The research is still evolving – but we’re discovering more about the overlapping similarities and key differences between moral injury and PTSD.
And as leading researchers like Bill Nash, MD uncover more insights, they’re finding that conventional trauma interventions may not be fully effective in treating this form of trauma.
In the video below, Bill shares an example of a moral injury and how trauma symptoms can persist if we don’t account for it in treatment.
Please have a look.
Here’s an example, and this breaks my heart to even think about it. But I was consulted by psychologist a year or two ago to consult with a family they were working with; a couple who had had their infant daughter attacked by the family dog. The dog chomped down on the baby’s head, and brain damage and still not clear how severe the disability will be for the baby. This happened at home with dad in the next room fixing a meal or something, and the first thing he heard was this scream and growl. And he went out there and pulled the dog’s jaws off of his child.
So, I am consulted and I sit and speak with this couple, and guess what? Their individual responses to this traumatic experience were very different. Because he was home. He failed. She didn’t fail, he failed. And it doesn’t matter that there may be nothing he could have done to prevent that from happening, he will always, until his death, will feel responsible for that, because that’s how we’re wired. Social institutions are not capable of moral emotion. That’s why we have to feel them for our institutions. Because corporations don’t feel shame or guilt. They don’t feel anger, so we have to feel that for them.
So to me, helping this person begins with setting aside whatever kind of theoretical understanding you might have of that. And just as a human, if that had happened to me, oh my God. Nothing else matters until you can sit with that. Right? That’s crazy. But the clinicians were… they were actually criticizing him for not doing his homework and not seeming to recover and improve as fast as his wife was. That’s adding insult to injury, literally. Literally. And we do it all the time. It’s heartbreaking.
In Mastering the Treatment of Trauma, we dive deeper into how you can distinguish moral injury from PTSD. You’ll also hear strategies to help you treat it (and what interventions might be contraindicated).
You’ll get the latest insights from Bessel van der Kolk, MD; Judith Herman, MD; Rachel Yehuda, PhD; Ruth Lanius, MD, PhD; Matt Gray, PhD; Wyatt Evans, PhD; and more top experts.
Now I’d like to hear from you. When have you encountered moral injury in your work with trauma? What strategies helped you to recognize it? I’d love to hear about it in the comments below.
I am working with a 19yo who at age 8 begged their mom to call a friend who was late in arriving to visit. They believe that, as a direct result of that phone call, the friend and his mother had a MVA in which the mother was killed.
This moral injury is so great that my client believes it would be “natural and fair” for them to also die in a MVA. As a result, they are unlikely to ever get a driving licence and they are always expecting an accident when driving with others. My client is on the spectrum. How do I help more with the moral injury that they cannot let go of?
Hello,
I am asking this community to please look into moral injury regarding spiritual beliefs and vaccination. I see people suffering online and there is zero awareness or help. I know it is not the most politically correct subject but takes courage to help this deeply suffering minority. Thank you and I appreciate your posting this comment.
Hi
A current client is experiencing moral injury, the sense of being beyond redemption. A Catholic upbringing and a mother who wasn’t able to give the client the feeling that they had done things right, that they were good enough just being themselves. So the client grows up trying to do ‘right’ all their life and continually feeling that they have failed and always guilty for their failure. I as a therapist, with my own childhood abandonment, neglect trauma who wasn’t able to give my own children what I so wanted which was the warm, safe nest that I didn’t have is also sitting in the room with my client feeling failure, guilt and remorse with no redemption. So both therapist and client are feeing the very human, painful moral injury – one as a daughter and one as a mother. What is the healing for this situation?
Hi Debbie
I don’t have an answer for you but only want to say that I find your situation quite beautiful, and that I can relate, and that if you are able to hold compassion for both of you something might shift?
Best wishes
I’ve taken CEU training with Center for Deployment around moral injury. Chaplain has been studying this in military to help treat. My son works with a Dr at VA. Son was a Corpman with Navy but assigned to Marines. He shared with me that Moral Injury occurs with Marines who have different culture If not fighting enemy fighting each other by finding weakness in peers persecuting them about faith, gender, body image, intelligence, ethnicity, sex. Both men and women are vulnerable. I counsel Coast Guard, Air Force, and Tricare families. Shame and guilt, suicidual attempts, avoid therapy, fear anxiety not safe, feel judged or if complain then will not move up in rank.
Merilee Perrine LPC LAC
I’m a recently trained Moral Injury facilitator with VOA for Veterans & Trauma Touch Therapy LMT…
Aprendi alguns conceitos de Disorders e como abordar o seu tratamento.
Obrigada pela partilha de conhecimento. Parabens pelo vosso Curso.
