“A Stain on the Soul”: Why Moral Injury Requires A Different Treatment Plan Than PTSD
with Bessel van der Kolk, MD; Judith Herman, MD; Rachel Yehuda, PhD; Ruth Lanius, MD, PhD; Matt Gray, PhD; Wyatt Evans, PhD; Bill Nash, MD; Megan Schmidt, PsyD; Ruth Buczynski, PhD
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Thank you for the information on moral injury experienced by health care workers, which may include any staff who end up as bystanders to another being harmed or neglected when they did not feel able to intervene to stop the harm.
I am wondering where to find information on how people’s suicidal behavior or action may be related to unrecognized moral injury they experienced.
Also, given that your team understands that what we see & hear can reactivate trauma/tragedy & thereby dysregulate the nervous system, which makes attending in the present moment & learning difficult, I request that you change the video that leads into every module & the music that is played. It is not helpful for my being to have more alarm experiences than I already have in my life. There are so many images & types of music that are more likely to help bring calm to our world.
I’ve been thinking about clients I’ve been working with and examples of moral injury that I didn’t recognize as such at the time. The shame and self hatred are what made me think about that in this broadcast. And just the sheer amount of time and trust it took for them to open up about that. And the relief they felt afterward when they saw my reaction was one of validation rather than condensation. And I can see how other cases would not be quite that “simple” as some of the examples shared here tonight. I’m grateful for this broadcast and the opportunity to expand my thinking. I like the mini exposures and creating safe ways to engage in connection again that allow the person to learn to regulate themselves more over time. And I’ll keep thinking about this. Thank you.
The last example, in which the person regularly engaged in actions that would prevent this kind of harm from occuring again, seems crucial to me. Simply addressing the aftermath is not enough if there is a material likelihood that this will occur again. This is one of my main challenges with psychotherapy in general, it often does not address the root cause that led to the truama or moral injury. This is because these root causes are often based in political domination (war) or economic exploitation. If the goal is to prevent, not just treat, moral injury and truama, we should become revolutionaries.
How would you deal with a 60 year old client who had moral injury front an abortion at age 25?
There are infants in hospitals with no one to ear them cry. I was one of them.
Perhaps you might find joy in brightening a child’s face.
A suggestion is to look for a support group. The sessions typically range from a weekend to a few weeks of weekly meetings. Some examples of programs are “Surrendering the Secret” or a “Rachel’s Vineyard” Retreat. To learn about them, check with a local pregnancy care center to inquire about what is called “after abortion recovery” support groups. Many women seeking this support are in the age category of the person described.
Thank you! Such an important learning that values really do matter. I’m inspired to continue helping my clients accept responsibility for moral injury to those they have harmed or the injury that has been foisted into them! Please keep offering this opportunity for those who aspire to help others!
How practical! Im
working with Royal Commissioners recommended after royal commission into Defence/Military Suicides and government is implementing all recommendations: as a potential taskforce complex project manager clinician /human s consultant: I will use this do shape more helpful services
!!
Thank you so much for this amazing lecture.
My country has conscript military force and the application of moral injury in military setting is enlightening.
Professionally, I teach restorative practices and utilize restorative practice as intervention for moral related issues like bullying. Today’s lecture expanded both my theoretical and interventive knowledge in addressing moral injury.
Thank you.
Thank you for this seminar. I have a client with moral injury that I am seeing tomorrow and am prepared to address what I have learned here within our session. I had not seen this before and I have done trauma therapy for 7 years! And thank you for what you do!
Thank you to all the experts
it was a mind blowing session indeed. lt creates more ideas on how to help my clients. thank you again
Thank you! I am going to think about moral injury as it relates to my bereavement as a mom of a child who died by suicide in my ongoing healing.
Fabulous training, as usual. Thank you. The concept of symbolic amends is beautiful.
Wow- love the balance sheet of life in moving forward and away from the trauma – great training, thank you
Thank you so much i plan on telling my trauma therapist
I’m wondering what my options are to get the gold pakige is im a studant learning to counsel like me who have gone through trauma and or disability but right now on both
Hi Dave,
Thank you for commenting. As the Gold Package is currently on sale for 50% off, we are not discounting the package further. I would recommend taking a look at our blog as we have lots of free materials and resources: https://www.nicabm.com/blog/ I hope this is helpful!
