experience of moral injury. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 197 Given the collaborative nature of this study, many of the participants and research team members emphasized that participating in this project, although triggering and painful at times, gave them an opportunity to give a voice to their experience and allow themselves to dwell in what that experience was truly like. All the individuals involved expressed that they valued the experience; more specifically, the feedback indicated that all individuals involved gained a deeper insight into the meaning of their lived experience, increased their understanding of themselves, and for some, the experience provided them with closure. Lastly, some of the individuals that were still suffering reported finding hope in the findings, for it gave them confidence that they too can come to a place of freedom and reconnection with self. Not only was this study a meaningful experience for the participants and research members, but it was also a very meaningful and impactful experience for me. For this study, the exclusion criteria did not address the degree of familiarity I had with the participants. I had met all the participants in various contexts prior to recruitment. I met the majority of the participants in my church community, and others through mutual family friends. Although the various shared contexts and diverse degree of familiarity could have caused difficulty and hesitancy with openness and honesty from participants, I found this not to be true for my experience. Having met the participants prior to the interview process, the participants and I had formed a foundation and sense of safety that appeared to strengthen the participants’ ability and comfort to share his or her lived experience of suffering. Similarly, while my own lived experience of moral injury was a strength (and a requirement) for conducting hermeneutic phenomenology, it simultaneously added a risk to the process of analysis. With my shared experience, I also brought personal biases, triggers, and understandings, which could have potentially compromised the findings by acting as a PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 198 vulnerability for me to impose my own feelings and thought on to the participants’ lived experience. However, due to rigorous reflexivity, clinical team accountability, and supervision, the shared experience proved to be an asset that allowed me to deeply encounter the participants without compromising the findings. The shared experience also enabled me to validate emerging themes and aided me with encountering a very complex phenomenon of moral injury. Next, the ambiguity of the concept of moral injury, stemming from the varying definitions and understandings within the current literature, could cause another potential limitation to the study. Although the screening was conducted using morally injurious events (MIE) scales and questions formulated from the available definitions and literature, the term moral was not defined. This ambiguity forced the recruitment process to be dependent upon the participants’ subjective interpretation of the term. Interestingly, the findings indicate that the concept of morality was identified and experienced the same way among all the participants in this study. This open approach nurtured a subjective meaning of morality to emerge by allowing the participants’ lived experience to speak to the understanding and meaning behind the moral within moral suffering – without any conceptual boundaries. On the one hand, the general ambiguity regarding the term and the phenomenon made searching for its thematic meanings and essence more difficult. On the other, it assisted in limiting my theoretical or conceptual influence and bias. The fourth potential limitation of the study is that its findings were contingent on retrospective recollection. For all the participants, the events described had occurred at least two years prior; for most, the experience occurred over a decade earlier, making it difficult to ensure accurate recollection of the lived experience. Additionally, most of the participants attempted to recall a period of time that was likely traumatizing – due to emotional abuse and infidelity being PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 199 the context of this study – and therefore, it is important to take into account the effects that trauma may have had on the recollection of experience. Finally, a potential limitation of the study is that hermeneutic phenomenology is an ongoing process with no definitive end. The time allotted for a master’s thesis was a variable that contributed (alongside the researcher’s comfort with the depth and understanding uncovered through the phenomenological process) to the conclusion of the cyclical process of analysis. It is important to note that phenomenology cannot be forced or rushed in order to validate the themes that have emerged; however, I acknowledge that the time constraint may have prevented further potential analysis. Conclusions By conducting hermeneutic phenomenology, this study illustrated the lived experience of moral injury within the context of intimate partner relationships. More specifically, it illuminated six core themes (self-estrangements, transgressions and discord, sudden awareness, lostness and sorrow, will to change, and the aftermath). Unlike the current literature on moral injury, the themes highlighted the lived experience as a fluid process, that inherently contained a potential for transformation and healing. In addition, the findings of this study found the “moral” component of moral injury to be experienced as