Religious considerations and self-forgiveness in treating complex trauma and moral injury in present and former soldiers.

Worthington, Everett L., Jr. ; Langberg, Diane

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

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

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

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

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

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

Self-Condemnation in Soldiers and Veterans

Self-Condemnation as a Stress Response to Perceived Wrongdoing

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

Litz et al. (2009) inquire whether there is a distinct syndrome of psychological, biological, behavioral, and relational problems that arises from serious or sustained morally injurious experiences. They ask whether existing disorders, such as posttraumatic stress disorder (PTSD), can sufficiently explain the sequelae of perpetrating moral injuries. Among Vietnam veterans, PTSD has been related to participating in atrocities (Beckham, Feldman, & Kirby, 1998). Witnessing atrocities--even if one did not actively participate (Hiley-Young et al., 1995)--puts a veteran at risk for PTSD. However, perpetration is more personally injurious than is mere non-participatory witnessing. Killing is an especially strong predictor of chronic PTSD symptoms--better than virtually all other indices of combat (Fontana & Rosenheck, 2004; MacNair, 2002; Maguen et al., 2009; Maguen et al., 2010). Maguen et al. (2010) studied 2,797 soldiers in the Iraqi Freedom campaign. Maguen et al. (2010) reported that about 40 percent of the soldiers reported killing or being responsible for killing during their deployment. Even after controlling for combat exposure, killing was found to predict PTSD symptoms, alcohol abuse, anger, and relationship problems. Maguen et al. (2010) observed that military personnel returning from modern deployments are at high risk of mental health conditions and related difficulties in psychosocial functioning related to killing in war. Such conditions set the stage for the internal conflicts of moral injury (Litz et al., 2009; Maguen & Litz, 2012). MacNair (2002), for example, found that Vietnam veterans who killed but were only in light combat had more PTSD symptoms than did those who did not kill but were in heavy combat. Fontana and Rosenheck (2004) found that, relative to being passive observers of killing, actually killing or not acting to prevent killing better predicted higher suicidality, more PTSD symptoms, and other mental health disorders. In fact, suicidality as a potential escape from self-condemnation is a particular difficulty in recent military service and its aftermath (Sher, 2009). Litz et al. (2009) concluded that it is necessary to conceptualize a model for explaining moral injury itself to provide a framework in which treatment could be considered. Later, we will describe their model and provide a critique.

Self-Condemnation from Failure to Meet Expectations for Oneself

It is not just war trauma, moral injury, or participation in combat that suggest a need to consider self-forgiveness in order to cope with self-condemnation. Part of the need arises from the military environment itself, which is highly result-oriented. Results are prized. Military personnel are supposed to get the job done (and not let feelings get in the way of performance), and usually soldiers get positive results. The orientation towards getting results inevitably means that performance evaluations are frequent and taken seriously. Promotion and continuation in the service depends on getting excellent fitness reports (i.e., the military term for an evaluation of performance).

This performance orientation has several implications. First, people are always being evaluated. Second, while teamwork and leadership are valued, dependency is anathema. Being viewed as "weak" or "dependent" can spell social ostracism, and (in a normal distribution) some will inevitably be judged as weaker or more dependent than their peers. Third, even military personnel who are not career-oriented live with continual performance evaluation. Social psychology shows that there

is enormous power inherent in situational pressures (Zimbardo, 2007). Because situations are so important, and the culture of performance evaluation permeates the military, we hypothesize that military personnel will likely become more self-evaluative as they adjust to being in the service.

In such a performance-oriented culture, some degree of failure is virtually inevitable--even if small. If there is any tendency to blame the self for such actual failures and perceived (but not veridical) failures, the military performance-oriented culture will provide ample opportunity for self-judgment and perhaps self-condemnation.

Aspects of the military situation that make self-condemnation more probable than in many other situations are several (Litz et al., 2009). First, opportunities for high-consequence failures are frequent. Risky situations are part of military life. Failure can result in loss of life, limb, or mates in one's troop or company. Second, war is competitive, and a competitive motivation is enhanced throughout the military. Thus, standards are high and advancement is absolutely dependent on neither just being good, but on being the best, nor just on having a good record, but on having a flawless record. Third, while soldiers are expected to be obedient to orders, they are also expected to show initiative. That requires self-analysis, not merely waiting for a superior to tell one that changes are needed. Because the situations one is likely to face as a warrior have high consequences (e.g., might result in a friend being killed, might pressure one to do something one feels is morally wrong, might be unable to follow through with orders), the necessity of self-analysis and acting to remedy potential, as well as manifest, flaws and weaknesses is paramount. Whether one lives up to one's own standard of performance and morality is vital to initiating self-improvement. This can lead also to self-condemnation--especially if one either sets abnormally high standards for oneself or if one does not see a realistic way of coping with a bad situation.

In a culture of evaluation where the stakes are high for failure or success, condemnation by others might be expected. Self-condemnation arises from judgments of inadequacy, and such judgments are subjective. As we know from 50 years of research on social influence (Baumeister & Bushman, 2008), people are highly likely to be influenced in their judgments of their own inadequacy if (a) others in the group voice condemnation; (b) the group is highly valued and important; (c) an authority rendering judgment is respected; (d) no respected person disagrees aloud within the group (hence a soldier's positive support from a loving family might be discounted by the soldier). Thus, condemnation by others, either informally or through fitness reports, is likely to trigger self-condemnation in soldiers who are at all disposed by personality toward self-judgment.