I am not a clinician but a client. I can’t help but associate moral injury with other types of abuse such as sexual abuse. This often happens in very religious homes as it did for me. it leaves one with a deep moral battle over who you are now. Difficulty in believing you are a worthy good person.
Make sense?
Perhaps this can ecplain why even after years of therapy I (and others) have a hard time finding deep peace and lasting joy.
After reading your article, I am curious regarding children sexually abused in foster care families as toddlers and young children, or biological families, trying to protect younger siblings. I am not sure this has been thoroughly addressed, but your article hit home to me. Thank you. Kathleen Friend LMFT
Yes, a father was driving his wife & infant daughter home in a snow storm. The infant in his car seat was crying frantically and the mom only wanted to hold & comfort the child. The dad said okay you hold him it’s only a short distance home. As she held and rocked the baby they were T-boned by a car out of control on black ice. The child was killed instantly. Mom survived with serious injuries that she eventually recovered from. Dad’s anguish and self-blame were horrific. Mom blamed herself the most and dad to some degree. While they will always carry the pain of this loss in their hearts , I was able to be with them in the pain. At some point, after considerable therapy,I inquired about a restitution for this tragedy. Their dream had been that this first born son would attend university one day. No one in their family had ever had this level of education. They never had any other children. However, they poured themselves into a thriving business and were extremely wealthy. They decided to make huge donations to local University for scholarships in their son’s name. This was the peace they found from their moral injury.
I wept with them for their loss and cried tears of gratitude for their creative evolution from the suffering.
I was born into a family built on moral injury. My grandmother’s family name is Donnelly. We are descendants of a first-born bastard son from the O’Donough clan. Our great-great grandfather, many generations ago, was exiled to a hostile land north of Galway. Her family started to leave Ireland as early as 1828, before the famine and civil war. They came to the Great Lakes region of Canada and the United States for better opportunities but could not shake the dissociation, depression, and the issues with alcohol. I have traced the behavior back five generations and a part of me yearns to return home.
I immediately thought of a client who will also always feel blame for her child’s abuse because she was not there. Despite having done nothing wrong – she was out working as a single mother and a trusted person was caring for her child in their home. While the client has been able to ‘forgive’ herself partially, she struggles still when triggers arise, and immediately will go to the self blame again. I see that these types of experiences get entangled with other childhood traumas where responsibility and control are involved. IFS and EMDR have helped this client lessen the responses in addition to work around increasing trust and vulnerability with others in her life.
Aspects of this make sense and thank you – however This is not completely accurate- Mom will also feel mortified that she was NOT there or that she did not recognize in her dog that they were capable of such damage . Somehow both mom and dad thought baby was safe with dog- they agreed to this it seems. Being there puts dad on the front lines of this tragedy yes but also mom has a deep journey of bargaining waves of loss as a result of this too- the notion that one ever gets over these types of traumas is also a myth- the best that may happen is that such traumas loosten their grip over time.
My late husband was a veteran of the special forces in the American army. An intellectually brilliant man, he was manipulated to believe he was doing the right thing, committed various unspeakable atrocities, and could never forgive himself. He blew his brains out with a 30-30 at age 66 after a life of torment, a few feet from our front door. It caps my own life of trauma, ptsd and insufficiency. My heart is failing at this point but I seem incapable of seeking or accepting help, as does my adult son.
Dear Rosalind,
I really do hope you will find healing, wholeness and a sense of peace…!
Jolande
Let’s talk about Moral injury in the church when it isn’t really a moral injury but differing worldviews of ministry. However, you are omitted because you are different. Then the minister preaches a sermon that inflicts more moral harm by nearly calling you a child of the devil coming to tear the church apart.
Church hurt. Some of the most difficult spaces to make Peace with your spirit. Thank you for adding this aspect. We have much collective work to do to give people space to heal their trauma at whatever pace they would like and whatever capacity in which they are capable of releasing the pain.
Agreed! And talk about moral injury, clergy sexual abuse. I work with survivors, people who completely trusted their priests and pastors, were sexually abused, and then most, if they told, were not believed because the clergy person “was so nice and would never do something like that. Then many were punished and/or ostracized by their parents for telling such “lies”. Then the different religious organizations did everything they could to cover it up and gaslight its victims. Moral injury continually perpetrated.
We are working with the survivors of the Mother and Baby Institutions here in Ireland. The trauma and attachment injuries are so deep
Thank you so much for this.
