Transcript of a Conversation by Batya Yaniger and Tani Burton’s with Maria Marshall About Moral Injury and the Search for Meaning. Transcribed by: Maria Marshall
Transcript published through the Ottawa Institute of Logotherapy, with permission from Dr. Batya Yaniger and Rabbi Tani Burton, Viktor Frankl Institute of Israel. Granted on September 27, 2024.
Deep Exploration/Life’s Re-discovery: The Search for Meaning
Podcast Series of the Viktor Frankl Institute of Logotherapy of Israel
Recorded in Jerusalem, Israel, July 25, 2024
BY: I’d like to introduce you to Dr. Maria Marshall who is a Registered Psychotherapist [Ontario, Canada]. She has a doctorate in psychology, and is a diplomate clinician in Logotherapy, and Faculty Member of the Viktor Frankl Institute in the United States. Together with her husband, Edward Marshall, she heads the Ottawa Institute of Logotherapy which is an accredited member of the International Association of Logotherapy in Vienna. Maria has written several books on logotherapy, the latest of which is “Viktor E. Frank’s Logotherapy and Existential Analysis: Theory and Practice” (2023). She brings a great number of empirical studies in that book, demonstrating how logotherapy is an evidence-based approach, which is something that is very much needed in the world of psychology, to let people know that logotherapy is legitimate, and not just legitimate, but has something great to offer. On a personal note, it was my enormous pleasure to meet Maria. I so enjoyed our meeting, which was one of these moments when I went to Ottawa to see family, and it was just so sweet and so special. So, above everything else that I learned about you, I just wanted to say that.
MM: Thank you very much, Batya, and a good evening to both of you, Tani, and Batya. I wanted to say first of all that it is an enormous pleasure and privilege for me to be here and to share some of my thoughts and the invitation to talk about a topic that we are going to address today which ties in very much with logotherapy–moral injury. I hope that I will be able to cover this topic really well. I had a lot of important things on my mind to say and as I prepared my notes, I went through them a couple of times. If it happens that I somehow miss something, I hope that I will be able to remember in the nick of time, but if that happens, please be kind, and remind me. In previous conversations you have been a fellow searcher with me and always more came out than what we started the conversation with, and we always ended up on a very nice note. I do not want to hyper-reflect too much and impose on ourselves that we have to achieve something very significant, but we want to bring something of worth and value to our audience and that’s why we are here today. Thank you for the invitation!
BY: That’s right. Thank you so much for accepting it.
TB: Good to have you here.
MM: Thank you, Tani.
TB: Maria, I’ve read your article on the concept of moral injury and because of course it was published in a journal, its technical and it speaks to people who are clinicians or people who are in the field and already familiar with the terminology, but let’s say if you were going to give the topic of moral injury as a five-minute TED talk, what would you say, how would you get a sense of that conversation.
MM: Thank you very much for this question, Tani, I must admit, and let me start with this thought; initially, I did not know very much about moral injury or about what it was. And I did not understand the concept myself in depth, and that was the beauty of it. During the COVID-19 pandemic, my husband, Edward, and myself came across this topic—moral injury—and it was related to the trauma field.
In the trauma field, researchers, leading researchers in the trauma field, started to talk about it in the field of medicine, education, and law enforcement. We got interested about the concept; what it is, what it entails, and what does it mean –moral injury. On the surface, we understood that “moral” must be related somehow to morality, so to ethics, ethical principles, guidelines, and values, maybe. And because it’s an “injury,” of course, some kind of trespassing of moral values came to mind right away. So, I wanted to give you a little summary of what we discovered and what we came across in our research. I want to apologize if this may be going over a five-minute Ted talk’s worth, but please stop me when the time is up.
Moral injury is not a new concept. This concept has been around for thousands of years. And surprisingly, or not surprisingly, it has been around in ancient Greek times, and Roman times. The ancient Greeks already talked about combat-related trauma that was not related to the visible injuries that they sustained, but the invisible injuries. They defined moral injury as “…when a noble cause for when one volunteered is compromised, moral injury occurs.” And they had their way of dealing with moral injury, and this is why they invented the theater, where they would act out different feelings and different events that happened to them that would lead to a catharsis, an abreaction, and acting out of different feelings, and dealing with them in a way of talking about it, screaming about it, laughing about it, until is does not hurt so much; until its shared with the audience and there is a group cohesion and support that gave them a sense of closure and a feeling of having dealt with this trauma.
The Romans dealt with moral injury in a different way. They designed and built wonderful, soothing baths and amphitheaters where soldiers could go on a retreat and receive a nice relaxing massage and be surrounded by soft music. That is how they dealt with overcoming the feelings and emotions related to being in wars and combat and sustaining invisible wounds of combat.
During the pandemic, the notion surfaced again, and came up very suddenly, abruptly, and exponentially. That was related to the medical field of course, because we have witnessed suffering on a scale that was very rare. It affected humanity in unprecedented ways. Most all countries were affected to more or a lesser extent, and people were dying. The health system was overwhelmed, and hospitals were sometimes described as battlefields, where doctors were running from patient to patient and relatives were sometimes not allowed in. During this time, the definition of moral injury became more refined and more concrete: it came to include the psychological, social, and spiritual impacts of events in high stakes situations, such as related to military combat. –High stakes situations, in other words, difficult life situations, that involved the betrayal, or the transgression of an individual’s deeply held personal, moral beliefs, and values. Thus, the definition really has advanced from the initial definition of invisible wounds of combat, to recognizing existential distress that resulted from moral transgressions in extreme situations that resulted from the actions of a person, or the lack of them, commission or omission, which violated one’s ethical code and moral principles.