transgression of internal or unique sense of right and wrong that each person experiences as part of their essence, rather than social or religious norms of one’s community. However, oftentimes one’s unique morals were compatible with the socially constructed ones. The current findings suggest that within the context of intimate partner relationships the individual is always responsible for violating his or her own unique moral standards (part of their true self) through their actions or inactions. The findings of this study suggest that the participants were simultaneously the perpetrators of moral transgressions and PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 200 victims of moral injury. This does not imply that toxic and abusive relationship did not contribute to or make one venerable to such transgressions. Lastly, it is important to re-emphasize that the findings of this study should not be generalized to other contexts, for the lived experience of those that have experienced moral injury in the context of military should be given their own voice and their lived experience should be honored in its own unique way. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 201 References American Psychological Association. (2013). 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Phenomenology of practice: Meaning-giving methods in phenomenological research and writing. Walnut Creek, CA: Left Coast Press, Inc. Voisin, D., & Fointiat, V. (2013). Reduction in cognitive dissonance according to normative PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 218 standards in the induced compliance paradigm. Social Psychology, 44, 191-195. doi:10.1027/1864-9335/a000103 Webster, G., & Bayliss, F. (2000). Moral residue. In S. Rubin & L. Zoloth (Eds.), Margin of error: The ethics of mistakes in the practice of medicine (pp. #). Hagerstown, MD: University Publishing Group, Inc. Weiner, B. (1985). “Spontaneous” causal thinking. Psychological Bulletin, 97, 74−84. Wertz, F. J. (2005). Phenomenological research methods for counselling psychology. Journal of Counselling Psychology, 52(2), 167-177. doi:10.1037/0022- 0167.52.2 Wilkinson, J. M. (1988). Moral distress in nursing practice: Experience and effect. Nursing Forum, 23(1), 16-29. doi:10.1111/j.1744-6198.1987.tb00794.x Wisco, B. E., Marx, B. P., May, C. L., Nartini, B., Krystal, J. H., Southwick, S. M., Pietrzak, R. H. (2017). Moral injury in U.S. combat veterans: Results from the national health and resilience in veterans study. Depression and Anxiety, 34, 340-347. doi:10.1002/da.22614 Witvliet, C.V., Phipps, K. A., Feldman, M. E., & Beckham, J. C. (2004). Posttraumatic mental and physical health correlates of forgiveness and religious coping in military veterans. Journal of Traumatic Stress, 17(3), 269-273. doi:10.1023/B:JOTS.0000029270.47848.e5 Yan, G. W. (2016). The invisible wound: Moral injury and its impact on the health of operation enduring freedom/operation Iraqi freedom veterans. Military Medicine, 181, 451-459. doi:10.7205/MILMED-D-15-00103 PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 219 Appendix A: Participant Informed Consent Form and Confidentiality Agreement You are being invited to participate in a study entitled The lived experience of moral injury in the context of intimate partner relationships: A phenomenological exploration that is being conducted by Sara Kuburic. Ms. Kuburic is a Master student in the school of Counselling Psychology at Trinity Western University, and is available for further questions at sara.kuburic@mytwu.ca. As a graduate student, Mrs. Kuburic is required to conduct research as part of the requirements for a M.A. in Counselling Psychology, which is being conducted under the supervision of Dr. Mihaela Launeanu. You may contact Dr. Launeanu at mihaela.launeanu@twu.ca. ——————————————————————————————————————— PART 1: INFORMED CONSENT The purpose of this research project is to explore the phenomenon of moral injury by exploring the “lived experience” of individuals within the context of intimate partner relationships. Research of this type is significant to the field of psychology as it attempts to understand the novel concept of moral injury as a means to set an appropriate foundation for the development of measures and interventions. Participation Requirements You will engage in a one-hour phone interview which will compose of a pre-screening and screening interview, which will assess the following: experience of moral injury, current safety to participate in the study, post-traumatic stress disorder (PTSD), acute stress disorder (ASD), severe depression, suicidality, severe acute anxiety, and dissociation. If you have had an experience of moral injury that fits within the literature’s understanding, and are not assessed to be at risk, you will be asked for a semi-structured interview. If your experience of moral injury is not congruent with the literature understanding, or if the study would be too high risk for you, an e-mail will be sent to thank you for your willingness to participate. Following the screening interview, the participants will engage in a 1-1.5 hour face-toface semi-structured interview. All participants are asked to come to the the interview sober and not under the influence of any illicit drugs, if this request is not granted, the interviews will be postponed to accommodate the condition. Assessments That Will Be Used (Appendix C) 1. Diagnostic and Statistical Diagnostic Manual (DSM-5): Diagnostic criteria for Dissociative Identity Disorder 2. Diagnostic and Statistical Diagnostic Manual (DSM-5): Diagnostic criteria for Acute Stress Disorder (ASD) 3. Diagnostic and Statistical Diagnostic Manual (DSM-5): Diagnostic criteria for Major Depressive Episode 4. Columbia-Suicide Severity Rating Scale- Screen Version 5. Generalized Anxiety Disorder 7-item scale 6. PC-PTSD Utility of the Assessments The screening assessments will be conducted for screening purposes only; no diagnostic purpose or consultation. The scores of the assessments will not be kept nor used for the purpose of the research, and will be destroyed immediately following the assessment. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 220 Potential Risks and Benefits Each participant will be notified whether they are invited for a semi-structured interview following the pre-screening and screening interview. In the case that you are not invited to participate, it is possible that you may feel negative emotions by knowing that you did not meet the criteria or worried regarding what that implies about your mental health. There is a risk that taking these screening assessments and/or engaging in the semi-structured interview will trigger uneasy feelings, emotional/psychological disturbances, lack of self-regulation, etc. Additionally, the experience may have a negative effect on you, if what you share in the interview surprises you and gives you a more negative view of your experience. However, there are also greater, and more probable, benefits of engaging in this study. It will allow you to share your story, express your emotions, and have your voice heard. More significantly, it will allow you the opportunity in gaining deeper insight, understanding, and meaning in your experience and who you are today. Participant’s Rights Participations in this research is completely voluntary. You may withdraw within a month following the interview, all you need to do is contact the researcher via e-mail. If you choose to withdraw from the study your data will not be included in the study. Here is a list of additional client rights: The participant has the right to disengage during the screening assessment at any point The participant has the right to disengage during the interview at any point The participant has the right to not answer questions they do not wish to answer The participant has the right to address the researcher with any discomfort, questions, or clarifications they need to feel comfortable Confidentiality Many steps are being taken to ensure confidentiality and anonymity of all the data. The pre-screening and screening material will be hard copy, but immediately once the pre-screening and screening interviews are done, they will be shredded. Your identity will be anonymous; you will be assigned an alias as a way to further protect your identity. All of your data will only be identified with an alias, your real name will not be used on any of the saved documents. All transcripts will be digital and typed by the researcher. Complete records of your interviews will be preserved and secured for the duration of the project, and for the 5 years following the project, on an encrypted USB, which will be locked in a safe. No other digital copy will be saved on a computer of any kind. Following the 5-year period, the USB files will be deleted off the USB on a computer, and the computer immediately emptied. If you decide to withdraw from the study during the process, or a month following the interview, the information will be immediately disposed off. With the exceptions stated below, no information will be released about your contact with us without your informed, voluntary, and written consent. Limits to Confidentiality The law protects the privacy of communications between a participant and researcher. The researcher can only release information regarding you with your written permission. Here are the following exceptions: PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 221 1. Instances of active or suspected abuse (physical, emotional, or sexual) or neglect of a child, an elder, or a dependent adult must be reported to the appropriate protective services. 2. If a participant threatens to harm himself/herself or to harm another individual, group leader(s) are required to take steps to help maintain the safety of the person at risk. 3. If a judge orders the researcher’s testimony/records or, in the context of a legal proceeding, a participant raises his/her own psychological state as an issue, the researcher may be required to release the client’s confidential information to the court Use of the Information Data collected for this study may also be used in a published article or professional conference to communicate the results of the research beyond a published master report. All data will be destroyed five years following the interview. Ethical Regulations In addition to being able to contact the researcher [and, if applicable, the supervisor], you may verify the ethical approval of this study, or raise concerns, by contacting the Associate VicePresident, Research at Trinity Western University. If you are interested in the findings of the study, please contact the researcher and a copy will be sent to you. If you have any questions or desire further information with respect to this study, you may contact Sara Kuburic at sara.kuburic@twu.ca or Dr. Mihaela Launeanu at mihaela.s.launeanu@gmail.com. If you have any concerns about your treatment or rights as a research participant, you may contact Ms. Sue Funk in the Office of Research, Trinity Western University at 604-513-2141 or sue.funk@twu.ca . Your signature below indicates that you understand the above conditions of participation in this study, rights and limits to confidentiality, and have had sufficient time to read and understand this document. Your signature