40 years ago I was in a head on collision. It was the other driver’s fault. It took 10 years to recover from the physical injuries but I never seemed to recover from the psychological effect of it. There was not even full recognition of PTSD back then. My first career as a university lecturer ended then and over the next 40 years I have trained in, practised and taught many different therapies from many different disciplines, and still do so. Often it has felt like a search for a missing piece to the puzzle. Bill Nash has just revealed it to me. My children were in the car and came away physically unscathed but shocked. They don’t remember the accident at all. But I was driving. I was there and I felt responsible. In all the therapy that I have done and all that I have undergone as part of my training, this has never been seen or approached. I have never sat with it or had support to do so because nobody knew. Because I was not at fault, the moral responsibility I felt, and still feel, was completely overlooked. We are going another layer deeper and it is an opening to something so much larger. This opening is adding to my insight and practice with clients. Thank you all for your wonderful, ground-breaking work. Please keep going.
Lynne Edwards
Natural Health Consultant
Interfaith Minister
I had a client who was an executive secretary. The man who was her boss was second from the top of a large powerful business. One of her duties was to take the notes at the closed door executive meetings. She had to record the egregious, untrue contributions her boss made about his actions into the official transcript. She had to look efficient, trustworthy and intelligent while she did it. She had seen her boss extract retribution from people who had tried to expose his criminal behavior, and she was afraid of him, whether she stayed in her excruciating position, or whether she left it. This was a long time ago. We actually used the phrase “moral pain” in our sessions. Along with other roles, I acted as witness to her multi-faceted dilemma and pain. She dropped out of treatment. I found out she had quit her job. Because she was unemployed, she had lost her health insurance.
listening to this IS traumatising !!!!!!!!!!!
Hello, a very informative video. Yes, moral injury can be just as bad, or worse, than trauma injury. I went through so much, so much. Countless hours of therapy, year after year. I had always wanted to write something about it, and after a lot of hard work, I wrote the book, “The Hollow Mask”. There my life was put out there, in black and white. It was the hardest undertaking of my life, but it did me a tremendous amount of good. I hope you will be able to read it and recommend it. Scott Ash
I suffer with both complex ptsd & I think maybe moral injury. I’ve been in hell for over 25 years. nobody can seem to help me & I don’t know how long I can keep this up. my mind is horrendous. I don’t know what to do anymore.
Hello there James,
my heart goes out to you. I am thinking of you. I know about excruciating, almost unbearable pain, but I do not know the extent of yours, albeit it sounds similar to my experience. I get you, I understand. Scott
Dear James,
This sense of being trapped by external circumstances is oh so familiar to me.
Finding a path toward self compassion can be a bridge to mending relationships with the world, and with people who have seemingly failed to hold up its end of the bargain.
I do not want to speak out of turn with any kind of answer for you. Simply recognizing my own reflection in your words and offering my reflections on the path through the dark night of the soul.
The advice to “live the question” so it resonates with every choice, every assumption we make, is for me a step toward developing deeper compassion for all of those other souls boiling in their own stew of resentment, grief, and longing. I aspire to an open heart of forgiveness and more adept boundary setting.
My sincere hope for you, and for me too,
Jenny
………………….
(An Irish Blessing. Please insert Nature or The Truth in place of “God” if you wish. )
AN IRISH BLESSING
May the road rise to meet you,
May the wind be always at your bac
James, I will add to the conversation. it seems that your dilemma is one many people share and strugglle with. I sometimes resent or feel jelous of other people whose lives seemd so effortless and easy. Then I remember I am on my own path a d maki g my own choices second by second. I believe we all came here with a plan and a purpose for our life. some of us are teachers, some are students and we all are both.
Deep down I know I am much bigger than my circumstances. I remind myself tobe grateful for all of my experiences for they have made me who I am and brought me to where I am today. I believe those of us who have been strengthened by fire are deeper, more resilient and appreciative than those who have not.
Stay on the path and keep learning and growing to light the path for others.
Dave
Dear James, my compassion goes to you. Please try things that could make a difference – movement, contact with nature, yoga, breath work, meditation, somatic practices, food supplements (witamin D3 for example). Small things can be very significant, especially if you commited to them and repeat them. Take care, remeber there is love
thankyou for your responses. I just wish I could find an excellent therapist here in the UK. I’m so exhausted & overwhelmed. I’m tired of fighting every second of the day. Obsessive ruminations of all my traumas keep, well, constantly traumatising me. I really don’t think I can beat this and yet I don’t want to die. I’m dissociated all the time & terrified to leave my own front door. I’m scared of ppl, I’m scared of everything. it’s very very painful.
Hi James,
I would recommend finding a Somatic Experiencing Practitioner, a Senior one if funds allow.
I can also recommend Irene Lyon for education and orienting exercises which help bring the body into safety. Clinical Somatics and Feldenkrais modalities helped my heal trauma and chronic pain. I firmly believe laying a new foundation of safety in the body allows the mind healing to follow.
Wishing you all the best
Kat – Ireland
thankyou Kat. I really appreciate the advice. I’ll make some enquiries. 🙂