Self-condemnation is hypothesized to be not just a product of failing to meet standards imposed by a military performance-oriented culture. It can also arise as a failure to meet Christian standards. We believe that, for the Christian, sin should ideally lead to confession (and divine forgiveness). We observe that when Christians sin or fail to meet their Christian-informed expectations, they often feel guilt and self-condemnation from God, and many Christians often seem not to get past those feelings to the freedom of forgiveness from God. Thus, we might observe that in military settings, though not unique to those settings, a felt condemnation by God might accompany or precede self-condemnation. Importantly, not all self-condemnation is wrong or pathological. Often self-condemnation drives people to recognize their wrongdoing and further drives them back to God seeking forgiveness, healing, and restoration. When these are the outcomes of self-condemnation, we must conclude that self-condemnation (however unpleasant) is a painful aid to righteous and healthy living. However, when it is crippling, entrenched, and stunts growth, then self-condemnation needs treatment.

There are a variety of personality predictors for developing self-condemnation. Few have been studied at present--at least relative to the study of personality and forgiveness of others.

The "machismo" culture of the military creates obstacles to seeking help. The military has a well-ingrained culture of self-reliance and an intolerance of weakness. It has historically not supported seeking emotional support and help for self-condemnation, especially regarding events in the line of duty. For a person who believes his or her performance to be in need of improvement or believes he or she has failed in some moral imperative, it is difficult to seek or obtain support or help.

Self-Condemnation and Complex Traumas

Definition of complex trauma. Complex traumas involve a history of subjection to totalitarian control over a prolonged period involving danger, stress, and an inability to escape from the situation (Herman, 1997). In fact, clinical research has linked diagnoses of Complex Trauma and of Disorders of Extreme Stress (DES, Not Otherwise Specified) with histories of interpersonal victimization, multiple traumatic events, and traumatic exposure of extended duration (Luxenberg, Spinazzola, & van der Kolk, 2001). Complex traumas also involve subjection to complete domination in cases of sexual and physical abuse (e.g., childhood physical or sexual abuse, domestic battering, or sexual exploitation).

Can complex trauma occur in military deployment? Situations giving rise to complex trauma might occur for prisoners of war, in a hostage situation, or during concentration camp imprisonment. But we argue that, more commonly, complex trauma could also occur if a person were deployed multiple times in settings in which life is continually, but unpredictably threatened by improvised explosive devices (IEDs), ambush, or a likelihood of lethal betrayal by civilians. Each of those creates a situation that a soldier might interpret as a prolonged confinement in which risky or damaging circumstances repeatedly occur. In addition, combat involves many things that a soldier could interpret as a damaging, confining, and potentially hazardous situation. Deployment to a war zone certainly involves multiple traumatic events for many soldiers and traumatic exposure of extended duration. Soldiers can feel that they are in dangerous situations that require them to do acts that they would not do as civilians (see Litz et al., 2009), and from which they do not perceive any possibility of escape. In addition, soldiers with a history of previous traumas, especially if untreated, are also more likely to develop complex trauma. In fact, Ford (1999) has observed that PTSD is often not sufficient to describe the interlocking co-morbid symptoms arising from moral injury, combat, and other experiences in a war zone.

Symptoms of complex trauma. Symptoms of complex trauma fall into seven categories (Luxenberg et al., 2001): alterations in (1) affect (e.g., affective dysregulation, explosive or inhibited anger, compulsive or inhibited sexuality, self-destructive behavior, suicidal preoccupation, and risk-taking); (2) consciousness (e.g., amnesia, dissociation, depersonalization, and intrusive memories); (3) self-perception (e.g., paralysis of initiative, helplessness, shame, guilt and responsibility, a sense of damage or defilement, a belief that no one can understand, and minimizing); (4) perception of the perpetrator; (5) relations with others (e.g., inability to trust, isolation and withdrawal, a repeated search for a rescuer, re-victimization, and victimizing others); (6) physical functioning (e.g., somatization); and (7) systems of meaning (despair and hopelessness, and loss of sustaining faith).

Several are of immediate concern to our contention. First, bouts of explosive anger and compulsive sexual acting out or other self-destructive behaviors following a return home can feed or lead to much self-condemnation. Second, alterations of self-perception involving shame, guilt, responsibility, sense of damage, and defilement are at the core of self-condemnation (see Fisher & Exline, 2006). Third, alterations in relationships leading to a lack of trust (in self, others, and God), and potentially victimizing others (with rage) affirm self-condemnation judgments and leave the soldier alone to deal with it. In addition, complex trauma is often accompanied by hopelessness and in a loss of sustaining faith. The combination can be lethal (literally) as a soldier sees him or herself as despicable and capable of unspeakable atrocities, as continuing to hurt others with his or her anger, as feeling isolated from others and God, and as utterly hopeless.