This session highlighted strategies that could have helped an older male client I worked with a number of years ago who was not only sexually abused as a young boy but also forced by his perpetrators to rape his best friend, an innocent young girl, who then later committed suicide. As pointed out, exposure therapy might have been detrimental for him because of his overriding sense of guilt, shame and self-loathing, but thankfully, he did benefit from ACT and mindfulness training. In retrospect, had I continued working with him, perhaps the next step in his treatment journey would have been an adaptive exposure group addressing self-forgiveness and making amends. In this client’s case, I suspect helping him find ways to symbolically make amends — thereby facilitating realignment with his core values, reducing negative self-judgments and building a more positive self image — would have been very helpful. I’ll remember to consider making amends an earlier component of any future treatment plan for clients struggling PTSD and moral injury, especially for those who caused irreparable harm to their victims.
Thank you for this highly informative, well-organized, concise, and extremely helpful series! The case examples selected for each Module have been excellent. 🙂
Jennifer
Sorry for the typo: I meant to write ADAPTIVE DISCLOSURE group! 🙂
My own experience shows a profound difference between trauma and moral injury in early childhood before age 7 or 8 and later in life. Is that the experience of others?
Thanks for another fantastic session. The explanation and examples helped me understand how widespread moral injury must be, because so many people have done things that go against their moral values or they have ignored their moral values in different situations (e.g. the silent bystander), that brought harm to others. A takeaway: I will now add to my questions: Have you done something which goes against your moral values? How has it impacted on you?
To add to the discussion, we need to also be aware of moral injury suffered by people not through their own actions, but through the action of a family member. E.g. a father who killed people and the shame and guilt it has caused the adult child. Working with these people to help them deal with the ‘sins of my father’ and help them ‘make amends’ allows the person to move forward with their own lives.
Thank you for the information shared in the Webinar that is very relevant to my work.
There were many gems of information. My question relates to what was mentioned on the setting of boundaries in the context of burnout and how if the moral injury isn’t addressed, treatment is limited.
I started to wonder about boundary setting with clients’ family and parents that are hurtful or abusive and how that could potentially involve moral injury. Is that something anyone has seen in their work? Also with regards to moral injury and burnout, are there additional resources you might recommend? Thank you.
I work with members of emergency services organizations (and their families), especially police and fire services. I believe that they can often present with both PTSD and moral injury – not either or. Often they are drawn to these organizations because of their moral codes and desire to serve and protect. But then when they are physically injured themselves or are suffering from the cumulative impact of PTSD and strug
This was an excellent program. I think this topic is the blind spot of the world just now. Very helpful
Great presentation on moral injury. I knew there had been something else going on in my practice for many years and had recently started thinking about the powerful area of guilt and shame and moral injury. This brought it all together. Thankyou!
I am a medical professional and believe I have suffered moral injury, so this was excellent and in particular Wyatt and William’s words, I would love to hear more about this, both in order to help myself and my colleagues (and as a flow on, our children, friends, families and patients)
Stranger a Home – a documentary on how the military needs to provide better mental health- is currently streaming for a $10 ticket and will be on PBS
Strangerathome.org
This was so informative. Thank yu for the fresh perspective and take on the tools we have and how we can adapt them.
This discussion today is so important for what’s happening in the world right now!
!!
I really liked the idea of “Reclaiming Goodness”.
I too much appreciate the information; as it was both new and very informative. I’m curious if there is often overlap or a layered effect from those that have experiencing both PTSD (especially if more complex or repeated exposure) and a moral injury . Such as in the example given of the person who was both the victim in trafficking ring and made to actively participate in whom would be chosen next. And if identified as experiencing both PTSD and MI how do we go about exploring each facet.
Good question – in one sense there often is an overlap between PTSD and MI but what matters most is not what we think but what the client thinks – are they ‘guilty’ (their perception) of a physical inability to prevent (ie PTSD) or a moral inability to so so (ie MI)
In the case of the person who was both the victim in trafficking ring and then made to actively participate in whom would be chosen next, I think we probably (not always) ought to go with the chronologically prior ‘offence’, ie they were a victim before they became a victimiser – and so most (but not all) addicts become dealers to continue being an addicts rather than for some other eg financial reasons.
In martial arts, bodily trauma is commonly reversed from the most recent to the most ancient, so psychological trauma would work the other way around.
