PTSD or Moral Injury? What Trauma Focused Therapy Misses

I first began to understand moral injury as a therapist working in a residential trauma treatment program for military veterans. I had quite a bit of experience working with active service members in outpatient settings prior to taking this position, and that may be why moral injury didn’t present so distinctly to me before. Like PTSD, moral injury may not set in clearly until a person has gotten out of the environment associated with the disturbance. Veterans in this residential program were responding positively to the trauma treatments provided, but it quickly became apparent to me that we were missing something important. That’s when my research led me to the concept of moral injury. It wasn't an entirely new concept, as my work with addictions often included helping people work through harm they had caused. The difference in working with veterans is that they were being thanked for their service even as they carried the pain of that harm.

I think of trauma as any experience that compromises a person’s core sense of safety. Moral injury, on the other hand, is an experience that compromises a person’s core sense of self. Moral injury can be caused by both action and inaction, and results from behavior that conflicts with a person’s individual morals and values, fundamental beliefs about right and wrong. Moral injury is a syndrome of shame, guilt, anger, grief, blame, disconnection, and demoralization that occurs when deeply held beliefs and expectations about moral and ethical conduct are violated. It may stem from one’s own behavior or someone else’s, and may be triggered by both action and inaction (failure to act). Moral injury has also been described as a soul wound.

Many people with moral injury also have PTSD, but the two don’t always go hand-in-hand. One hallmark of post-traumatic stress disorder is the cognitive distortions (i.e., I’m shameful, I can’t trust anyone, I’m not safe) that contribute to the condition. With moral injury, there may be judgments and beliefs about an experience that are entirely realistic and useful, and simultaneously contribute to immense pain and suffering (i.e., I was part of this heinous wrong-doing, I did this terrible thing) . Healing from moral injury, therefore, requires a greater focus on the healthy experiencing and resolution of painful emotions, and a lesser focus on identifying and changing the thoughts/beliefs that contribute to that pain.

The following assumptions, borrowed from the Adaptive Disclosure treatment model developed by Brett T. Litz, Leslie Lebowitz, Matt J. Gray, and William P. Nash, inform my work in helping people recover from moral injury: 1) Pain means hope. Anguish, guilt, and shame are signs of an intact conscience and self- and other-expectations about goodness, humanity, and justice. 2) Goodness is reclaimable over the long haul. 3) Forgiveness and repair are possible regardless of the transgression.

When I talk about trauma, I speak often of the central role that relationship plays in healing. I believe that healing happens in relationship. This is as true for moral injury as it is for trauma, but not necessarily in the same ways or with the same interventions. In trauma work, the entire story may not need to be told. With moral injury, holding oneself accountable is a big piece of the work. Not because I think you’re bad, but because you do. You're not comfortable with your own choices.

People impacted by trauma often create stories that assign blame where it may not belong. Perhaps a child witnessed abuse and feels guilty that they didn’t provide protection. Often, that child was equally vulnerable and didn’t actually have the capacity to protect. The experience was traumatic, but the idea that they did something wrong may be more of a cognitive distortion than a transgression of deeply held values. If another child were in the same position, the person wouldn’t judge or fault them for failing to intervene. This is where moral injury is different from trauma, even though the same experience may be both traumatic and morally injurious.

Healing from trauma entails reprocessing old material so that beliefs that were helpful at the time and are no longer helpful now can be shifted, and emotions that weren’t safe to be felt then can be processed and released now. Healing from moral injury entails processing and releasing painful emotions; it also requires identifying the wrong you believe you’ve committed, owning it, and taking action to repair that wrong. We can’t change the past. What happened, happened. But we can hold ourselves accountable for who we are today, and take steps to make amends and repair the harm we believe we’ve caused. This may involve direct engagement with people who we’ve harmed, or steps to help other people who’ve been harmed or are vulnerable to harm in similar ways. In my experience, it always involves telling your story in some way.

I’ve had some debate with other professionals about who can claim an experience of moral injury. Some have suggested it’s a condition that only applies to people in law enforcement, the military, or similar positions of responsibility to protect and serve. I disagree. I think anyone may have high moral standards and find themselves in a position where they’re choosing between one person’s safety and another’s, or choosing between maintaining their inclusion in the group or being ousted. These are the types of experiences that lead us into behaviors that feel like transgressions.

As social animals, humans need community. If your values don’t align with the community available to you at any given time, especially in a dangerous environment, you may behave in ways that absolutely conflict with who you are and how you want to be. That doesn’t have to be the conclusion of your story. We grow, we learn, we change. We can make repairs and amends. Healing is possible.