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.


Comments

  • I would remind Capt Nash that we had a similar conversation while he was still active duty. In those emails, we identified a single amnesia event in early childhood that fuels triggering events such as the event in this article.

    Our research has done a very job of proving it through 150+ cases over the last 5 years.

    Perhaps it is now time to look at Repetitive Behavior Cellular Regression™ (RBCR) again from this perspective.

    Thanks you.

  • Great blog Dr. Nash. So, if the pedestrian has a near miss and his/her child is hit and severely injured/killed, what are the mediating "cognitive/appraisal/self-evaluative" conditions that would increase risk for PTSD or say, MDD? With PTSD would the person chastise himself as a "bad" or "not good enough" father, who failed to be a "good" father, and develop moral injury/PTSD? What if the person appraised himself and actions/inactions as a "personal failing, incompetent boob, a loser and failure", would this appraisal (of self, situation, etc) more likely lead to feelings self-blame and self-loathing and possibly MDD?

    Warm regards,
    Steve Messer

  • Very good topic for discussion and action in therapy with combat trauma. My experience as a combat vet and as a psychotherapist working with combat vets both have shown me starting in the mid 70s that many of us were experiencing a major shift in our thinking and processing information regarding trust. There was a major breach of trust, a betrayal of our beliefs, of our ideas about government, religion, education, and family. For many of us this was about almost getting killed, seeing many of our fellow soldiers killed, seeing civilians killed by major air strikes and at some level not feeling that we were protecting our country from anything that was a threat to them. It was only a threat to us because we were sent to Vietnam to hunt and kill people who were not a threat to the US or the world. The physiological reactivity of PTSD can be managed to some degree with cognitive behavioral training over time. This moral injury from betrayal by the society and most of its institutions seems to stay under the radar. One of the reasons is because many believe that it is a political, non-therapeutic issue to get involved in this gigantic elephant in the room, and to focus on the obvious PTSD symptoms instead. After I had been working as a clinician with the Vet Center program for a few years, they renamed it the Readjustment Counseling Service. I have a problem with this name. It implies that the mission was to get these ex-soldiers readjusted back to the society that they left. Not gonna happen. One does not readjust to those who were involved in the ignorance, deception, and betrayal that caused so much death and destruction. So without addressing this aspect of the "Moral Injury", many of my fellow combat vets will go on confused in emotional and cognitive dissonance with, at best, some relief from PTSD symptoms or physiological reactivity through behavioral intervention in conventional CB therapy, or get inappropriately medicated for it. This problem continues today with the current wars in Iraq and Afghanistan, Syria and elsewhere, with so much of the society and even its healers afraid to take on this elephant in the room.

    • I agree

  • Bill Nash never disappoints when it comes to discussions of war trauma, its sequelae and why manualized treatments are mostly insufficient to the task at hand of military mental health clinicians. Recently, I met a patient of his from 20 years before who was readying to retire from her active duty career. Even twenty years ago, then Lieutenant Commander Nash's understanding of moral injury informed his practice, permitted an attunement to the patient, and allowed that particular patient to make meaning of what had happened and integrate this meaning into her life paradigm. He left an impression with her. As scholar practitioners, the more attention we devote to applying principles of moral injury in our trauma-informed practice the better off those we serve will be.

    • I have never liked manualized treatments and consider them perhaps only useful for research. I think Edward Tick, PhD is on the right track with his work. I also spent many years learning in the Q'ero Indian tradition as well as with Shipibo medicine people in the Amazon. Sparks would fly around here if I cranked up my rattle and had a fire ceremony! But, for the life of me I can barely remember having PTSD!

  • agreed, more research and dialogue is needed on Moral Injury. I ask my clients to consider PTSD Sx. as a reaction to the physical safety of the body and Moral Injury as a reaction to the soul's question - am I good person? Did I do the 'right' thing? etc...

  • Thank you Dr. Nash. You may already know, but perhaps your readers will not--"Waking the Tiger," by Peter Levine, Ph.D. offers a profound understanding about trauma and how to heal it.