Working with domestic, sexual abuse & ACE’s this was a really useful session. It has given me time to reflect on my work with practitioners as well, especially where we support those who have perpetrated, as often this includes work with the client’s own trauma as well as the acceptance of harm to the other & for many delivering interventions and therapeutic support the practitioners frameworks for programmes are CBT based and I often explore with them areas where altering approach / adapting tools may be needed; this session helped with some of that reflection & exploring that difference in PTSD & moral injury. The aspect of consideration with healthcare staff has also given me some thoughts for working with clients where this is relevant in a way I’d not quite connected previously. Thank you.
Thank you for this informative video, which has helped me to get clear on the difference between moral injury and PTSD and how to treat it. It’s an area I would definitely like to explore further, and look at Acceptance and Commitment Therapy, how this can be adapted for peer group work.
This brief presentation helped me gain a clearer understanding for how to distinguish between PTSD and MI, knowing that a person may have experienced being both a victim and perpetrator. Thank you for highlighting the need for non cognitive approaches to therapy as a patient’s access to coherent memories may be limited and somatic techniques more useful.
Thank you for an informative and rich session! I truly appreciated the discussion on moral injury and the contradictions of traditional cognitive restructuring as treatment interventions; the presentation was effective in communicating the nuances and context of critical concepts like trauma, PTSD, moral injury and treatment modalities of CBT, ACT, Attachment therapy, self-esteem as tools of treatment. THANKS AGAIN!
I am working with someone who feels immense shame for a past sexual offense and as his charge mandates he is on the registry, so the shame is triggered with each job rejection. To me this appears to be a moral injury. I’ve tried to point out that he repeated what was done to him (he is also a victim) to try to promote more self-compassion. I’m seeking approaches to assist him with acceptance and with moving on in spite of repeated stigma and rejection.
Wow, a really tricky one. I suspect your client is truly conflicted – between what he wants and what he believes in. And in one sense this is a massive opportunity for him to be an integrated person, not in your or our formulation but in his own
Either he finds that he is a willing sexual offender who ought to be in the list – in which case he needs to dig really deep into finding out the (presumably childhood trauma) reasons for being as he is, and someone of whom society disapproves
Or he might find out that his own past sexual offence is in fact contrary to his ultimate core values, ie the offence was an aberration against his values, ie MI
The depth of his plight is also the enormity of his opportunity – as indeed it is for all of us
What makes this even more difficult is that the feelings of rejection at being repeatedly turned down for employment may be similar to the feelings of helplessness of victims of sexual abuse. In both cases someone more powerful controls someone less powerful who has no hope of escape from that control. So how can your client let go of his guilt over past actions as the aggressor AND be at peace with those who now control him? Either it is bad to be controlling or it is okay to be controlling, but to say it’s okay for them to control him while he should feel nothing but remorse is difficult. Yes, that’s what CBT calls black and white thinking but I feel many of us struggling with moral injuries struggle with that sort of all or nothing attitude. So, I think you may somewhat help him by helping him understand that he is both aggressor and victim in this very situation, regardless of what led him to his aggression in the first place. I am NOT a clinician! But I hope this helps.
I was on Moral Injury committee at the VA Hospital here ten years ago. They initiated some groups for treatment of Moral Injury in addition to individual treatment. I retired several years ago, but am in contact with the leaders of the movement here. I will inquire if you are employing Behavioral Activation techniques. Ift makes perfect sense. I will share with my supervisees for licensure!!!!
I think Behavorial Activation techniques are NOT indicated until the client expresses the need and desire for the same. Otherwise such techniques simply accentuate the moral ‘seriousness’ of their action and thus drive them into further guilt, shame and pain
This is very humanizing, to take the position that our moral compass, values are central to our capacity to heal and thrive, not only survive. Focusing on values is profound and in the context of healing from the effects of moral injury, this loving approach is sure to accelerate our healing as a society. What if we are all violating our core values, at some level. For example, driving a car knowing that petroleum and even the coal required to fuel the electric vehicles is harming our world but doing so to support a profession or a family. These are moral violations, perhaps appearing as micro aggressions, we are “doing something that we know is causing harm.” What we must be sacrificing in our inner world to live in this world as it is today is tremendous. Blessings to us all. I look forward to approaching my next clients with this lens and to viewing the next module synopsis.
Fascinating questions but I think the real questions are always ‘relative’ not absolute, ie are our actions better than the real alternative rather than the speculative alternative –
I find myself considering how moral injury applies to LGBTQ+ patients… especially those who grew up believing that expressions of their innate feelings of love and sexuality were morally wrong within their family and community cultures and society at-large.