There are intrapersonal, interpersonal and spiritual consequences to moral injury. It came to be researched and understood as having the symptoms of guilt, shame, feelings of betrayal, difficulty forgiving, loss of meaning, loss of trust, self-blame, spiritual struggle, feelings of inner conflict about the moral implications of those transgressions. The interpersonal symptoms became also more recognized and more talked about, such as loss of faith in others, loss of trust in authority figures, avoidance of closeness, avoidance of intimacy, and spiritual consequences such as loss of faith or religious beliefs, loss of confidence in goodness, and a just world came to be described. Also, in keeping with the DSM, the contemporary categorization of mental disorders according to the APA, moral injury was first linked with PTSD, post-traumatic stress disorder, then researchers slowly came to distinguish how exactly PTSD is different or similar to moral injury.
It crystallized out of research that when symptoms of moral injury are ignored or denied, or not talked about, they can be related to, or present in addition to PTSD symptoms, or lead to PTSD symptoms as well as to anxiety, depression, and negative mental health outcomes. The hallmark of moral injury is a strong feeling of disgust and anger that is different from some of the symptoms of post-traumatic stress disorder, which is mostly characterized by the re-experiencing of the traumatic events, high arousal and avoidance. So moral injury can be present with PTSD symptoms, or without PTSD symptoms. It is a syndrome, a clinical syndrome of concern to clinicians. So it cannot be categorized as a mental disorder. It is not a mental disorder as we are going to see it, in fact, it is a very human phenomenon and a very existential phenomenon that is present when someone sustains severe trauma and they are affected in a way that their values and moral system is questioned and there is a dissonance between what is, what can be and what ought to be, in existential terms.
In the medical field, moral injury came to be defined as occurring in situations in which physicians, nurses and other health care workers are required to make decisions that violate their professional commitment, inherently related to the curing and caring for the sick in the course of providing health care services. So moral injuries occur in health care workers when they are unable to live up to, or to defend and uphold their values or moral beliefs. So, as we said moral injury is a complex trauma related syndrome that can have adverse impacts on mental health. Its hallmarks are disgust and anger, which is different from guilt and shame, which are predominantly found in PTSD, and it can be conceptualized as the transgression of personal values that gives rise to existential struggles resulting in a sense of loss of meaning accompanied by existential suffering.
In closing, it has been found, and there is extensive research to suggest, that meaning mediates post traumatic response and fosters the possibility of post traumatic growth. Now these are all concepts that we can expand on and talk about, but meaning has a central role, and this is where logotherapy comes in, with evidence-based research showing that meaning is an essential component of trauma-informed care that considers the whole of the person, body, mind and spirit. Maybe, this is where I would stop with a brief introduction on moral injury and what it is.
TB: You mentioned that in ancient times moral injury would be termed to speak of what you called the invisible wounds that would have been suffered by soldier in combat. I am wondering if those invisible wounds are let’s say the feelings of guilt and shame on the one hand, and/or the crisis of meaning on the other. That’s one question that I have, and the other question is, how is this different than the classic ebb of faith moment or just the experience of extreme disillusionment. It’s a new term that people have used throughout history that has clinical ramifications but is it really different from any time one loses faith or hope or the world around them and the people around them.
MM: You ask very good questions, Tani, because they make me think. And your questions are very complex as well, so let me see if I can give a full answer and let me know if I didn’t. Moral injury, I would think about it along a continuum. Obviously, there are everyday situations that make one ponder, and that is part of being a sensitive and conscientious human being. It is unavoidable that there are going to be situations that make one wonder. In fact, this can happen on a day-to-day basis. We just wonder about the motivation of a person or why certain situations happen to us, and we wonder how to respond and what to do about certain things. When it comes to moral injury, and we were talking earlier about the definition of moral injury, we are talking about serious trauma that affects people’s everyday functioning, so it is not only from mild to moderate on a continuum, but reaches the severe on this continuum affecting a person’s functioning, their beliefs, which has a repercussion on how they are able to conceptualize meaning in their lives. When you were asking about the invisible wounds of combat and whether there can be meaning and finding meaning, or not seeing meaning as a result of that, of course, we are talking about not seeing meaning on a more chronic and long-standing way on that continuum. Thus, not just existential frustration, but long-standing existential frustration, where the wound, the impact, is severe enough that it interferes with everyday functioning. That of course is the consequence of a person in a way, we could conceptualize it this way, being or experiencing a temporary but severe disconnection from their core values, in a way from an aspect of themselves and a dimension of themselves, of their core and of their essence, and what they believe, their orientation. That is the kind of wound that we are talking about that research is increasingly recognizing as going beyond just thoughts and beliefs and the events that happened but affecting the core and the essence of the person. This feeling of disconnectedness form the very core, the very essence of the person, and, as a result, a feeling of disconnection from one’s surrounding, from people around oneself; not wanting to be around people, feeling disconnected to the point of being ashamed of oneself, feeling guilty of what happened, but yet having a difficulty talking about it and addressing this, is of course because the trauma is deep seated and many times even unconscious, as this part of the self, our deepest essence, is also mostly unconscious. And we will expand more on that when we talk about values because moral injury is related to the transgression of values, deep seated values.
BY: I hope I’m not jumping the gun, but I also wanted to ask a question about what you said in the beginning, when you said that a noble cause is compromised. So, I am kind of adding on to Tani’s question. Because a noble cause being compromised causes us to be disconnected from ourselves and from the people around us and what is a noble cause? Maybe we’ll get to that later? Has anyone identified what a noble cause is?