Prevalence of complex trauma within active-duty military and veterans. First, we observe that no empirical study of complex trauma (per se) within the military exists. We suggest that this needs to be remedied. We anticipate that the incidence of such complex trauma can occur particularly in (a) current and former prisoners of war, (b) people particularly dissatisfied with their deployment who feel that it is imprisoning, (c) a soldier's participation in immoral acts, or required interactions with squad leaders or peers who are abusive, and (d) soldiers dealing with particularly troubling relationships at home. It is likely that this last reason is not trivial. Generally, critical incidents that trigger suicides have been studied (Sher, 2009). Most suicides occur after some failure in the home life. For example, a person's spouse has an affair, their child gets in trouble at school, with the Jaw, or has a drug or alcohol problem, or conflict with a romantic partner is high. Such events, especially if the soldier feels that he or she is trapped on deployment and can do nothing to deal with the domestic issue, can result in suicide--as has been shown--but we hypothesize that soldiers who do not commit suicide are at risk for complex trauma. Analysts have observed that when soldiers, who are desensitized to violence and possess a weapon, are placed in an intractable situation, suicide risk is amplified.

Resilience and the Response to Potentially Traumatic Stress

Being at risk for complex trauma is not the same thing as experiencing it. It is well, at this point, to mention the resilience of a typical person. Soldiers are not typical. First, they are trained to expect and deal with violence and unexpected violence, death, and mutilation. Second, in today's services, they volunteer for such potential exposure to horrific situations. Third, soldiers are not typical because the situations that they encounter are often more morally charged--attempts to kill or avoid being killed--than are many of the potential traumas that people typically face.

When we hear of or read about horrific situations that sometimes lead to complex traumas, we assume that virtually everyone will respond to the situation with a trauma response and perhaps with PTSD or Complex Trauma. This is not actually the case if we can generalize from studies of potentially traumatic situations in non-military settings. Bonanno (2005) has investigated potentially traumatic events for over 15 years (Bonanno, Brewin, Kaniasty, & La Greca, 2010). Bonanno and his colleagues have repeatedly shown that most people who were exposed to what might be thought to be potentially traumatic circumstances--natural disasters, witnessing violence, being physically abused, and the like--did not develop trauma. Most recovered slowly or were resilient and bounced back quickly. Only a few participants developed trauma symptoms immediately or later.

Bonanno's research also shows that there are multiple and sometimes unexpected factors that might promote resilience. These include supportive relationships, the personal capacity to adapt flexibly to challenges, as well as the ability to express or suppress emotions when the situation demands (Bonanno, 2005), hardiness, and finding meaning in the disruptive events (Tedeschi & McNally, 2011). Seligman and others have studied positive emotions and a resiliency program in military personnel (Reivich, Seligman, & McBride, 2011). They considered assessment (Peterson, Park, & Castro, 2011), personality, positive emotional experience, and the treatment of military personnel to enhance positive responding and to create resiliency to potential traumas (Cornum, Matthews, & Seligman, 2011). It is clear that a strong and mature faith in God along with a sense of meaning even in the midst of terrible things supports resiliency. Algoe and Fredrickson (2011) reviewed the research on positive emotional experience and expression within the military. They found that, while resilient people react appropriately to negative events, they also worry less and can bypass non-materializing threats better than non-resilient people. They also grow more after stress. They argue that soldiers are capable of learning skills that help them maintain a healthy balance of positive to negative emotions. Even though many soldiers are resilient by personality and training, research shows that many soldiers (a) do respond with symptoms indicating trauma, (b) experience PTSD, and (c) contemplate or commit suicide (Sher, 2009). Problems are worse the longer people are deployed in a war zone and the more times they are sent back (Maguen & Litz, 2012). Soldiers are more likely to react negatively the more violence they witness. Soldiers are more likely to have mental health problems the more violence they perpetrate. This implies that complex traumas will often result from combat. This also suggests that soldiers' moral guilt, remorse, and a failure to extricate themselves from morally challenging situations can lead to self-condemnation. That self-condemnation can produce consequences.

Understanding Self-Condemnation

Prevalence of Self-Condemnation in General within the Military

As we see, soldiers have many risk factors for developing self-condemnation. It can arise in parallel with moral injury or with complex trauma. Once self-condemnation is developed, soldiers typically have few social supports for dealing with it effectively. Many seek to deal with their self-condemnation by trying to suppress the rumination, self-hatred, and negative emotions. They seek to inhibit motivations toward harm of self or displacement of violence onto others. These are not productive ways to handle self-condemnation. Although prevalence of self-condemnation has not been determined by an adequate survey, we might infer that it is prevalent from suicide rates (Sher, 2009). The rates in current veterans are high and are increasing, especially in those with additional deployments, with each deployment increasing the likelihood of performing morally repugnant acts, of observing others perform morally repugnant acts, and of experiencing failure and negative judgments by peers and superiors resulting in adjustments to one's evaluation of the soldier.