Very good question but what matters is not what their community thought but what they themselves ;thought (and by that we mean ‘they themselves’ not their parents etc)
In either cases (opposite cases), they can be led out of turmoil and pain
I also wondered about the role of forgiveness & self forgiveness during this podcast
To have the concept of moral injury be separated from PTSD is a huge leap forward for me in my healing process.
I have been aware of shame entangled in my trauma and have struggled to release it with protocols for PTSD.
I can now do that because you have validated what I’ve always felt.
Thank you to all for the incredible gift of your understanding and compassion for those of us who have needed them.
I’m curious to know if a newborn child has a soul that can be stained. If not, when does that happen in development?
Thank you so much for this opportunity to broaden and deepen our knowledge, understanding and skills in the treatment of different kinds of trauma. I am not sure if this has been mentioned already, but is there any chance I could see the first Module – which would be the most helpful for the sort of clients I mostly work with – without the Gold package as unfortunately I have only found out about the whole event and thus was only able to join it after it started? Thank you in advance for your reply, Petra
You can buy the gold package at any stage – it’s not too late
Acquiring knowledge that not all conventional treatment methods for PTSD are necessarily compatible to Moral Injury treatment are added great information and insight to my career. Thank you.
This discussion created a curiosity in me on moral injury and how this informs which of the modalities to use for therapy. This was eye-opening and looking forward to learning more. Especially coming from a third-world country, and from a marginalized community where moral injury has been normalized.
This learning is deep.
Atyang
I am a professional chaplain who works with first responders. Often first responders have to make quick decisions that affect whether a patient lives/dies or is paralyzed/a vegetable. Those decisions can affect a person’s sense of morality to its core. I would like to see more studies done with first responders especially EMS providers. Thank you for providing this educational session.
BWRT -Brain Work Recursive Therapy – developed in the UK and South Africa is a very effective tool to dissipate psychological symptoms of trauma, as is Schema Therapy when working with shame and self-identity.
CORRECTION – physiological symptoms!!
As a coach, It’s not in my lane to “treat”, but I do work with people in treatment who are freshly released from prison, who are veterans, and who have lived the drug scene for extended periods of their lives.
These situations all lend themselves to traumatic events, but recognition of “Moral Injury” and the distinction between the two, I feel is essential to prevent me from “Doing Harm”.
Especially in the realm of possibly undoing mental health progress.
Thankyou for your comment, as someone who works with people in prison or recently released from prison I was thinking the same thing – that committing a crime can in many cases create a moral injury on the person even though to all intents and purposes they “chose” to commit the crime… of course influenced by many shaping impacts on their life (usually trauma), but apparently by “free choice”, I don’t think that takes away the moral injury or the need to treat it if they are to be able to take a different direction in future
It is going to be helpful to learn more about using exposure-based therapy in conjunction with ACT to help clients recover from moral injuries. Also, how do one define when a presenting issue is solely a moral one versus it being PTSD?
I think it may well be both issues, but in that case, I would be more immediately concerned with the Moral Injury component.
Since treating for PTSD might be contraindicated for Moral Injury, and therefor counterproductive, I would think it safer to start with MI, knowing that if that proved ineffective, I could paddle on the other side.
Caveat: I’m a coach, not a practitioner.
Case studies were especially valuable
Thanks you for informing me about Moral Trauma!!!!! I have it.
Now I can name it and continue to work with it. Not knowing where to turn
after my moral injury, some of the solutions you mentioned I have intuitively
…discovered but I will be purchasing Dr. Wyatt Evans
The Moral Injury Workbook. Thank you with tears in y eyes!!!
I first learned about the concept of Moral Injury this past spring, when my supervisor suggested it might be relevant to a client I am seeing. This is the first chance I have had to attend a training delineating how I can use tools I have in a way that treats moral injury specifically. I hope to use them with this client and others, and am very interested in the confluence of Moral Injury and PTSD, when both are present in a client either form the same event(s) or from different evets at different times.
Very interesting, the distinction between PTSD and MI (moral injury). One added problem (not addressed) is that PTSD ‘events’ present themselves in client’s narrative, whereas MI issues might be shrouded in denial
I am curious about moral injury as it pertains to healthcare workers and its impact on burnout. Are there specific treatments fo this type of moral injury?