MM: Yes. Let’s give a superficial definition. On the surface, a noble cause would be something in which a person makes a lot of investment, a group of people make a lot of investment, and they find this a worthwhile cause. Now whether this would be a worthwhile cause and really worthwhile pursuing at all costs, seeing the consequences, see, as things evolve and being able to reflect and evaluate the course of events and whether this was really the way of doing things, and eventually the meaningfulness of this cause, is what is decisive. There is a difference between the value, the worthwhileness, the evaluation, and the discernment in the process of being confronted with meaning and what is really meaningful. And then when we are talking about the superficial way of looking at it, I would like to bring in some examples, some concrete examples through which maybe this could be made a bit more palpable, a bit more here and now. What would be some relevant examples to consider? And that would be some ways for the audience to be able to relate to the concept of moral injury? If you do not mind, I will present some examples.
Let’s say, there is a life-affirming pastor, a pastor who really believes in the worthwhileness and the dignity of life, upholding life under all circumstances up to the last breath and finding meaning in life up to the last breath. So, this is a Rabbi, a Minister, or a Priest, who have been serving their congregation over many years and he or she is called to the house of a parishioner, a member of the congregation, who now informs him or her, that they have a date arranged for receiving medical assistance in dying. That means, they have passed through two assessments that are required medical assessments and they have received approval that on such and such day a doctor is coming to their house to administer a lethal injection, and now they are asking this Pastor, Minister or Rabbi, to be present during this procedure and to accompany them during these last minutes, the last minutes left from their lives. The Rabbi, the Minister or the Pastor is contemplating now what to do. To make matters more difficult, or more complicated, what if this would be, let us say a Catholic priest, who received instructions from their Bishop not to attend such an event. That if one of the parishioners requests medical assistance in dying, not to accompany them and to give a clear message that the Catholic Church does not support medical assistance in dying. Therefore, priests of the Catholic church are not going to accompany someone and not going to give the last rights to a person who is receiving medical assistance in dying. So now, what should a Minister do, what should a Priest do under such circumstances? This is a call of conscience, a unique situation, it is a high- stakes situation because they invested a lot of time and effort and they are dedicated and committed to their congregation, [and their response potentially has a bearing on their parishioner and their family]. So let us say they attend this event. And I am not making this up, I just received one day ago, as on my news feed I receive information about new research, a report about the outcomes of a recent qualitative research. They interviewed Pastors about their experience. One of the Ministers reported that, on the one hand, it was an immensely precious experience to be present with their parishioner, but on the other hand, their way of death was different from what they were used to before, when people did not request medical assistance in dying. How it was different, said this Minister, is that the doctor appeared, they administered this lethal medication, and the person, though peacefully, stopped responding and died in front of them. Otherwise, there would have been a conversation to the end and people would have had maybe a highly spiritual experience. There would have been perhaps more suffering, but despite of that, in spite of that, especially in the face of death, they would relate to those around them, tell their relatives about their last wishes, and in some instances find peace and they would find comfort in the presence of the Pastor, or the Rabbi, or the Minister. There would be sharing up until the last instance. In this case, said the Minister, it was different. There was no longer sharing, the person died, and they were left in this room, the Minister and the family members, looking at each other, and trying to comfort each other, that it was peaceful, after all. Yes, it was peaceful, but it was different. And then this Minister, who they interviewed, went to great lengths at describing and confronting her feelings of how she actually felt about this. She was debating back and forth whether this was really a good way of dying or maybe not exactly. She recalled that she had witnessed people in very difficult life circumstances where the assistance given, the care given, and the quality of care given, made people make a different choice. She especially recalled an elderly lady who had been hospitalized at a long care facility and she received palliative care, a very good quality palliative care. Under those conditions, even though she was approved for receiving MAID (medical assistance in dying) she decided otherwise. In the last minute, she changed her mind, and she said, “No, I am not going to do it. Just ask the doctor not to come. Not today. Not at this time. Maybe some other time.” And she changed her mind. That was the conclusion of this article. Many other priests and ministers joined in, voicing their concerns of the same nature. These were ministers who were freely speaking and who were under no obligation, but they questioned their conscience. And so, for them, the conclusion was, that it was akin to experiencing moral injury to witness someone who had suffered and who requested medical assistance in dying. So that could be one example.
Another example: A doctor who practices in a war zone where essential care cannot be provided because the electricity grid has been damaged. In one of our books where we wrote about moral injury, “Logotherapy and Existential Analysis for the Management of Moral Injury,” seen from the perspective of a doctor practicing in Africa. He was talking about the indignity of it all, of being the stewards of life, and having to accompany people to their deaths. And the suffering that came with that.
Or an educator who notices that some of her students are failing due to discrimination or lack of opportunity. Or a judge who witnesses an unreasonable outcome because of racially biased jurors. Or a nurse, who struggles to provide a high standard of care in underprivileged conditions. And the list goes on and on.