Costs of Self-Condemnation

The costs of self-condemnation to an individual are impossible to evaluate precisely, but costs include those that are documented in the literature on failures to forgive. For active duty personnel these costs may be to an individual's mental (and physical, relational, and spiritual) health (Beckham, Feldman, & Kirby, 1998). Without a good sense of their prevalence, we cannot accurately estimate other costs, but we can enumerate them. For active duty personnel, there are risks to the functioning of operational units because soldiers dealing with self-condemnation might be ruminating and, thus, less vigilant for IEDs or other dangers. That translates into injuries and deaths, which impose many financial costs as well as psychological costs on society. People who are disturbed by dysthymia or depression might be less efficient at performing essential duties, which imposes financial costs. For veterans, there will be a continuing financial cost for mental health services (costs, availability, etc.), especially for those with lingering self-condemnation and its associated mental, physical, relational, and spiritual problems. For veterans, there are likely to be additional financial costs because family functioning is impaired, likely resulting in financial burdens trickling down to spouses and children (Sheppard, Malatras, & Israel, 2010). There will also be financial costs that are incurred by employers for an impaired veteran's performance on his or her civilian jobs (Hoge, Auchterlonie, & Milliken, 2006). Overall, untreated self-condemnation is costly to the individual, the armed services, the taxpayers who provide veterans services, and the civilian families and employers.

Different Problems for Different Ranks and Military Responsibilities

There are differences in the problems related to self-condemnation faced by senior officers, junior officers, non-commissioned officers, and enlisted ratings (Worthington, Danish, & Antonides, 2012), but problems span the entire hierarchy of military personnel. For senior officers, command decisions can be guilt-producing, especially as they accumulate and if the commander has few social supporters. Junior officers experience the common plight and difficulties of mid-level management. They have responsibility for their unit, its mission, and the soldiers under them, but they often feel that they have no authority to act independently. Non-commissioned officers are career soldiers, often deployed repeatedly, who lead their troops in immediate leadership roles. As immediate leaders, they typically feel a greater sense of failure should the soldiers in their care be injured or fail to perform their duties effectively, especially if other lives are lost or people are injured. Due to repeated deployments over many years and due to increasing military responsibilities, non-commissioned officers are the most likely military personnel to see loss of life and injury, and are the least likely to believe that they can escape the stressors of combat. Thus, they are the most at risk for developing self-condemnation. Enlisted ratings are often younger, less experienced in life, and may not be cognitively mature. They are the most likely to encounter an enemy combatant face-to-face and thus, to kill, injure, or witness violence. A final group deserving special attention is medics. They are forced to decide whom to treat and whom not to treat, to make life and death decisions, and to hold dying buddies in their arms they cannot save. With the felt power to make life and death decisions they often bear the weight of self-condemnation for many years post-conflict.

Overall, there are challenges for experiencing both (a) events of wrongdoing and (b) judgments by the self of failure to meet expectations or standards. Rumination is likely if these events occur, resulting in self-condemnation as well as the condemnation of others.

Self-Condemnation Conceptualized

Emotions. Fisher and Exline (2006) have found that self-condemnation is accompanied by changes in emotion that recur periodically or chronically and that persist over time. These involve regret and remorse. The regret and remorse accompany feeling and thinking that one wishes he or she had not done some morally reprehensible behavior, or wishes that he or she had done some desirable behavior. When wrongdoing is perceived, it is usually accompanied by feelings of guilt. Tangney, Boone, and Dearing (2005) has shown that guilt feelings are often associated with perceived wrongdoing, and that almost all people experience such guilt feelings. Only when guilt feelings are excessive and impair normal functioning are they symptomatic. Tangney et al., (2005) argues that shame, however, is a state in which people feel, not that they have done wrong, but that they are wrong. That is, shame leads to a sense of lowered self-esteem. People with a fragile senses of high self-esteem are often at most risk for shame. People with a low but stable sense of self-esteem are at some moderate risk for experiencing states of shame. People with a high but stable self-esteem are at least risk of shame. Some people are more predisposed to guilt and shame than are other people. High shame-prone people often are at the most risk of self-esteem disturbances. Shame (i.e., feeling that one is a bad person as a result of wrongdoing or of having brought dishonor to one's unit, family, or country because of one's acts) is a risk factor for numerous psychological and emotional problems.

Motivations. Typically, emotions energize motivations (and vice versa, motives imbue acts that fail to satisfy the motives with emotional feelings and often emotional expression). Emotions due to failure are often determined by people's learning history and temperament. Some might respond with despondency, others with anxiety, and still others with anger or rage. The usual motives engaged and energized by self-condemnation are to cope with negative emotional states (i.e., to minimize regret and remorse), to reduce guilt feelings, and to minimize shame. Other motives might be cognitive--such as defending against accusatory thoughts or justifying misbehavior. Still other motives might be to attempt to make amends for wrongdoing or failure. Shame is a particularly unpleasant emotion, and vigorous efforts can be made to minimize shame. One might blame others for wrongdoing or for more distal causes of one's behavior (i.e., the person might blame command structure, trainers for inadequate preparation, or even former teachers or parents), bolster one's sense of self-esteem by self-aggrandizement, or bolster self-esteem by putting down other people or acting in ways that abuse civilians, or even prisoners.