below indicates that you had your questions about the study answered to your satisfaction and have received a copy of this consent form for your own records. Your signature indicates that you consent to participate in this study and that your responses may be put in anonymous form and kept for further use after the completion of this study. ________________________ Name of Participant _______________________ Signature _________________ Date PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 222 PART 2: INFORMED CONSENT 1. I have read and received a copy of the attached information sheet (PART 1) Yes No 2. I understand the benefits and risks involved in participation in this study Yes No 3. I understand that by agreeing to participate I am agreeing to take part in a 2-3-hour process (pre-screening, screening, and semi-structured interview). Yes No 4. I understand that my participation in this study is completely voluntary. If I agree to participate in the study, I understand that I can withdraw at any time. Yes No 5. I understand that Sara Kuburic may use this information from this study to publish articles or present at a professional conference. Yes No 6. I have had confidentiality and anonymity explained to me and I understand that while every attempt will be made to protect my identity some particulars may be familiar to someone who knows me. Yes No I agree to participate in this study as explained above. ____________________ Signature of the Participant Date _________________________ I believe that the person signing this form understands what is involved in this study, what the potential risks are, and voluntarily agrees to participate. ______________________ Signature of the Researcher Date ___________________________ THANK YOU FOR YOUR CONTRIBUTION ON THIS STUDY PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY Appendix B: Client Resources Need further help or counselling? Here are some suggestions for YOU: BCACC: BC Association of Clinical Counsellors http://bc-counsellors.org/find-a-counsellor Find a counsellor that fits YOUR needs. Women’s Transition House and Support (BC) http://www.bchousing.org/Options/Emergency_Housing/WTHSP Ann Davis Transition Society http://www.anndavis.org Phone Number: 604-792-2760 Administration/Counselling Office: 9046 Young Rd, Chilliwack, BC V2P 4R6 Voth Counselling Services http://www.vothcounsellingandtherapy.com Suite 260-2655 Clearbrook Rd Abbotsford, British Columbia Canada V2T 2Y6 (866) 330-0677 Agape Counselling http://agapecounselling.com Langley, British Columbia Canada V1M 3W3 (866) 638-0179 Lavender Counselling http://www.lavendercounselling.com/index.html #101, 8047-199 Street Langley, BC, V2Y0E2 223 PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 224 Appendix C: Pre-Screening Interview Part I: The following questions are designed to ensure the safety of the potential participants: 1. Are you currently living in a relationship that would qualify as intimate partner violence (IPV)? 2. Do you still feel you are a part of the IPV relationship even though you are not living with the individual? 3. Do you feel safe participating in this study? 4. Do you believe having an alias will be enough to keep you safe from any repercussions participating in this study may have? Part II: The following questions are inspired by the Moral Injury Event Scale and current MI research (Jinkerson, 2016; Litz et al., 2009; Nash et al., 2013; Shay, 2014). 1. Do you feel that during your experience of IPV you perceived an action that you deemed morally or ethically wrong? 2. Do you feel that during your experience you violated your own values? (e.g., values by failing to do something or stop something). 3. During the IPV did you feel betrayed by someone that you trusted? 4. Do you trust others to live up to their core values? 5. Do you trust yourself to live up to your moral code? 6. Has the experienced altered the way you perceive the world? 7. Do you feel guilt and/or shame about your IPV experience? Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., et al. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695-706. doi: 10.1016/j. cpr.2009.07.003. Jinkerson, J. D. (2016). Defining and assessing moral injury: A syndrome perspective. Traumatology. Advance online publication. http://dx.doi.org/10.1037/trm0000069. Shay, J. (2014). Moral Injury. Psychoanalytic Psychology, 31(2), 182-191. doi:10.1037/a0036090 Nash, W. P., Carper, T. L., Mills, M. A., Au, T., Goldsmith, A., & Litz, B. T. (2013). Psychometric evaluation of the moral injury events scale. Journal of Military Medicine, 178, 600-646. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 225 Appendix D: Screening Assessments Dissociative Identity Disorders - DMS-5 Diagnostic Criteria A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of passion. The disruption in identity involved marked discontinuity in sense of self and sense of agency, accompanied by related alternations in affect, behaviour, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual. B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The disturbance is not a normal part of a broadly accepted cultural or religious practice. E. The symptoms are not attributable to the physiological effects of a substance or another medical condition. American Psychological Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, DC: American Psychiatric Association. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 226 Acute Stress Disorder - DSM - 5 Diagnostic Criteria A. Ensure to actual or threatening death, serious injury, or sexual violation in one (or more) of the following ways: 1. Directly experience the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred others. 