I prepared the case of a young nurse, a recently qualified nurse, who is working at a memory care facility for people with dementia. I do not know if it would be a good time that you allow me to go through her experience, which if you let me present it here, is a composite. It is not the experience of one specific person, but an example put together based on what people have said in several interviews. Although they do not come from one person’s report it is something that could be and would be related to an experience that is very much a real life-like experience. We have some real-life experiences, so-called phenomenological experiences that have been reported and those are very moving, and very beautiful. One of them comes from the work of Dr. Breitbart. I do not know if you are familiar with the work of Dr. Breitbart, but he is a leading researcher, who also introduced logotherapy in his work at the Sloan Kettering Cancer Treatment Centre in New York. During the pandemic, he wrote about his own sense of moral injury, and he detailed it. The way in which he dealt with it is that he recalled the memory of his parents who were concentration camp survivors. They survived Auschwitz. In one of the critical moments, he recalled a memory of his parents, and he felt overwhelmed by gratitude and gratefulness that they survived and that he was born. And he said, shall I now render all this to be meaningless? And he said, no, to the contrary. I, with my own example and with my own life, should try to actualize a meaning that can answer this situation to make it even more meaningful, to bring even more meaning into this world because of this suffering that no one can take away, no one can erase. And so, a change of heart came about in Dr. Breitbart, and he said, I am sure after the COVID we are going to stand shoulder by shoulder and there will be hope and there will be more fraternity.
But before I present that example, let me come back to this very present-day example of a young nurse. Not Dr. Breitbart, a very experienced professional and logotherapist, and prime example, or a perfect example of a logotherapist, but someone who is yet inexperienced in logotherapy, someone who has not yet heard about logotherapy, but someone who is a quality nurse and has the potential to be one.
BY: With all of these examples, excellent examples and all different types of what different walks of life are and different scenarios, we want to bring this to life, by asking you whether you have experienced moral injury?
MM: I was fearing this question. [Laughing] Because this question makes me talk about myself. Of course I have experienced moral injury. And of course, my husband and I have experienced moral injury.
TB: Is there something that you feel comfortable sharing?
MM: Oh, yes, of course, and you decide if you keep this, or you cut it out. [Laughing] Of course. That is why we had an interest in moral injury because it was very present to us, and it was very present to our everyday lives. Well, moral injury, as I talked about it, on a continuum, from very mild, I would say is like this: we keep very much in touch with the news and whenever we see or hear images of people in war related situations, our heart reaches out to those who are suffering. I think this is a very normal and natural human reaction. And when people are mistreated, or when we see people suffering or dying… [it affects us].
Research has been done on how acutely one feels the pain of others. And this was done in the military setting. I’m not going to deviate too much from my own experiences but just let me mention this piece of research. It was found that the further away from the physical place, the further away the camera and the physical distance there is between you and the people who are suffering, the less you’re going to feel their pain. But now, with modern technology, we can see everything right in front of us on the screen and the images are playing right in front of us and the people are screaming and dying right in front of us, so this brings it, everything, into our living rooms. Research illuminated a very sad reality of all of this, because [they found that] now soldiers who are trained, you know the sharp-shooters in the United States, Great Britain, and Australia, from the NATO forces, where they did this research on how it is now in comparison to how it used to be previously for soldiers, described how now it is possible to see everything on the screen and when you direct a bullet you see exactly where it’s going to go, and how it penetrates, and the impact of it, right in front of you in the screen. The impact on soldiers is far much greater than what it used to be. It used to be that one dropped a bomb, and one did not see the impact. One flew over a territory, and one did not see the damage, one just heard about it later in the radio, so one was more removed, whereas now one is right in front of the camera, right there as it’s happening in real life. So, of course the impact is much greater. This is research.
Now about our personal experience and my personal experience. One of them was, and see, moral injury is a subjective thing. To someone else it may not be so much traumatic this what we experienced, but to us certainly it was. When we moved to Canada, my husband was not able to practice as a doctor anymore. We started to have little children and some of them died before they were born. We lost some of our children. First, I was unable to conceive, and later I was unable to keep my pregnancies, until I was properly diagnosed and treated for this condition. In the meanwhile, my husband, to be supportive of me, gave up his medical license, which was his life work. By this time, he was forty years old, and no one could have asked him to do this. I did not ask him, but we decided, for my sake, and for the sake of our future family to do it, because the licensing process was so contracted and so expensive and proved so difficult that we could not do it. It was against helping our children… [I required bed rest and there was no one else who came to help us]. So, even as I talk about this, it brings back goosebumps and the feelings, and the memories. You need to bear with the person who shares with you these kinds of experiences for that is what’s going to happen to them. It affects the core of their essence, of what they struggled for, or what they strived for, of what they believe in and their life work of where they were willing to put in their efforts and what they were willing to fight for, and what they thought was meaningful, and then something else happened and life brought something else that really made them question all that. And the first question is, “What is it that I can expect from life?” Is it what I struggled for, is it this what should be my end, is it this that I should see at this point? And then, of course, one may question one’s own beliefs, question God, and cry and so on. I am not alone with this because Viktor Frankl wrote it down so beautifully in “Man’s Search for Meaning,” and that is why over ten million people can relate to “Man’s Search for Meaning,” so beautifully and so intensely, because in there, there are the same words, that maybe, what is left is to pray a little bit, and to pray over the Psalms, and then to gather oneself and to see what is there and what is left. And to realize that the question that is left is “What now?” Not “Why me?” but “What now?” What am I going to do now? And then there is this Copernican revolution that Frankl talked about. We cannot ask other people, we cannot force people to do this, but eventually they realize that it is not that we question life, but that we are questioned by life, of what we are going to do now. As Frankl so beautifully stated, that “Sometimes it is first amongst the ruins that the stars become visible.” Of these stars, which star stands closest to us? What now? Which value to actualize now? And that is why Frankl said that meaning is objective. It is not something that we can make up, not something that we can force on another person. The same way, heroism, or this achievement of a change of heart, cannot be forced on a person, it cannot be forced on someone else. Heroism, Frankl said, can be only asked from only one person, and that is from myself. And then comes this questioning of Rabbi Hillel: That if not me, then who? Who will do it? If not now, then when shall I do it? And if only for myself than who am I? And that is when logotherapy comes in and its beautiful potential and what it can offer in the healing of people who have experienced moral injury. Because Frankl’s works are words of healing.