  • Thank you all for commenting. I was hoping someone would. But I never expected such kindnesses and encouragement. And so many interesting perspectives that it will take me a while to digest. Stay committed, my friends.

  • Thanks. I've appreciated your work. In the coming months, Jessica Kingsley Publishers will be producing my monograph titled: "Moral Injury Reconciliation: A Transdiagnostic Approach for Treating Moral Injury, PTSD, Grief, and Military Sexual Trauma through Spiritual Formation Strategies." Although I'm taking a very large bite of a complex problem, I'm convinced that a religious/spiritual framework has something to offer in this fight to support our Veterans. Thanks for all you do, I'm learning a lot.

    Respectfully,

    Chaplain Jeff Lee, DMin, BCC, LMFT
    (LT, USN) (SEAL, RET.)
    VA San Diego Healthcare System
    San Diego, CA 92161

    • Jeff, I'm a retired SEAL working with vets recovering from PTS here in San Diego. Would like to get in touch. matt@mightyoaksprograms.org

  • Absolutely an interesting read sir! Thank You for all that you are doing for our Veterans and Service Members. I can say I wish I had more protective factors in place before a couple of my deployments which still grind me to this day. I do believe though, as a paraprofessional in the Mental Health Field, some of the lessons learned which you have developed are landlines in my own survival with BOTH PTSD and Moral injuries. Thank you for this Sir!

    Very Respectfully,
    Tom Murphy

    • Tom, If anything I could ever say or do might help lighten your burden, That will have made the whole crazy trip worthwhile. Thanks, dude. I'll bet you bike far better than I these days. Stay committed, brother.

  • I would be interested in your opinion on MI with respect to the spiritual/cultural differences between US troops and our islamic enemy. While our enemy's culture regularly validates brutality and barbarity on the battlefield, ours completely abhors this. There is strong evidence in the SOF/Infantry communities that dishonorable conduct by our enemy has also provoked retaliatory acts by our own forces on the battlefield. Additionally, US forces are keenly aware of the strong religious motivations of our enemy, and those US troops that lack spiritual resilience often adopt the ethos of ancient warrior cultures (Apache Indians, Vikings, etc.) in response. These warrior cultures can provide a measure of spiritual equality on the battlefield, but upon return, US culture which does not support this kind of expression can lead to perhaps a "moral hangover". Soldiers who have behaved under the influence of these warrior cultures return and often wonder if their families would still love them if they knew what they had done. We see this often at Mighty Oaks Warrior Programs, and I'm curious about your exposure to this phenomenon.

    Matt Heidt
    Chairman, Advisory Board, Mighty Oaks Foundation
    SOCS, USN Retired.

    • My own experience in combat was that out of our platoon there were maybe 1 or 2 men who tried to slip into this brutality, revenge, and out of control emotions against the Viet Cong and civilians who may have been supportive of the Viet Cong. The rest of us stopped them and would not allow this kind of primitive "warrior culture" behavior. If it comes to this kind of military behavior in the battle field, then we are no better than those who we are calling enemies. It is another thing to help those vets who went rogue and violated this. If they are not sociopathic, then they can be worked with, but not in the context of rationalizing too much, or saying you had to do this because of the enemies brutality. There are better ways of healing than to rationalize or justify this kind of behavior in combat. This moral wound of violating ones own humanity needs a very trusting long term therapeutic relationship to get deep enough to heal. The dominant culture likes to ignore that some of its soldiers do such things. They would rather cover it up and make them all heroes or condemn them all as baby killers. Neither extreme is helpful. Its much more complicated emotionally and spiritually than that, but the society wants noble cause rationalizations, and a quick 10 sessions or pills for the vet to cover it up and not allow the context of cultural/societal responsibility for the war to enter the picture. If we heal together and admit the reality of how we end up in these wars as a society and as individuals, we may put an end to such evolutionary obstacles. Let There Be Light.

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