Treating Trauma: How to Work with the Shame of Moral Injury

When a client experiences a moral injury, the guilt, sadness, and shame that come with it can be debilitating. It can create a deep wound at the center of a person’s identity.

So how can you help a client who’s suffering from a moral injury begin to heal?

In the video below, Ruth Lanius, MD, PhD will walk you through the approach she used with a first responder to help him process his actions at the scene of a car accident. Have a look.

Click here for full transcript

Dr. Lanius: I worked with a first responder, once, who was called to an accident scene where five teenagers were in a car and they had been involved in a head-on collision, and four out of five of the teenagers were severely injured. One of the teenagers, who was the most severely injured and had severe internal bleeding, was begging this first responder to call his mother on the cell phone. The first responder was really in survival mode for this teenager, he knew there was a low likelihood the teenager was going to survive, but he wanted to do everything that he could, and so for that reason, as well as, I think, for the reason that he would have found it very difficult to call the mother, he didn’t call the mother and he just focused on helping this teenager survive. The teenager died, and he was left with incredible feelings of guilt and shame about not having called the mother, and it literally tore him apart inside, and he had great difficulty coming to terms with what he had done. So, we talked about that there were really two sides to him, and that the side that has to rescue people that just focuses on that fight and flight mode of helping people and on getting the job done, that’s the part of him that is most active when he works as a paramedic. But he also has this other part of himself that has empathy, that’s often suppressed because that part can’t be present at all times when you’re doing this difficult work. But that part was really suffering as a result of his actions and how to work collaboratively with the two parts of himself to resolve this issue, but also to move ahead when he returned to work, to acknowledge those two parts and really give a voice to both parts. For the longest time, he’d really suppress that more empathic side of himself because he wanted to be strong and a tough guy. He was an advanced care paramedic and he’s always in charge and so he pushed aside that empathic part, and we talked about how important that is that how we’re all human, and as a human being, you know we have different parts. That empathic part you know makes him a good human being and makes him a good father can also help in his paramedic practice. Sure, you need to suppress it to a certain point because you can’t be called to an accident scene and just have empathy, you also need to act. But to bring it online more and to really acknowledge all parts, he did very well and was able to return to work and I think it made him much more human.

For more insights on working with post-traumatic shame, have a look at this short course featuring Bessel van der Kolk, MD; Marsha Linehan, PhD; Peter Levine, PhD; Stephen Porges, PhD; Pat Ogden, PhD; Richard Schwartz, PhD; and other top experts.

Now we’d like to hear from you – what approaches have you found useful when working with moral injury? What do you find helpful for working with shame? Please let us know by leaving a comment.

If you found this helpful, here are a few more resources you might be interested in:

What Can Help COVID-19 Frontliners Who Are Exhausted and Overwhelmed?

Helping Clients Talk About Shame

[Infographic] Shame vs. Guilt – A Client Handout

9 Comments

Jennifer Prohaska, PhD, Psychology, Overland Park, KS, USA says

That was it? Just that? I work only with first responders. That would have had a very low impact with my population.

John Thompson, Teacher, Seattle, WA, USA says

Sorry, but I was hoping for something more current and impactful. Talk, talk, talk is so last century. Understanding is overrated. Much more efficient and effective is to directly address the actual nature of the problem, which is in the mind-body and nervous system. It’s easy to learn well proven methods and get one session permanent clearings of these kinds of issues. (eg., memory reconsolidation, acu-point tapping.)

Jose Morales, Psychotherapy, Brooklyn, NY, USA says

This is one of my biggest takeaways from attending these webinars on trauma. The issue of integration of different parts of self as a vehicle for healing.

Kati Morrison, CA says

Dr Ruth Lanois to helped me a great deal with her interpretation about the dilemma of first responder.
I am a Holocaust educated and was asked recently about the silence of the survivors for decades about their experiences.
The answer was given in her approach.When one is in survival mode, empathy even toward self is dormant.All psychic energy has to focus on just simply making it everyday.
Many thanks

Christina Thomas, Counseling, San Diego, CA, USA says

I talk about the concept of integration with my clients, and the importance of integrating all parts of oneself. I like to approach it that it isn’t all one way (e.g. all bad or all good) but that, as humans, we are part of a collective whole- working to recognize, acknowledge, and respect all parts of ourselves, understanding that each part plays an important role.

- Al, Psychotherapy, FL, USA says
  
  This is very helpful and interesting explanation about the importance of staying centered. Thank you for sharing.
  
concha bonet, Medicine, ES says

How interesting to acknowledge thet we have different parts of “self” that can be in oposition with one another in difficult situations. Thanks for the oportunity to learn more.

- Alexandra MacKay, Social Work, CA says
  
  Thank you for this demonstration. It reminds me of Dr. Richard Schwartz IFS work. Acknowledging and holding all parts-

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9 Comments