BY: You’ve experienced this in such a personal and raw way, and you’ve gotten through it somehow because of your firm belief and it made me realize that moral injury is more than just suffering. It’s like the idea of adding insult to injury. –That old expression. And what does that mean? It means that something is being, it’s not just that you are suffering, because this has happened, but something has been cruelly taken away from you.
MM: [Thinking]
BY: Because your husband was not able to continue, because of the circumstances it was not possible to continue.
MM: It was not possible, but then life opened some other possibilities.
BY: Yes, so, just as in suffering in general life opens new possibilities but the nature of the suffering, I think is all those examples that you brought and your own is that something is very unjust on the top of everything else beyond just feeling that this hurts….
MM: Yes, exactly. Like Frankl said, in the concentration camps, it’s not just that they were put into the concentration camps, it’s that your name was taken away, your profession was taken away, your clothes were taken away, your diplomas were thorn up right in front of you and laughing to your face, “Ha, Ha, Ha,” with a swear word, now what are you going to do, ha, ha, ha…and, I am not going to say that Frankl’s suffering was relative, because as he said, suffering can completely fill a container. So, everyone’s suffering is relative to that of the others, but when you have it, it fills the container completely. So, it was for us that people were, as if taunting. Now what are you going to do? Now the doctor, what is he going to do now? No friends left; no colleagues left. Who wants to talk to you now? Nobody. You have not passed a single exam, you are nobody. You are not welcome here. Go somewhere else, go back to your own country. And that is what they said to us, go back to your own country. Why are you even here? If it was me, I would not be here. Or, it was said to me, “Why are you struggling to have a second child? You should have an abortion because you are the cause that your husband is not a doctor anymore. And if we did not have our second child, woe to us, where would we be without our son? It’s our son. And I said, “No, you do not understand. It’s our child.” And then we went on to have another child, and another child, and another child. Until we have five children, the most we could have. Because it was all out of the defiant power of the human spirit that Frankl talks about—the defiant power of the human spirit. When everything is taken away from you and you are reduced to what may appear as nothing; behind that nothing, there is everything! Because then you are reduced to your essence. And that is what we found. We were reduced to our essence. What was left. And that is where there is hope in what is left because there is an incredible amount that is left. All our inner strength is left. And that is what is the question, Frankl said, now do you decide to bring out the worst in you, and you become like one of them, and you just maintain this chain reaction, and you respond to disappointment with disappointing behaviors, [laughing], all right, you slap them back, you hurt them back, you insult them even more…But that would bring even more suffering even to yourself. Or you actualize a different part of yourself. Despite the pain, you are patient–and we could be patient. We found out that we could be patient. And we could be kind. And we found out that, especially in the midst of pain, we could be kind, and it made the most sense to be kind, and to look for the little opportunities that we could have to be kind to somebody, somebody around us. Not the fancy colleagues, because they turned away from us, but the person on the street, who cares nothing for degrees, but he cares where his next piece of bread will come from. So, give a piece of yourself; give a piece of bread, or a smile, or good words, or share around with people what you have, or your child, or the people who are still around you, or the tasks that are still awaiting. Every day there were still tasks waiting, and the tasks kept coming and coming.
BY: It seems like, you know, Frankl said that, in a way, suffering is the highest of the three values because it shows human achievement at its best to overcome suffering and the lower you sink down the higher you can climb up. If you said that when they lost everything, then they were reduced to their essence and the more that you are…your dignity is taken away, that’s when the defiant power of the human spirit rises up strongest.
TB: Yes, interesting also that we tend to not want to suffer and yet from Maria’s story here and so many others that we encounter in this field it’s specifically the suffering that brings all of these unbelievable resources to the fore if we know how to capitalize on it properly. What you said, Maria, just resonated with me, which is that the meaning crisis is subjective, like you said, which means that it has this kind of intentional element or intentionality or intended for the person. I would say that my understanding of this concept of moral injury is that that’s your run of the mill meaning crisis whereas the clinical moral injury takes us up to the realm of severity where it impedes functioning. Whereas the meaning crisis often might inspire or evoke functioning at a much higher level, somewhere we cross the line, I would say, from almost a positive meaning crisis to the negative moral injury. Can you pinpoint that?
BY: Are you saying that the most severe moral injury does not allow the defiant power to come to the fore?
TB: That’s my question. How do we distinguish this item that can bring a person to PTSD from this highest value in suffering that can bring out the hero in the person?
MM: There is a very nice metaphor that came to my mind. Frankl likened, made a simile, compared the work of a very seasoned, good therapist to that of a mountain guide. Few people know that Frankl was also a mountain guide. As a mountain guide you learn how to go down slowly, and to lead people how to go down slowly, as well as how to go safely up. Which are the safe paths and how to navigate and how to avoid the dangers. And how you do that is through practice. You yourself, us as therapists, we need to be also ready to face our own challenges and suffering. On the one hand, Frankl said that suffering is not necessary to find meaning. On the other hand, suffering is unavoidable in life. So, when you are suffering you always have this dialectic. On the one hand, on the other hand. On the one hand, suffering opens up what is most vulnerable in a human being: fallibility, finality and vulnerability. Pain, guilt, and death. Like the three aspects of the tragic triad that Frankl named as such. Now, it comes down to a human element and a choice. –If we leave a door open to the possibility to grow beyond the self, leaping from what is to what could be, personal growth, possibilities and the possibility of meaning…And that is what Frankl said that he wanted to do with his books. Not to tell people what meaning is, not to push them to what is meaningful, but to illustrate that even amidst the most difficult types of suffering it is still possible to find meaning.