3. Learning that the event(s) occurred to a close family member or close friend. Note: In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposure to details of child abuse). B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred: Intrusion Symptoms 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). 3. Dissociative reactions in which the individual feels or acts as if the traumatic event(s) were occurring. 4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Negative Mood 5. Persistent inability to experience positive emotions. Dissociative Symptoms 6. An altered sense of the reality of one’s surrounding or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing). 7. Inability to remember an important aspect of the traumatic event(s). Avoidance Symptoms 8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 9. Efforts to avoid external reminders that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Arousal Symptoms 10. Sleeping disturbance 11. Irritable behaviour and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression towards people or objects. 12. Hyper-vigilance. 13. Problems with concentration. 14. Exaggerated startle response. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 227 C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure. D. The disturbance causes clinically distressed or impairment in social, occupational, or the important areas of functioning. E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by brief psychotic disorder. _____________________________________________________________________ American Psychological Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, DC: American Psychiatric Association PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 228 Major Depressive Episode To qualify for a diagnosis of major depressive episode, the patient must meet criteria A through E: A. Five or more of the following symptoms have been present and documented during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation) 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day 4. Insomnia or hypersomnia nearly every day 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) 6. Fatigue or loss of energy nearly every day 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide B. The symptoms do not meet criteria for a mixed episode. C. The episode is not attributable to the physiological effects of a substance or to another medical condition. Note: Criteria A-C represent a major depressive episode. Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include feelings of intense sadness, rumination about the loss, insomnia, poor appetite and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual's history of and the cultural norms for the expression of distress in the context of loss. D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. E. There has never been a manic episode or a hypomanic episode. Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 229 Severity is based on the number of criterion, the severity of those symptoms and the degree of functional disability. Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational functioning. Moderate: The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for “mild” and “severe”. Severe: The number of symptoms is substantially in excess of that required to make the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning. _____________________________________________________________________American Psychological Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, DC: American Psychiatric Association. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 230 Columbia-Suicide Severity Rating Scale - Screen Version 1. Have you wished you were dead or wished you could go to sleep and not wake up? Yes 2. No Have you actually had any thoughts of killing yourself? Yes No If YES to 2, ask questions 3-6. If NO to 2, go directly to question 6. 3. Have you been thinking about how you might kill yourself? 4. Have you had thoughts and has some intention of acting on them? 5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? If yes, ask: How long ago did you do any of these? • Over a year ago? • Between three months and a year ago? • Within the last three months? Posner, K. (2008). Columbia Suicide Severity Rating Scale (C-SSRS). Retrieved from http://www.cssrs.columbia.edu PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 231 Generalized Anxiety Disorder 7-Item (GAD-7) Scale Over the last 2 weeks, how often have you been bothered by the following problems? Problems Not at all (0) Several days (1) Over half days (2) Nearly every day (3) Feeling nervous, anxious, or on edge Not being able to stop or control worrying Worrying too much about different things Trouble relaxing Being easily annoyed or irritable Feeling afraid as if something awful might happen Add the scores for each column Total Scores (add column scores) Options Yes No Not difficult at all Somewhat difficult Very Difficult Extremely Difficult If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? —————————————————————————————————————— Spitzer, R. L., Kroenke, K., Williams, J. B., Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder. Archival Internal Medicine, 166, 1092-1097. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 232 Primary Care PTSD Screen (PC-PTSD) It is suggested that in most circumstances the results of the PC-PTSD should be considered “positive” if a patient answer “yes” to any 3 items. Those screening positive should then be assessed with a structured interview for PTSD. The screen does not include a list of potentially traumatic events. Instructions : In your life, have you ever had any experiences that was so frightening, horrible, or upsetting that, in the past month, you: 1. Have had nightmares about it or thought about it when you did not want to? 2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? 