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Moral Injury: A Mechanism of Harm

Two Soldier walking with guns
DoD photo by Fred W. Baker III
By Navy Capt. (Ret) William Nash, Director of Psychological Health, United States Marine Corps
June 26, 2017

A little over 10 years ago, Maj. Gen. George Flynn, then commanding general of Marine Corps Training and Education Command, and I were on Capitol Hill waiting to brief congressional staffers when he asked me a deceptively tough question. “If I cross the street and almost get hit by a car but I jump out of the way in time, could I get posttraumatic stress disorder (PTSD) just from that experience?” Flynn asked. “No,” I admitted, “that would be very unlikely.” He wasn’t trying to trick me; he just wanted to better understand the nature of PTSD and the events that cause it. It haunts me to this day that I couldn’t tell him why a car versus pedestrian near-miss would have a low likelihood of producing persistent PTSD, beyond transient physiological arousal and a little counterfactual imagining.

Conceptions of PTSD that have emerged since the diagnosis was first codified in DSM-III have increasingly painted it as a disorder of fear conditioning. But the fear-conditioning model of PTSD has never offered a truly satisfying explanation for why normal fear extinction doesn’t occur in all cases. Avoidant coping is thought to be central to the process that sustains (and in many cases worsens) PTSD symptoms, but is avoidant coping the chicken or the egg? Worst of all, too many people believe that a pre-existing vulnerability (i.e. weakness) is a necessary precondition for PTSD, a view which clothes stigma in science.

Lt. Gen. Flynn is now retired and I doubt I will ever see him again. But if I do, I plan to remind him of our conversation a decade ago just so I can take another shot at an answer. “No, sir,” I would say, “a near miss on the street would almost certainly not give you PTSD. But what if – just imagine – what if you successfully jump out of the way of the car and survive, but someone else on the street next to you isn’t so lucky? What if that someone else who is injured or killed is your own son or daughter or spouse? And you failed to protect them. What then?”

Today some would call this form of psychological harm moral injury, an emerging concept with a growing evidence base. In moral injury, it is not safety that is lost but trust – trust in oneself and others. Best of all, the moral injury construct explains how anyone can get PTSD regardless of their genetics, early life experiences or past traumas – even family members, chaplains and mental health professionals. Ironically, service members may have a greater vulnerability to moral injury just because of their high moral expectations and willingness to attempt the impossible on behalf of others.

Moral injury is in its scientific infancy. We have a validated exposure scale, the Moral Injury Events Scale (MIES), but no instrument yet to assess for moral injury symptoms, whatever those might be. We can’t yet describe the full spectrum of moral injuries, from day-to-day moral pinches to more lasting moral bruises or potentially devastating moral betrayals. We can’t yet explain the relationship between moral injury, as a mechanism of harm, and the normative process of moral remodeling as a necessary step toward emotional maturity. And we don’t yet have evidence-based tools for the prevention, recognition and care of moral injury.

Yet two facts seem certain. First, moral injury has been around a long time. It is clearly evident in the world’s most ancient and revered writings. And second, non-scientific stakeholders have as much claim to the concept of moral injury as mental health care providers and other health care professionals. As we gain empirical knowledge about moral injury, we may need to think outside of the doctor’s office to integrate the components of moral injury. That’s our best hope of avoiding oversimplifying the complexities of trauma, as the fear-conditioning model may have done for the concept of PTSD.

Dr. William Nash is the director of psychological health for the Marine Corps. After retiring from a 30-year career as an active-duty Navy psychiatrist, he continues to collaborate with DoD and VA partners to conduct research on combat-related PTSD and its clinical cousins, moral injury and loss, and develop tools for the prevention, identification and treatment of stress-related problems in war veterans.

The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.

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