Regardless of the topic on which I am presenting, if I have a bit of time at the end, I always speak briefly about the concept of moral injury. It’s heartening to see that clinicians are becoming familiar with this important issue and that it resonates deeply on a professional and personal level. For those to whom this is a “new” idea, it’s amazing to see that “ah-ha” moment as they consider past and current patients, family members and, yes, even themselves in light of this concept.
One participant at a recent presentation told me afterward that when her 94-year-old Korean War veteran father was on his deathbed, he turned to her and asked, “Do you think I will ever be forgiven for what I did in the war?” After hearing the definition of moral injury, she realized, for the first time, that her father had a deep moral wound that he had carried for all of his adult life. Far from feeling sad or burdened by this possible explanation of his words, she felt a heightened connection to her father and a greater understanding of his refusal to talk about the war, and his times of withdrawal from his family
Moral injury is generally defined as psychological pain that results from a transgression of deeply-held moral beliefs. It may occur as something a Service member does, or fails to do, such as killing a civilian or not intervening when they feel they should. It can also result from a betrayal by a commanding officer or other leader.
The most commonly used definition of moral injury is “an injury to an individual's moral conscience resulting from an act of moral transgression which produces profound emotional shame.”(1) More descriptively, it has been referred to as a soul injury or soul anguish.
In the past few years, interest in the concept of moral injury has rapidly grown among the mental health community. It has been grasped intuitively by those working closely with Service members who exhibit signs of PTSD, depression, and anxiety, and it is being looked at as one possible explanation for the excessive suicide rate among those who have been in combat. Research is being conducted to help further define, understand, and identify when and why moral injuries occur. Assessment measures and rudimentary self-report tools are available to assist.
As a proponent of educating providers on this concept so they are aware of and alert for it, it occurs to me that we also have an obligation to educate family members and close friends. These are the individuals who are most available for support and, when it becomes necessary, to intervene in the lives of emotionally wounded Service members to obtain professional help and resources. Educating one group (mental health providers) while also considering how to bring this vital information to families, friends, and the general public will provide the best wrap-around support for those individuals experiencing moral anguish.
"Every generation gives war trauma a different name," explained Korean Veteran Jiwon Chung. "Soldier's heart, shell shock, battle fatigue, and Post Traumatic Stress Disorder (PTSD). Moral injury, the latest term, is important because it de-pathologizes the condition. If you go to war, come back, and are not the same, not at ease, troubled, or suffering, it is not because you are psychically weak, but because you are morally strong. What you witnessed or did went against your deepest moral convictions, violating our humanity to the core." (2)
Educating others about moral injury involves helping families and communities understand the moral implications inherent in war. Acts are done or not done that may be vilified by the general population, and this fear of negative judgment, as well as self-blame, prevents emotionally wounded Service members from talking about it or seeking peace and understanding.
Chung later added, "That we vets suffer moral injury, despite the tremendous suffering and anguish it brings, is actually a validation of our humanity. War is the reason for moral injury, not any individual shortcoming. Peace, justice, and reparation are the cures for moral injury.”
How can we, as mental health professionals, help bring that peace and reparation to those in anguish? We can educate ourselves about this concept and share our knowledge among our own circle, and we can listen for opportunities to teach the general public.
While living in Annapolis, MD, I frequented a local coffee shop where I often saw “Jim,” an Army National Guard officer. When Jim received orders to deploy to Afghanistan, the coffee shop staff as well as numerous customers did what they could to let him know they cared. Recently, I returned to this shop and a staff member asked to speak with me about Jim. He told me that since Jim’s return from Afghanistan months before, he had not come into the shop “at least to just say ‘Hi, I’m back.’” Staff and customers were puzzled and somewhat angry by this behavior, which they perceived as being ungrateful for all they had done in the days prior to and during Jim’s deployment. While I had no knowledge of Jim’s experience, it was a perfect chance to talk with the staff and customers about the possible reasons why Jim, and others returning from combat, may feel a need to withdraw. After talking it through, they felt a greater understanding of all combat Service members, including Jim. Hopefully, when Jim does come back to see them, he will be met with this understanding and an openness in which he can find comfort.
(1) 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.
(2) Bliss, S. (2012, December 18). Military Veterans Explore "Moral Injury." Reader Supported News. Retrieved from readersupportednews.org/opinion2/282-98/15105-military-veterans-explore-qmoral-injury
Laura Copland, MA, LCMHC is the Senior PTSD Treatment Trainer at the Center for Deployment Psychology (CDP) at Uniformed Services University of the Health Sciences in Bethesda, Maryland and a National Cognitive Processing Therapy Trainer. She received her Master of Arts degree in counseling psychology in 1989 from Antioch University New England.