3. Were constantly on guard, watchful, or easily startled? 4. Felt numb or detached from others, activities, or your surroundings? Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D.S., Shaw-Hegwer, J., Thrailkill, A., Gusman, F. D., Sheikh, J. I. (2003). The primary care PTSD screen (PCPTSD): development and operating characteristics. Primary Care Psychiatry, 9, 9-14. PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 233 Appendix E: Semi-Structured Interview Questions I know that discussing one’s journey with moral injury can be difficult at times, and I just want to encourage you to take the time you need and to only answer questions you are comfortable with. 1. Could you tell me a little bit about the context of the relationship, were you dating, married, common law, etc.? 2. Tell me a little bit about your partner, where and how did you meet him/her? How long did the relationship last? Why and how did it end? 3. When did you notice the relationship change? How? 4. When and how did you notice the relationship was unsafe, unhealthy, or even harmful to you? 5. Were there instances when you didn't agree with your own action or felt you crossed your own boundaries? Would you mind sharing an example? 6. What sorts of thoughts or feelings surprised you within that relationship? Do you have an example when these thought or emotions came up? 7. Did you have any regret, guilt, or shame during the relationship? 8. Now that you are no longer in the relationship, how do you understand that experience? 9. What meaning did you make of the experience? 10. Do you feel that you have changed as the result of your experience? If yes, how? 11. After the experience, have you had a hard time trusting others or yourself? 12. This is how the study defines moral injury… could you tell me an experience that would relate? PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 234 Appendix F: Debriefing Document Oral script/questions: I understand that some of the questions I asked during this interview may have been difficult, and may have compelled you to think about uncomfortable memories. Given the honor you have provided me by allowing me to listen to your life’s journey, I wanted to ensure that the process wasn’t too difficult for you. I will ask you a couple questions as a way to evaluate if further assistance is necessary for your well-being, and allow you some time to reflect back and debrief on your experience. Please feel free to elaborate as little or as much as you deem appropriate and necessary: 1. How was it for you to share your experience with me? 2. Are you experiencing very strong emotions right now? If yes, which ones? 3. Do you feel comfortable with me including your interview in the data? 4. Do you feel calm enough to go back home? 5. Is there anything you need from me before you go home? 6. Are you experiencing any suicidal ideations or urges? 7. Please make sure to look at the “client resource list” in case you feel like you need someone to talk to about your experience or your current feelings PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 235 Appendix G: Resonance Check Questions 1. Do you feel like my findings resonate with your lived experience of suffering within the context of your intimate partner relationship? (if willing, please elaborate on how so). 2. Do you feel like there are parts of my findings that do not resonate with your experience? (if so, could you please provide me with further insight as to what would be truer to your journey). 3. Do you feel like there is something missing that you would like to add? 4. Do you have any further comments or feedback? PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY Appendix H: Demographic Questionnaire Please answer the following questions as they describe you. 1. Gender (circle one): Female Male 2. Age ____________ 3. Religion (circle one): Christian Orthodox Christian Catholic Christian Protestant Muslim Jewish Other _______________________________ 4. Marital Status (circle one): Single Married or Common Law Divorced Widowed 5. What is the highest degree or level of education you have completed? ___________________________________________________________ 6. How many hours per week do you USUALLY work at your job? (circle one) 35 hours a week or more Less than 35 hours a week I am not currently employed 236 PHENOMENOLOGICAL EXPLORATION OF MORAL INJURY 237 Appendix I: Suicide Response Protocol EMERGENCY PLAN FOR HANDLING SUICIDE IDEATIONS STEP 1: Investigate your suspicions or concerns regarding the person’s suicidal thoughts or attempts. • Have you had any thoughts about wishing you weren’t alive? • Have you thought about ending your life? • Do you know how you would end your life? • Do you have the necessary means to complete your plan? STEP 2: If the individual has an ideation, but no concrete plan or means of ending their life: • Encourage the individual to seek help from the “client resource” sheet • If possible, encourage the participant to go see their primary therapist • Give them the number to the SUICIDE & CRISIS HELP LINE 604-872-3311 (Vancouver, BC) STEP 3: If the individual has the will, a plan, and the means of ending their life OR if they feel unsafe, not trusting themselves not to hurt themselves: • The person should be seen by a mental health professional as soon as possible • The individual should never be left alone The individual should be taken to the hospital or 911 should be called.