Post-Traumatic Stress Disorder (PTSD) among Service members and Veterans receives a lot of well-deserved attention. That said, it was not until 1992, that the term Moral Injury was coined by Dr. Jonathan Shay to describe the devastating impacts of an event or experience that violates one’s personal ideals, ethics, moral expectations, conscience, or attachments. Since moral expectations are at the core of who we are as humans, moral injury describes a fracture to one’s deepest sense of being. The result of this moral violation can lead to guilt, existential crisis, and loss of trust (Jinkerson, 2016).
In the context of war, moral injuries may transpire from direct participation or exposure to combat. This does not just include acts of killing or harming others, but can also extend to indirect acts such as witnessing death, failing to prevent immoral acts or following orders that conflict with one’s ones deeply held values or principles. During times of war, Service members often must do those things they have been taught were wrong.
I recently sat down with Dr. William (Bill) Nash, a pioneer in combat and operational stress control in the U.S. Marine Corps. Dr. Nash served as the Director of Psychological Health for the U.S. Marine Corps and psychiatric researcher on risk and protective factors, new measures for early recognition, as well as psychological treatments for combat related stress injuries. While on active duty in the U.S. Navy, CAPT Nash provided psychological health services to the first Marine Division and authored the current Navy and Marine Corps doctrine for Combat and Operational Stress Control. Dr. Nash has also been recognized as a pioneer in the prevention, recognition, and treatment of moral injury.
In my meeting with Dr. Nash, I learned a great deal. Given our current conceptualization of moral injury, Dr. Nash brings to question the applicability of traditional PTSD treatments grounded in the fear model of trauma to the experience of moral injury (Nash, 2019). The very concept of moral injury emphasizes psychological, spiritual, social and cultural aspects of trauma. As a result, our current diagnostic understanding of PTSD, while devastating, does not represent the pain and suffering resulting from moral injury. Although moral injury is theoretically related to PTSD, a number of unique outcomes resulting from moral injury include shame, guilt, negative self-attributions, and lack of trust in self and/or others (Litz et al., 2009). These experiences can lead to isolation, social difficulties, re-experiencing of the moral conflict, attempts at self-punishment, and an overall sense of deep demoralization (Jinkerson, 2016).
Those who experience moral injury are disturbed by their own internal cognitive dissonance. For those who experience moral injury, they are often left questioning their sense of moral self, leaving a great sense of inner anguish. Although moral injury is not considered a disorder or psychiatric condition, it has been found to have profound effects on one’s overall mental health.
In summary, moral injury is a particular type of psychological trauma that is characterized by a violation to one’s moral beliefs often leading to feelings of guilt and shame, alienation, demoralization and spiritual crisis (Litz et al., 2009; Nash & Litz, 2013). Combat theater provides situations in which Service members are confronted with numerous moral and ethical challenges, sometimes leading to actions or exposure to events that conflict with their long-standing moral beliefs. Although moral injury is theoretically related to PTSD, there are a number of distinct differences. Whereas traditional PTSD develops through the experience physiological distress resulting from danger or threat, moral injury develops through a moral conflict with one’s own actions or the actions of another. As a result, Service members and veterans may experience invisible wounds that are not well captured by the current conceptualizations of PTSD (Litz et al., 2009).
Most importantly is the understanding of the healing process. No person can restore his or her way to a new moral identity alone. Currently, there is no agreed upon gold standard treatment. Nevertheless, the listening ear of an empathic, non-judgmental, trustworthy person is vital to begin the process of a transformative healing process.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Sharon Birman, Psy.D., is a clinical psychologist serving as a Military Behavioral Health Psychogist with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
Jinkerson, J. D. (2016). Defining and assessing moral injury: A syndrome perspective.
Traumatology, 22(2), 122-130. doi:10.1037/trm0000069/
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009).
Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706. doi:10.1016/j.cpr.2009.07.003/
Nash, W. P. (2019). Commentary on the special issue on moral injury: Unpacking two models
for understanding moral injury. Journal of Traumatic Stress, 32(3), 465-470. doi:10.1002/jts.22409
Nash, W., & Litz, B. (2013). Moral injury: A mechanism for war-related psychological trauma in military family members. Clinical Child and Family Psychology Review, 16(4), 365-375. doi:10.1007/s10567-013-0146-y