Moral Injury: What I Have Learned About the Wounds We Do Not Name
By Jonathan Sherin, MD, PhD
Dr. Sherin is a psychiatrist and neuroscientist who served for over a decade at the Department of Veterans Affairs, most recently as Chief of Mental Health for the Miami VA Healthcare System. He was also Director of the Los Angeles County Department of Mental Health, the largest public mental health system in the United States. He has had numerous academic appointments and is currently Vice-Chair for Public Policy and Partnerships in the Department of Psychiatry at UCLA.
Much of mankind’s most dangerous suffering has been one that patients have trouble naming, and clinicians have trouble diagnosing. In more recent years, however, the term “moral injury” has emerged to describe a uniquely human affliction that is particularly relevant as a risk factor and a core driver of self-injury, especially in the military veteran community. And while the act of taking one’s life is highly complex by nature, it is important that moral injury, separate and apart from PTSD, be elevated in both our general lexicon and clinical practice as it relates to the human condition, spiritual pain, and suicide.
Many veterans who endure traumatic exposure in service develop classic signs and symptoms of PTSD, such as intrusive thoughts, flashbacks, nightmares, paranoia, hypervigilance, insomnia, agitation, irritability, dissociation, depression and more. In such cases, the nervous system is stressed, becomes dysregulated, gets stuck in fight-or-flight cycles, and does not reliably stabilize in either the acute phase or the long-term without medical, neuro-modulatory, and or psychological interventions to help reestablish a sense of safety, security and calm. In these scenarios, evidence-based trauma treatments for PSTD can be lifesaving, and the VA has led the field in both crafting and making such treatments more accessible to veterans in need; when we identify PTSD in a veteran accurately and provide care properly, we can change a life trajectory.
That said, in over two decades of working with the military veteran community, I have come across numerous veterans diagnosed with post-traumatic stress disorder (PTSD) whose healing was not complete after receiving evidence-based PTSD treatment modalities. In other words, not all veterans who present with signs and symptoms consistent with PTSD (or with a prior diagnosis of PTSD), will respond to PTSD treatment alone. Such presentations, notably when associated with anger, self-hatred, social withdrawal, relationship collapse, substance use, violent tendencies toward self and or others, require focused exploration for spiritual trauma and (in many cases co-morbid) moral injury.
It is therefore critical to know whether the distress of an individual veteran tracks back to specific life threatening trauma exposures alone (PTSD) and or whether trauma experiences that violate personal ideals, long-held values, expectations or codes of behavior might be at play. In the latter setting, if feelings surface of blame for a bad outcome, or guilt and shame for doing harm to others through action or inaction, or if there is a loss of trust and faith (religious of not), a spiritual trauma and a moral injury are likely. Veterans with PTSD often complain of feeling anxious day to day, while those with moral injury describe being beleaguered by existential questions about the meaning of their life, identity, agency, purpose and belonging in the world.1
The topics of PTSD and moral injury demand careful handling because military experience does not fit common civilian stereotypes. For example, though a major contributor to both, combat exposure is not the only risk factor that comes with service. Military training and operational life are built around heavy responsibility under authority, repeated decision-making on topics with moral implications, and precise functioning under almost constant uncertainty. In other words, service members do not have to be in harrowing firefights to encounter morally challenging experiences: witnessing inhumanity yet being unable to intervene; participating in actions that clash with personal values; making tough choices with incomplete information; and experiencing leadership failure or betrayal can all be morally consequential. I have seen how these experiences follow veterans home quietly. And while outwardly successful, the lives, families and careers of too many veterans deteriorate from an inability to tolerate honest vulnerability when it comes to these internal struggles which can lead to feelings of failure and isolation (not deserving closeness).
In a foundational paper, Litz and colleagues offered a model of moral injury in war veterans and emphasized that moral injury requires moral repair. They described how perceived transgressions can generate guilt, shame, avoidance, and social alienation, and they proposed interventions that foster meaning, accountability, forgiveness, re-engagement of values, and pathways forward with disciplined processes for truth-telling, contextualizing responsibility, restoring moral identity, and rebuilding connectedness.2 Caring for the whole context of a person’s life is therefore essential when dealing with moral injury, including both spiritual language and faith (whether religious of not) which are part of how human beings often express their suffering. When clinicians avoid this territory, patients can interpret the avoidance as confirmation that their story is unacceptable to tell, so it is key to remain present when individuals name what they have been afraid to name.3
It is important in finishing this blog to call out the VA system for long recognizing the value of collaboration between clinicians and chaplains when indicated and or desired. To me this is a clear acknowledgment by VA, whether knowingly or not, that spiritual traumas such as moral injury can only heal when needs for meaning as well as reconciliation and forgiveness are addressed by access to spiritual resources alongside clinical care. In my experience, outcomes improve when veterans receive integrated care from teams that coordinate across disciplines.4 It is these principles that make me appreciate LUKE’s ability to get the right staff into the right roles, comply with useful gold standards to deliver consistent quality services, and support workforce retention so that care does not collapse under turnover. This type of operational detail shapes whether a veteran meets a provider who can recognize moral injury and respond with competence and respect.
To this end: we cannot assume that a diagnosis explains suffering; we must ask about potentially morally injurious experiences, listen for spiritual struggles and screen for suicide risk when despair and self-condemnation are present beyond a diagnostic category; we have to address moral injury when it is part of the bigger picture and intentionally consider approaches that explicitly address meaning, values, forgiveness, and reconnection.
Naming moral injury is not an academic exercise. Recognizing it, talking about it openly, and building systems of care that take it seriously is something clinicians, leaders, families, and communities all share a role in. America asks extraordinary things of those who serve, and they deserve every opportunity to flourish in return, especially when just living life becomes unbearable.
Endnotes
- S. Department of Veterans Affairs, National Center for PTSD. “Moral Injury.”
https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp - 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. VA-hosted PDF.
https://www.ptsd.va.gov/professional/articles/article-pdf/id33165.pdf - S. Department of Veterans Affairs, National Center for PTSD. PTSD Research Quarterly, Volume 33, Number 1: Moral Injury(PDF).
https://www.ptsd.va.gov/publications/rq_docs/V33N1.pdf - S. Department of Veterans Affairs, Health Services Research & Development (HSR&D). Evidence Synthesis Program: Moral Injury and Mental Health Among U.S. Military Service Members and Veterans(PDF).
https://www.hsrd.research.va.gov/publications/esp/moral-injury-report.pdf
