“Moral injury” is a term that has emerged over the last thirty years that describes a particular reaction to events that occur in the course of a service member’s military experience. It is closely linked to, but also separate from, post-traumatic stress disorder (PTSD). Events that can cause a moral injury are also likely traumatic, catastrophic physical injuries, for example, or the loss of a fellow service member. However, moral injury can occur separately from PTSD.
The concept of moral injury emerged from clinicians’ work with veterans of combat who were experiencing difficulty readjusting to their lives after returning from conflict. The phrase was coined by psychiatrist Jonathan Shay based on observations made while working with veterans at a Department of Veterans Affairs outpatient clinic in Boston. In his book, Achilles in Vietnam, Shay introduced the concept of moral injury, defining it as the psychological, social and physiological results of a betrayal of “what’s right” by an authority in a high stakes situation. He goes on to describe how experiences in the military, and especially experiences in combat, can sometimes change service members’ beliefs about what is right and wrong.
Later the psychologist Brett Litz and his colleagues refined the concept, describing moral injury as an effect of acts that create dissonance and conflict because they violate assumptions and beliefs about right and wrong and personal goodness. Morally injurious acts include events such as “…perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”
Moral injury and PTSD
Moral injury is a cluster of symptoms that is, as stated above, linked to but separate from PTSD. There is an emerging effort to distinguish between the two and recognize moral injury as a common and distinct syndrome that requires targeted treatment. Several factors complicate the establishment of this distinction. One of the difficulties is that an event that meets Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criterion A for PTSD — exposure to death, threatened death, actual or threatened serious injury — may also transgress deeply held beliefs. For example, an act may be morally injurious if the client believes it was indefensible or should have been prevented.
Identifying moral injury in individuals is complicated by the reality that service members are trained to overcome social taboos against killing or inflicting serious injury on others. In basic military training, trainees experience a dedicated effort to overcome an aversion to violence. Bayonet training, hand-to-hand combat and weapons training using realistic plastic human-shaped targets are all methods designed to help individuals overcome a natural tendency to not engage in violence. In his book, On Killing: The Psychological Cost of Learning To Kill in War and Society, Lieutenant Colonel (Ret.) Dave Grossman cites a study by military historian Brigadier General S.L.A. Marshall related to the firing rates of soldiers in World War I. Grossman states that Marshall found that a significant number of rounds that were fired did not hit the target, and that many soldiers were not aiming at their targets but instead firing away from them.
In “Assessment of Moral Injury in Veterans and Active Duty Military Personnel with PTSD: A Review,” a 2019 article published in the journal Frontiers in Psychiatry, the authors assert that moral injury can occur in conjunction with PTSD but is a separate syndrome.
Specifically, a service member or veteran can have PTSD without moral injury, can have moral injury without PTSD, can have both, or can experience events that meet criterion A, yet have neither.
Betrayal as a core concept
The core aspect of moral injury is one of betrayal: betrayal of one’s own core beliefs, a betrayal by others, or both. In my clinical experience, as well as my own lived experience, moral injury is a significant aspect of one’s military service. A service member or veteran’s reaction to or behaviors resulting from moral injury can cause significant distress. This, of course, complicates the transition to post-military life.
While there are a number of large egregious manifestations of moral injury such as My Lai in Vietnam and Abu Gharib in Iraq, there are also more subtle manifestations of moral injury. Growing up, I was always taught to obey traffic signals, go the speed limit—be a “good driver.” This behavior was “right.” When we got to Iraq and Afghanistan, however, things that were “right” became wrong. There are no stop signs in Iraq, no traffic signals in Afghanistan. A one-way street was whichever way we were going. This wasn’t because service members were bullies or unconcerned with local safety, but a security measure. Then, we had to return to a community of rules and laws and make the adjustment back to what was right but had seemed wrong while overseas.
This is another complicating factor for moral injury. Some behaviors may be acceptable in one environment but unacceptable in another. In a 2018 interview for my podcast Head Space and Timing , psychologist Shira Maguen, a VA clinician researcher who is an expert in moral injury describes how a service member can engage in behaviors that are not morally injurious at the time, such as killing or violence directed towards an enemy. These actions are necessary and even encouraged while in the environment of a combat situation. However, when the service member returns to a non-combat environment or relative safety, these actions may not be considered acceptable, and therefore may become morally injurious.
Addressing moral injury
As mentioned, it is critical to explore whether or not a veteran is experiencing moral injury related to their military experience. Many veterans, like many clinicians, may have never heard the term, but after having the concept explained to them, understand it immediately. In discussing these distinctions with a fellow veteran (not a client), he said a light bulb went off in his head.
This veteran, a Marine who served in Operation Iraqi Freedom, was on a rooftop providing overwatch for a raid. He saw movement in the alley below, challenged the individual to respond with a password, and when he did not receive a response, opened fire on the figure in the alley. It turned out that the person in the alley was a fellow Marine, who had been wounded in the leg. While the wounded Marine ultimately recovered, my friend experienced significant guilt about the incident. After leaving the military and entering therapy, he was told repeatedly that he was struggling with PTSD. But, it wasn’t until he heard about moral injury that he understood that what he was experiencing was different than a traumatic stress reaction.
In the next few columns, I will be addressing other critical aspects of moral injury, including survivor’s guilt, the difference between shame and guilt, and the assessments and modalities available to help service members, veterans, and their families receive a measure of relief from the burden of moral injury.
Duane France is a retired U.S. Army noncommissioned officer and combat veteran who practices as a licensed professional counselor in Colorado Springs, Colorado. He is the director of veteran service for the Family Care Center, a private outpatient mental health clinic specializing in service members, veterans and their families. He is also the executive director of the Colorado Veterans Health and Wellness Agency, a 501(c)3 nonprofit that is professionally affiliated with the Family Care Center. In addition to his clinical work, he writes and speaks about veteran mental health on his blog and podcast at veteranmentalhealth.com. Contact him at firstname.lastname@example.org.
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