Cognition. Self-condemnation involves the entire person--affect, motivation, behavior, and cognition. Which of these is treated as causal is a matter more of theory than of true causality. Litz et al. (2009) conceptualized the emotional consequences of perpetrating a moral injury on others as primarily a cognitive problem. We think of it as a primary disturbance of affect with motivational, cognitive, and behavioral aspects attached. This conceptualization brings self-condemnation, and later self-forgiveness, in consonance with Worthington's (2006) conceptualization of forgiveness as a coping mechanism. He suggested that perceived injustices were stressors and if they led to threat appraisals, they demanded that the person cope with the stressor, appraisal, or stress reaction. Forgiveness is of two types--both a decision to forgive and emotional neutralization of negative unforgiving emotions subsequent to a perceived injustice. This also places self-condemnation (and later, self-forgiveness) within the framework of a stress-and-coping model, with cognitive and emotional stress responses to perceived stressors (Pargament & Sweeney, 2011). In Worthington's (2006) stress-and-coping model of forgiveness, the disturbance is a perceived injustice that is evaluated as potentially injurious and thus threatening. The stress reaction involves the whole person (body, cognition, emotion, and behavior) and can be coped with using a variety of mechanisms.

Ways to Cope with Self-Condemnation

If indeed self-condemnation can be understood with this stress-and-coping model, then there are many potential coping mechanisms to deal with self-condemnation. Some are more adaptive than are others. Those that might not produce the best results include denying self-condemnation, ignoring it, externalizing blame, passing the pain along to others through unconscious displacement, and, in general, refusing to accept responsibility for legitimate wrongdoing. More positive coping mechanisms include, dealing with self-condemnation in a personal but psychologically informed way, and talking the self-condemnation out to gain perspective, thereby enhancing coping mechanisms by conversing with a friend, family member, chaplain, or counselor.

Many coping mechanisms use religious and spiritual means (Drescher & Foy, 1995). Moral injury frequently involves religious or spiritual conflict. Treatment can help people of faith, who are questioning aspects of their faith due to moral injuries, to reconsider and reconnect with God or what they previously held to be sacred (Fontana & Rosenheck, 2004). Pargament and his colleagues have identified numerous religious and spiritual coping methods, and have found some to be especially deleterious toward people's mental and physical health. If veterans or soldiers employ these methods, both their faith and their mental health can be damaged. Spiritual struggle that might occur as a consequence of moral injury is not always deleterious, but in non-military populations spiritual struggle predicts poor mental and physical health outcomes (Exline, Park, Smyth, & Carey, 2011; Pargament & Sweeney, 2011; Wood et al., 2010). Shults and Sandage (2006) have discussed the recurring cycles of spiritual dwelling and spiritual seeking, treating anger with God as something that is not uncommon. In studies of seminary students throughout their education, they showed that those who were in times of spiritual seeking had decreased mental health functioning relative to those who were in times of spiritual dwelling, but many of those in spiritual seeking recovered and strengthened their faith (Williamson & Sandage, 2009).

In particular, Exline, Park, Smyth, and Carey (2011) conducted five studies to examine anger with God, often a particularly virulent type of negative religious coping. In general, several variables predicted whether people got angry with God. These included holding God responsible for severe harm, attributing cruelty to God, having difficulty finding meaning in an event or in life, and seeing oneself as a victim. Anger toward God was frequently reported in response to negative events particularly among those younger in age and with low religiosity.

Some coping methods are externalizing--blaming God or the other. But, some are internalizing. The person turns the psychological energy back onto the self This is especially likely when a person feels guilty or ashamed, or feels that he or she has dishonored a valued group--like family, fellow Christians, soldiers, or countrymen. Self-condemnation is an example of the internalizing guilt and shame. Coping methods seek to deal with self-condemnation and do so ineffectively or effectively. One of those coping mechanisms is self-forgiveness.

Defining Self-Forgiveness

What Self-forgiveness Is Not

In theorizing about self-forgiveness, Hall and Fincham (2005) have described the difficulty of precisely defining self-forgiveness. As with forgiveness (Fehr et al., 2010), it is easier to tell what self-forgiveness is not than what it is. It is not letting oneself off the hook irresponsibly, accepting oneself and moving on with life, finding someone to blame such as one's parents, spouse, commanding officer, the President, Osama bin Laden, God, or life.

What Self-forgiveness Is

We define self-forgiveness parallel to the way Worthington (2006) defined forgiveness. That is, there are thought to be two types of self-forgiveness--decisional self-forgiveness and emotional self-forgiveness. Decisional self-forgiveness is making a decision to act toward yourself without malice, self-blame, and self-condemnation and to treat oneself as having at least equal worth as do others. Emotional self-forgiveness is the emotional replacement of unforgiving emotions toward the self with positive emotions toward the self like self-empathy, self-sympathy, self-compassion, and self-love.

Worthington (in press, a, b) has articulated a Christian theology of self-forgiveness. One of the great joys of being a Christian is that we expect ourselves to fail repeatedly. But we know that we have the awesome privilege of bringing our sins and failures to God. We know that those are paid for at the cross and believe that we can receive forgiveness and freedom from divine condemnation. Yet, release from moral guilt does not necessarily heal social effects of wrongdoing and failure. For example, Samuel proclaimed that God forgave David for infidelity and murder (2 Sam 11:13b), but psychological consequences and social consequences still ensued (see Ps 51). Amends making aims not at winning God's approval, but at social repair. It might also contribute to psychological repair. Psychological repair mostly happens as one deals with rumination and brings about changes in expectations and standards that are unrealistic or too harsh. Self-forgiveness is the culmination of moral repair (initiated by God's conviction and fulfilled by God's mercy and Jesus' sacrificial love), and the derivative social repair and psychological repair. Self-forgiveness does not let oneself off of the hook without consequences, but occurs as a culmination of responsibly dealing with God, others, and finally oneself.