BY: I feel like this is just so much to think about, but I’d like to go in a slightly different direction now, which is in the case of moral injury personal values have been violated. How would you define personal values?
MM: This is a very interesting question. When we were researching personal values and the question of values, Edward, my husband, who is trained in neurology and psychiatry, and holds a doctoral degree in neurology and psychiatry, reviewed research in the area of values. What we found is these definitions of what are personal values and what is meant by personal values: they are deeply held guiding principles, ideals, dispositions that guide goal directed behavior. What is interesting about values is that they can be codified in the brain. This is where neuroscience interfaces psychology and spiritual practices. So, we go from the borderline of what is traditionally medicine and physiology to what is psychology and spirituality. Values can be codified in the brain. There are two neural pathways, and my husband would love this topic, because it is his own area of research interest. There is a slow processing system and that’s where discernment takes place in the frontal lobe, and associated areas, and there is a fast-processing system that is in the limbic area. The limbic area is located more in the back. When we codify these values, sometimes it may seem that we make decisions at an instance, seemingly totally unconsciously, just like that [snap of a finger]. Where did that come from? It is because of these codified values, from time tested ways of behaving, values and principles that are guidelines for our behavior, that were time tested and turned out to be good guidelines for our behavior. But they are relative because they are relative to a particular situation as to what worked in a particular situation for a particular person, so they can be reflected upon. And when we reflect in the prefrontal cortex, we use the slow pathways to maybe reflect on our values and change our values.
This happens for example in a home where a child is brought up, let’s say, with racist values. The child grows up and reflects and realizes they do not want to follow racist values “I don’t want to follow racist values; I do not want to be discriminating [against certain people]. Although I was raised with those values, I do not want to live like that. What speaks against this? What alternative values exist? More inclusive values. So let me learn about those and try to implement those and see what happens that is different. And so, from discernment they are now adopting different values than what they were raised with, so it’s not a matter of genetics, nature and nurture, but more than that, personal choice and decision, to discern the values that we want to live for. So that’s a possibility with values. Although they are relative. Does that answer the question of what personal values are?
BY: In a way yes, but I feel like we think of values as being universal values that become personal when we see how they apply in particular situations. Because Frankl said that meanings are universal and that, I mean, values are universal, and meanings are unique. The situation is how you are actually called and called forth and that makes me think that values are relative. Or rather, that values are not relative, it just depends on what each person thinks. That when somebody grows up in a certain atmosphere and decides that these things are immoral then they are actually getting more in touch with their essence and realizing the universal values that should be guiding him.
MM: Correct.
BY: But at the same time, there are personal values which resonate with us most, what speaks to us most for some reason.
MM: Yes. I was anticipating your question on universal values and that’s why I was not answering that part of the question. And I think I can go into that, universal values. Personal values, we try to make them harmonious or synchronized with universal values. What are universal values? Universal human values are so to speak rules of the universe. There are universal ethical principles that transcend cultural, religious, or geographic boundaries, and promote harmony in the world. That is the official definition, like a dictionary definition, such as the value of human life, the dignity of the person. Some people would also list justice, compassion, respect, and integrity. When we talk about meaning, we talk about truth, beauty and goodness. The pathways to what is meaningful and I had in my mind this image of cascading, stepping from step to step to get to the definition of meaning, of what is meant by meaning, which Frankl, who was a very thorough thinker, and he thought this through very well, gave this definition: “The trans-subjective reality of a value standing in relation to a person in every situation.” I am going to repeat it because it’s so good:” The trans-subjective reality of a value standing in relation to a person in every situation.” So, a value is like imagining stars on the horizon. Not every star is equally bright, but every person is in a unique situation and at a unique period or point in time the unique person with their unique condition, and therefore the value, or what life asks of them in any moment is going to be tailored to that what is their unique situation. So, sometimes it may feel like it is the same as for everybody else, but sometimes it will be very radically different from what is asked of a person in a particular situation because situations sometimes repeat, or sometimes seemingly repeat, but sometimes they are very different. That’s what is meant by meaning. Meaning is a value that stands in relation to a person. In other words, meaning is objective. Meaning is given by life. Meaning is a call of life to the person. And so, therefore, a person stands in relation to that value. A person always is in relation to different values and from the horizon, from the different possibilities, they need to discern, in other words, in neurological terms, use the slow pathways and decide, discern, which value stands closest to them and meant for them in this particular situation. Which is it that they ought to bring into reality? Frankl had to develop this [open] system because he wanted to immunize people against radical reductionism that considers people as nothing but. Nothing but the product of their genetics, the product of their upbringing, and to bring in this element, the possibility of a choice, of free will. How is that possible is through a three-dimensional view of the person: body, mind, and spirit. But that maybe is a different lesson and a different topic. Although we may be able to touch on it briefly, that Frankl has this holistic view of the person as body mind and spirit, and only that holistic view of the person and of humanity, which he called monanthropism—one humanity, every person, allows us to consider that people can decide for a value, decide to actualize a value, which then become eternalized, recorded for eternity if it is meaningful. And if it is in harmony with universal values, with universal human values, then it is more likely that it is going to be along the lines of truth, beauty and goodness and it will be worth bringing it into the world and actualizing in reality. The more our world suffers, the more we see darkness, the more we need that light of choice.