Can One Forgive Oneself?

Hall and Fincham (2005) have proposed a model of self-forgiveness. They suggested that forgiveness of the self is related to making amends to the wronged person, seeking to make things right with God. Hall and Fincham (2007) tested their model with N = 148 people using eight waves of data longitudinally. They found support using growth curve models.

Worthington (2006) has suggested a therapeutic, psycho-educational group, or self-guided psychoeducational process for moving toward self-forgiveness that incorporates many of Fincham and Hall's variables. It can be learned through reading (books, workbooks), participating in psychoeducational groups, counseling, and engaging in self-directed activities. Scherer et al., (2011) tested the efficacy of brief self-forgiveness groups (N = 79) involving the genesis of Worthington's (in press) six steps to self-forgiveness in an in-patient treatment program for alcoholism. He used a waiting list design, and he found that people who went through the psycho-educational group for 10 hours in addition to treatment as usual improved more than a waiting list group, who also improved during their treatment. The immediate treatment group also maintained their gains. Campana (2010) used a similar waiting-list design for (N = 74) college undergraduate women who had been rejected by steady male partners. She also found that the women who completed a two-week at-home workbook to receive immediate treatment had superior outcomes to the delayed treatment group. Also, the immediate treatment group maintained their gains.

The Scherer et al. (2011) and Campana (2010) projects used the same basic treatment protocol, but the treatment regimens were tailored specifically to the groups and the mode of delivery (psycho-educational groups or workbooks) was different. The basic protocol in its early form is described in Worthington (2006). It suggests that group participants--in either psychotherapy or psycho-education or self-administered psycho-education--can promote self-forgiveness through following a number of steps.

Steps to Self-Forgiveness

In the following sections, we describe what needs to be done to complete self-forgiveness. At the end of the section, we name six steps to self-forgiveness to aid in memory. The order of the steps does not need to be followed precisely.

Repair Sacred Bonds

The person who has committed wrongdoing or who berates himself or herself for failure to live up to standards or expectations can begin by making things right with God. People who do not believe in God might repair sacred bonds that were disrupted by a perceived crime against nature or humanity or due to a violation of something felt to be transcendent. For Christians, this involves telling the truth about what has been done (confession/repentance) and asking for God's forgiveness based on the substitutionary death of Christ. For others, it might involve compensatory spiritual acts or acts of spiritual penance.

Assessment and Treatment of Potential Causes

There are two likely causes for self-condemnation. Each should be assessed, and if assessment warrants, treated.

Failure to live up to expectations or standards. The person must evaluate the degree to which the self-condemnation is due to failure to live up to expectations or standards. If failure to live up to expectations or standards is the main problem, the person can identify those human standard or God's standards that he or she is falling short of He or she can also evaluate the realism of the standards. Cognitive therapy has shown much success in helping people deal with unreasonable or unrealistic standards (such as a medic believing no soldier should die on his watch), so methods derived from cognitive therapy are appropriate. These might include teaching cognitive or cognitive-behavioral methods.

Wrongdoing and its direct and indirect effects. The person needs to assess the degree to which wrongdoing is responsible for self-condemnation. This might require seeking feedback about whether one seems to be self-justifying or rationalizing one's actions. Then, if harm was caused, the person should make amends with the person harmed. This might involve apologizing, making restitution, expressing sincere emotions like regret and remorse, and going beyond making up for harm by some sort of punitive damages. If the person harmed is not available, which is often the case with combat situations; amends can be made on behalf of the person harmed. This can include charitable work, such as contributing one's time, money or effort to a charity for orphans in the event of having killed a parent in combat. This is done in honor of the ones harmed. In addition, wrongdoing might have been witnessed by others, and by that witnessing, they might have been injured morally. Thus, the person should consider whether making amends to others who are involved is necessary.

Dealing with Oneself

Reduce rumination. Rumination is highly involved in many mental health disorders, including obsessive-compulsive disorders, depression, anxiety, anger, stress-related disorders, psychosomatic disorders, and many personality disorders (American Psychiatric Association, 2000). Rumination is negative thinking that is uncontrollable. The content of rumination determines the emotions experienced (Berry, Worthington, O'Connor, Parrott, & Wade, 2005). Even though, strictly speaking, rumination is a different cognitive problem than modifying unrealistic expectations or coping with failure to meet one's standards, each of these can also engender rumination. Thus we include it within the cognitive modifications that are needed to deal with self-condemnation through forgiving oneself.