BY: It sounds like my next question which was that all experiences of moral injury share something in common, sounds like based on what you have said, that the only thing in common is that we are all meant to face a value that is meant for us. I mean, there is nothing in common, because it’s going to be a different value that’s meant for each person, but we all encounter it, and we all have to face that.
MM: Yes. And you are again talking about these dialectics. See, on the one hand, uniqueness, and on the other hand, that everyone who is conscientious and who really tries to listen and tries to search their selves, their conscience of what is worthwhile to accomplish. And whenever there is these dialectics, then there is a dialogue. And that is what we capitalize on, this search, this will from within.
TB: I was just thinking that this is maybe the dialectic you are speaking of, moving between the objective and the universal, it’s almost like there’s going to be things that are just universally important but if you want to talk to somebody and you want to bring their attention you have to call them by name.
MM: Yes, exactly. That’s beautiful. I wholeheartedly agree with it. That we are not alone and addressed by name. Yes. And when we talk to people, also in therapy, or we see them in a clinical setting, yes, to called by name, and to be looked into the eyes and to be known and to be allowed to express all the hurt and the pain and to be allowed to name it, and to be heard and not to change it, not to alter it, not to try to take it away, not to help people in their distress to run away, but to face what they have to face.
TB: If we were to go back to what you were saying two minutes ago, which is that we have to approach body, mind and spirit, how would you approach a case of moral injury?
MM: What makes the experience of moral injury very difficult is verbalizing the feelings. Because we talk first about [thoughts] and feelings and feelings point to values. So, like an entry point, seeking an entry point, in a person who is seemingly in a cocoon. Manifested in the posturing of people who have been deeply traumatized. Their facial expression and their voice, their whole entire posture is withdrawn into themselves as if in a cocoon, so you are looking for a way to be in. The way in is through verbalizing [being with]. Because when we are talking about dialogue, there is always a voice and a response. When we talk about being addressed, there is a voice and how we respond to that. So we are looking for the “son” –“son” as in per-son—persona, the person, being known, being addressed personally. Sonare is the sound, and re-sonating with that. With a wish of the heart, the desire of the heart, to find an answer. What makes this difficult is that sometimes the experiences are pushed into the unconscious and they are denied, suppressed, and that we have to help people to be value-discerning. To lead them toward the discovery of what is valuable and what is worthwhile, and where does that start? First, it starts with compassionate listening. How you would start relating to a person is through compassionate listening. From there, we can continue with gratitude for what is left. Being grateful for what remains.
Frankl had a funny expression about this, that people sometimes do not know how to translate into English, and that is “the joy of what we have been spared of.” This is hard to translate exactly, and to know how to interpret exactly: the joy of what we have been spared of. But we have to notice that it is still there. What is left, what remains. And then, we go to areas of freedom. Capacity in one’s spirit to take a distance from oneself. Take a distance from the experience, distance from the event and observe it from the outside. And then, finally, self-transcendence, which is the capacity of the human spirit. We are kindling the capacities, the possibilities, the abilities of the human spirit. Most importantly, two of them: self-distancing and self-transcendence. Self-distancing is the ability to observe oneself from the outside, take a distance, even from oneself, from a situation and not identify oneself with the situation, and self-transcendence is simply transcending toward a value, transcending beyond the self, transcending toward a task or another person. So those are the basic principles of applying a meaning-oriented approach. Being aware of the trauma, the tragic aspects of suffering, being aware of the prevalence and the extent of trauma, being aware of the signs of trauma, and then introducing a system that can respond to trauma. Logotherapy or the meaning-centered approach complements other approaches. Not just the behaviors, not just the thoughts, but existentially what is happening with a person. And in this sense, Frankl’s words are very much in my mind, that in the face of pain, it makes sense to find meaning in suffering; in the face of guilt, it makes sense to change oneself to the better; in the face of death, it makes sense to act responsibly. So, to lead to areas of what is still possible, lead to areas of what is still there, so with a very severely traumatized person, one of the observations that we make is that “…look, all these things happened, and you are here today. What a miracle that is. What a miracle of creation that is.” And right away, we change the tone. As you see, from something that is [potentially] utterly negative tone, to something that is positive [uplifting]. Dr. Lukas called this the alternating diagnostic process. To right away acknowledge what is positive, not just talk about the negative but right away bring in something that’s positive, that’s good about the person, that’s worthwhile and then talk about what they have already done, accomplished and what they accomplished that no one and nothing can take away from them. So, do not dwell on the negatives, don’t dwell in the abyss, but look at the heights as well, so to speak.
BY: How do you help a person regarding how they relate to other people in their situation, in their work situation, social situation, where they feel like it altered the relationship, and they don’t know how to deal with that?
MM: That I think can be very different depending on the situation of the person. You are asking a very good question and what comes to my mind is that not in every situation it is possible to reconcile, and reconciliation to mean that we just forgive and forget, and we move on as if nothing has ever happened and now everything is fine and all the sudden the person is back, and they are happy. Because this is what our society often predisposes, this toxic positivity: always just put a smile on your face, change your thoughts, snap out of it, fix yourself up and move on. And then everything will be fine [Laughing]. But it’s not that. It’s not just what one would call ‘resilience,” bouncing back, but is a bit more, growing beyond. And with that comes sometimes the recognition that one cannot continue in the path that was meaningful before but one needs to choose a different path, so that one has a different path ahead. And that path can be something that opens up new avenues that one may not have thought of before. Sometimes, they come as a complete surprise. Have you thought of that before? No, no, really not. No, I really haven’t. That’s something that I really haven’t. I haven’t thought of it that way. Sometimes there are these surprising outlooks that come up exactly because one experienced something significant. And I can’t think of an exact example and a concrete example but there are examples of these, and if I think hard enough, I’m sure that I can come up with one. When the solution is not where it was thought to be. Sometimes it’s unexpected and it requires a lot of creativity, a lot of creative thinking, of what now and which way now, and it’s not the path that seemed obvious before, but a new path. That is different.