Decisional self-forgiveness. The person can grant decisional forgiveness to the self The person makes a decision to treat the self as a valuable person based on the imago dei rather than on behavior. Whereas granting decisional forgiveness is an instantaneous decision that can lead to a changed outlook on life, it might still require days, weeks, months, or even years to conclude that one wants to grant decisional forgiveness to the self. Sometimes the person is inhibited from granting decisional forgiveness because he or she believes it is necessary to earn decisional forgiveness. Helpers can discuss the relationship of justice to forgiveness (Worthington, 2009) to help remove that roadblock. People might think that one can earn decisional forgiveness by restoring justice (often including restitution, reparations, or social justice). Though such complete restoration of justice is often impossible. A killed person cannot be brought back to life; a destroyed reputation cannot be restored; harm to civilians cannot ever be repaired because the civilians might never be able to be located again. If the self-condemning person holds out for strict justice, the self-condemnation may never be eliminated. However, if one adopts a belief in restorative justice, then reasonable attempts are made at restitution, reparations, and social justice, but some attempts at social justice must be relegated through faith to the future. That is, the person might have a sincere commitment to restoring damage done in the past, but might proceed to forgive the self even though the social justice has not yet been accomplished, and the restoration promised in restorative justice has not yet been realized.

Emotional self-forgiveness. Emotional self-forgiveness is replacing negative unforgiving emotions with positive other-oriented emotions toward the self. The replacement emotions are empathy toward the self, sympathy for one's inevitable imperfections, compassion toward oneself as a needy person who needs the help of others, and love toward the self by treating oneself mercifully. These emotions mirror Christ's feelings and attitudes towards us as he sympathizes with our weaknesses and draws near with mercy and grace (Hebrews 4:15,16). The person seeks to experience the positive emotions toward the self through structured exercises, hoping to replace negative self-condemning emotions with the self-forgiveness emotions. For forgiveness of others, Worthington (2006) has developed a five-step program to REACH forgiveness of the other. REACH is an acrostic (for a free download of secular version or Christian-tailored version of both leader and participant manuals, see www.people.vcu.edu/~eworth). R signifies recall of the hurt without blame of the perpetrator or emphasizing the victimization of the forgiver. E signifies emotional replacement. A signifies an altruistic gift of forgiveness--not on the basis of forgiveness being deserved but on the basis that the forgiver wants to do something virtuous to bless the offender. C signifies committing publicly to the forgiveness experienced. H signifies holding on to forgiveness when doubts arise. The five steps to REACH forgiveness can be adapted to self-forgiveness (see Campana, 2010, for a workbook intervention; see Scherer, 2010, for a psychoeducational group intervention).

Dealing with One's Past

Self-forgiveness (1) of one's failure to reach expectations or live up to one's standards, (2) for serious wrongdoing to others, or (3) for being an observer of heinous acts (and often making no effort to stop the wrongdoing) is often not the most difficult part of dealing with self-condemnation. The most time-consuming and difficult aspect is often to accept oneself as flawed in a way one didn't want to admit. Humans are frequently deceived about their capacities for injury or evil to others. Combat can shatter that deception and reconciling one's self to the objectionable truth takes time. Combat exposes humans to themselves and their potentialities in ways they were previously blind to or denied. Full treatment of self-condemnation can require psychotherapy depending on the entrenchment of the self-condemnation. There is also great comfort to be found in that facts of God's love and forgiveness and in knowing God knew our capabilities long before we did and is not surprised by our capacities. Self-acceptance, however, is always a primary struggle in full self-forgiveness.

Dealing with One's Future

Coming to a resolution on self-acceptance can take years. However, even before that work is complete, one must orient toward the future. Having failed to live up to expectations and standards or having perpetrated a moral injury on others, one has, by this point in treatment, sought to make amends and restore a right relationship to God. The person must make a commitment to live as virtuously as possible so that a repetition of the failure does not occur. In positive psychology, the commitment to virtue for self and others is called eudaimonia. A variety of interventions can be employed to this end (for summaries, see Snyder, Lopez, & Pedrotti, 2010). These include interventions and self-guided programs to build and express gratitude, compassion, altruism, forgiveness, and social justice. Expression of those virtues is also encouraged to build positive families, workplaces, and communities. Participation in a faith community can function as a support of maintaining a newness of life.

Failure in life is inevitable. While having an orientation toward pursuing a virtuous future is important, it is also important to give oneself space to fail. This prevents a quick failure to meet perfectionistic standards and expectations by the self. It also prevents a return to the deceptive state that led to a naivete about one's capacities. The truth is, we are still flawed.

We summarize six steps to responsible self-forgiveness as an easy-to-remember alliterative acrostic. The steps are as follows (with explanatory comments in parentheses):

Step 1: Receive God's Forgiveness

Step 2: Repair Relationships (i.e., making amends or paying it forward)

Step 3: Rethink Ruminations (i.e., controlling rumination, dealing with unrealistic expectations, and coming to terms with failure to meet one's standards)

Step 4: REACH Emotional Self-forgiveness (which includes decisional forgiveness)

Step 5: Rebuild Self-Acceptance (as one flawed by sin yet loved by God)

Step 6: Resolve to Live Virtuously (i.e., seeking to live a life pleasing to God but giving oneself mercy when one fails so that perfectionism is avoided).

Agenda for Future Research

With a growing number of suicides in military personnel and veterans who have served in combat situations, it is time to take seriously the prevalence of self-condemnation and its associated negative emotions--depression, guilt, shame, regret, remorse, and hopelessness. We examine self-condemnation and find that it is rooted primarily in a failure to meet expectations and standards, and in wrongdoing in which one inflicts a moral injury on people or kills. Thus, religious and spiritual issues deserve thorough consideration if we are to understand self-condemnation and self-forgiveness in veterans and soldiers. Self-condemnation likely occurs in military personnel and veterans due to different pressures and situations that are shaped by rank and by type of service. We hypothesize what some of the pressures are and assert that forgiveness can be extended to the self as one way of dealing with self-condemnation. Furthermore, the opportunity to deal with religious and spiritual issues presents itself at various points during treatment for self-condemnation after experiencing a complex trauma (Pargament & Sweeney, 2011). In the course of trauma treatment, self-condemnation is likely to be an issue and will involve consideration of how realistic the standards and expectations are. In addition, the Christian message of justification--that Christ died for people's sins--is important and for many people it will lead to freedom from the weight of self-condemnation. For others, though, failing to understand the forgiveness of God through the death of Christ and his sympathy with our weaknesses can feed self-condemnation. This is especially true if they feel that failure to experience complete relief due to God's forgiveness is yet another failure for them.

We describe the outline for a treatment for self-condemnation for soldiers and veterans. We tailor the treatment to soldiers and to Christians (obviously, some of what we suggest would have to be altered when working with those who are not of faith or are of a different faith). In the present article, we have proposed several testable hypotheses that advance a research agenda.

1. In military personnel and veterans who are at risk for suicide and mental health disorders, self-condemnation plays a major role. This suggests that psychometrically sound instruments need to be developed to assess self-condemnation and this hypothesis should then be tested. Furthermore, we hypothesize that military personnel and veterans who have perpetrated or observed more combat-related violence will experience more frequent and more disturbing states of self-condemnation. This needs to be established through surveys of military personnel and veterans.

2. Self-condemnation is hypothesized to be a state that is associated with a stress response. If this can be demonstrated, the experience of frequent intermittent states of self-condemnation or chronic states of self-condemnation will produce physical health-related disorders. The prevalence of physical health, mental health, relationship, and spiritual problems need to be measured.

3. States of self-condemnation will arise due to two fundamental reasons: failure to live up to standards or expectations and wrongdoing or inflicting moral injury. We hypothesized further that senior officers, mid-level and junior officers, non-commissioned officers, and enlisted personnel will differ in the two sources of self-condemnation--with higher level officers reporting more failure to live up to standards and enlisted personnel reporting more direct and indirection infliction of moral injury and non-commissioned officers and junior officers experiencing both. These deserve investigation.

4. It is likely that some military personnel might object to self-forgiveness. Just like other psychological concepts, self-forgiveness might be suspect in a warrior culture. We would suggest that several potential objections might be profitably dealt with. These speak directly to how extant self-forgiveness interventions can be successfully tailored to the military. These objections include the following: (a) self-forgiveness does not fit the warrior ethic. We suggest that this might be dealt with by characterizing self-condemnation as a fitness issue and self-forgiveness as a way of increasing military fitness; (b) soldiers or veterans might not want to attend a psychoeducational self-forgiveness group. We suggest that other modalities--like workbooks, online courses, and DVDs--might be tested for acceptability to soldiers and effectiveness; (c) self-forgiveness does not seem especially relevant to military situations. We suggest that treatments must be tailored to rank and military responsibilities and separate adaptations be presented for different constituents. These deserve an empirical investigation.

5. There is a need to adapt both assessment and treatments to a military population, using examples that are relevant to today's armed services. For example, Fisher and Exline (2007) could be used for assessing self-condemnation, but tailored assessments, rather than Fisher and Exline's more general assessments, would likely give better data. Such assessment instruments need to be created. Whereas the six steps to self-forgiveness have been used and tested in clinical trials, that treatment needs to be expanded and adapted for military personnel.

In the present article, we have argued that military situations, especially repeated combat and killing, can place soldiers at risk for trauma and even complex trauma. Moral injury--internal conflict over wrongdoing in opposition to one's standards--is frequent. Self-condemnation is wrapped up in both complex trauma and moral injury. We suggested that one way to deal with self-condemnation is through the promotion of self-forgiveness. We considered a six-step method, which has initial support in alcoholism treatment and in college women, but none in military populations. Testing in a military setting would require adapting existing treatment specifically for a military culture and testing reactions of soldiers and former soldiers in the problem of self-condemnation and its potential treatment, including the modality by which the treatment could most effectively be delivered.

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Everett L. Worthington, Jr.

Virginia Commonwealth University

Diane Langberg

Private Practice, Jenkintown, PA

Author Information

WORTHINGTON, EVERETT L. PhD. Address: Department of Psychology, 806 West Franklin Street PO Box 842018 Virginia Commonwealth University Richmond, Virginia 23284-2018. Email: eworth@vcu.edu. Title: Professor of Counseling Psychology, VCU. Degrees: PhD, University of Missouri-Columbia. Specializations: forgiveness, REACH forgiveness intervention, religion and spirituality in counseling and marriage, the Hope-Focused Couple Approach to marriage/couple enrichment.

LANGBERG, DIANE. PhD. Address: 512 West Avenue, Jenkintown, PA 19046. Email: info@DianeLangberg.com. Degrees: PhD (Counseling Psychology) Temple University; MA (Psychology) Temple University; BA (Psychology) Taylor University. Specializations: see www.dianelangberg.com.