T.B.: Maria, if we think about the way things are today. Where I think that it is not the PTSD level of intensity but every day that you turn on the news, you contemplate what is happening in the world today, you see what is happening in the world from top down, you see what the media does with it, the absolute overload of this kind of thing, of the feeling of disillusionment, that I think is experienced by many people, most of the time, what message of hope and advice you can give to people?
MM: I resonate with this, and I feel the same way. So, what message of hope can we transmit, and given that the media is all the time bombarding with information and seemingly there is not a way out of a situation, it is not our making, is not to our liking, it is not our taste, but it is how it is, and some situations are entirely out of our control. In that case, we need to draw back to our own area of freedom, and perhaps a quote, from this example of this nurse, whose story I was going to mention, this composite story, can speak to our experience, and it will help, because she made me aware of a quote from Mother Theresa, where she said: “ I may not be able to change the whole world, but I can cast a stone through the pond and make ripples.” This quote is personally meaningful to me. We need to be mindful that sometimes, some situations will not be in our hands, and they are not meant to be changed by us single handedly. But what is meant for us is right in front of us and the path is right in front of us, and on that path, the first step is right in front of us. And that is to pick up that little stone and cast it across the pond and be an advocate of kindness, of goodness, of human decency, of humility, of bravery. This we can only accomplish in our own respective situations. –Dare to be the light. Dare to be that light in the world. That little light. There may be the only one but dare to be one. If there is none, be the one.
BY: Wow. That’s beautiful. And it is a beautiful place to end our discussion. I feel like we only started to open up the whole discussion about all this. But we’ve gone into so many directions, so many unexpected directions, and I want to again deeply tell you how much I appreciate this discussion and appreciate you and I really enjoyed having this conversation.
MM: Thank you, likewise. If you let me share this one last thought, I heard this many times, and people are attracted to this brief quote, which is becoming very famous in the trauma world. It is attributed to Gabor Maté who is a fellow traveler [and trailblazer] in the area of trauma treatment and is known world-wide. Gabor Maté was born in Hungary and is originally Hungarian. As a baby, he went through the holocaust. During the war his mother had to leave him in the care of someone. So, this postulation which I heard from people over and over again, what people take away from his books, is that we are one trauma away from each other. I would like to complement this view. Some time ago, many years ago in fact, I sent a book to Dr. Maté, and it was “Man’s Search for Meaning.” His reply to it was that it hit a nerve, but it remains to be seen how he unpacks the meaning of it. So, I would like to complement this saying, “We are one trauma away from each other,” with “we are one hope away from each other.” We are each other’s hope, and we are one hope away from each other. –And this is the message of Logotherapy.
TB: That’s such a nice note to end on. It will remain deep in our minds. Thank you, Maria.
BY: Thank you.
MM: Thank you, Tani and Batya.
This conversation was based on the following publications:
Marshall, E. & Marshall, M. (2021). Logotherapy and Existential Analysis for the Management of Moral Injury. Ottawa, Canada: Ottawa Institute of Logotherapy.
Marshall, E. & Marshall, M. (2024). Management of Moral Injury in Health Care Workers During the COVID-19 Pandemic: Contribution of Viktor E. Frankl’s Logotherapy and Existential Analysis. In: McLafferty, C. and Levinson, J. I. (Eds), Alexander Batthyány (Series Editor). Logotherapy and Existential Analysis: Proceedings of the Viktor Frankl Institute Vienna. Switzerland: Springer.
Contributors:
Dr. Batya Yaniger, PsyD, is a Logotherapist in private practice and a senior trainer of professional courses in Logotherapy in Israel and Istanbul. Dr. Yaniger received her Clinical Diplomate in Logotherapy from the Viktor Frankl Institute in the U.S. and holds a Doctor of Psychology from California Coast University. In addition, she holds a bachelor’s degree in social work from Loyola University in Chicago and is a licensed social worker in Israel. In addition to her clinical work, she facilitates workshops, and she teaches and supervises students of Logotherapy [themeaningseeker.org].
Rabbi Tani Burton, LCSW, holds a Clinical Diplomate in Logotherapy from the VFI – USA. He has been a private practitioner, consultant, author, and educator in Jerusalem for twenty years, and has presented at conferences worldwide. In addition to his work as a Logotherapist, Tani utilizes many modalities from hypnotherapy to coaching to enhance the quality of people’s lives. He is Trainer with the Viktor Frankl Institute in Israel [themeaningseeker.org].
Prof. Maria Marshall, PhD, RP, holds a certificate in Logotherapy from the South German Institute of Logotherapy, Prof. Dr. Elisabeth Lukas, and a Diplomate Clinician in Logotherapy from the Viktor Frankl Institute in the US. She is the Mignon Eisenberg Professor of Logotherapy and Spirituality at the Graduate Theological Foundation in Sarasota, Florida. She is a Registered Psychotherapist in Ontario, Canada, and co-founder of the Ottawa Institute of Logotherapy.