“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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I would like to see some sessions utilizing moral injury techniques and a list of questions to ferret out the difference between PTSD and moral injury.
Two things stood out to me from this talk:
1. Interdependence is necessary for sustainable healing.
2. Connection to what is happening both mentally and somatically is critical. I noticed how little body-based elements were highlighted when things like shame and guilt may primarily live in the body.
Both feel very important.
I am a shamanic practitioner. When a client’s complaint is spirit possession, in the practice of compassionate depossession, we find that many possessing spirits suffer from the belief that they cannot move on to a better place because they would face punishment there for their “sins” of commission or failure to do what they should have done. We tell them that the angelic beings we call on their behalf will not judge or punish them, and they usually then allow this to happen. In ordinary life (consensus reality where we don’t typically interact with spirits) I have found that judging others, even when they do things against my moral values, is counterproductive. Usually they didn’t have much, if any, ability to do otherwise. This is true even if they had decided that having sinned once they were ruined and might as well keep on doing wrong. Even though society disagrees that they did and locks them up to protect the rest of us from them, they can be encouraged to learn from the experience of guilt and practice good, kind behaviors until they form a new identity as a “good” person.
thank you Ellen that you are talking about the judging. Yes, I think too that judging others never helps. but understanding, compassion . the fact that they had no other possibility to act ist so important.
I work for a charity that offers short interventions over the phone (12 weeks/6 sessions) for no cost, working with those who have complex mental health presentations. This is not ideal, however all most of our clients can access.
I have a client who has been diagnosed with PTSD (by another health professional, I am a counsellor). Their son was sexually abused by their mother’s boyfriend when he was 3. The son is now 11 and on the Autism Spectrum (ASD) and they are struggling to care for them, home school and afford their extra needs.
They focus on teaching their son life skills and schoolwork at any cost (often bullying and emotional blackmail). This is a great cost to the child and adds to the clients feelings of self-loathing and inability to care for their son.
They feel powerless to offer their son compassion and understanding; feeling disgust at the way the son behaves and looks when displaying ASD behaviours. We uncovered fear, a deep fear that the son will always be dependent on their mother. We looked at what is and isn’t controllable, unhooking from catastrophising about their future, consequences Vs punishments and yelling etc. The client felt too much fear and overwhelming responsibility to stick with these approaches.
After watching this I realise there is also moral injury. Keying back into their values to look at what matters. How they would like behave and parent now, using their values – not acting out of fear for their future. Compassion, patience, presence. Working within my short time frame, naming moral injury and working with values is something we can do. Thank you.
Thank you to all who helped put this session together
Moral injury in a medical environment creates problems for both staff and patients – staff who are unable to stop what is happening and patients who may need at some stage in the future to be referred to or admitted into hospital for care So very glad this is now acknowledged rather than patients being treated as ‘difficult’ patients
Would be helpful for hospitals to have an assessment where PTSD or moral injury is suspected or presents itself
The National Center for PTSD, which is part of the veterans administration has a free screening tool for Moral Injury. I will not post the link since that was forbidden above, but you can search online and this is a government website for a free item that we all paid for with our taxes, that gives an important resource that is not included in this presentation today – if we want to treat moral injury, we must identify it. Carolyn, your wrote it would be helpful for hospitals to have an assessment where PTSD or moral injury could be identified – well, there is a Moral Injury screener and also a choice of tools to screen for PTSD at this website for the National Center for PTSD, though you will have to spend some time searching carefully to find the tools, but several are available for free download. I hope that is helpful and that the webmaster can permit this post since it is not advertising a product that is for sale – since it is a free government resource. I have also wondered about whether “moral injury” is recognized by all, since it is not in the DSM, but – since it is recognized at an official government website, with a professional screening tool, that is pretty validating in my opinion.
I work with sexual assault victims, often also having had substance abuse problems. This class stimulated the work I can do that will support those who are parents address their moral injury relative to their children who have been exposed to violence and addiction as a result of their life experience or choices. Also, allowing therapeutic group discussion of moral injury will aid in providing community and building common language. I also like the idea of group discussion of how to further make amends aligned to client’s core values.
Great seminar, thank you.
Thank you. Will be using to help women experiencing trauma from past abortions, abuse, and trafficking. Explanations in module on Moral Injury very helpful to heal these deep wounds often hidden and suppressed. One client had already chosen to do a “symbolic” making of amends by making small toiletry gift packs for new moms with words of hope…from her own healing. Sincerely regretting what she was forced to do prior. Stating “I’m doing this to honor my own child, valuing and honoring the life of my child after I did something that was against my own moral code…” This was her idea, through prayer, God showing her how to redeem the pain and loss…producing a layer of healing by giving and caring for another.
Hello, I am doing similar work as yourself. zip am grateful NICABM introduced this topic to provide a forum for education. I am takingball the series NICABM and studying the work if many of the NICABM teachers to assist those I counsel or colleagues. Both to intervene with trauma victims to prevent abortion, and to assist others who did suffer the trauma of abortion to recover their spirituality. Moral injury implies the assistance of spiritual support is needed.
It is excellent to bring in this spiritual and moral dimension in the therpeutic work to enhance and expand the clients’ potential for full human integration. This will provide for for deeper, more mature healing for clients that psychology alone cannot achieve. This recognition of the moral/spiritual dimension or dynamic has been absent from traditional “secular” or materialistic modalities. Raising awareness of clients’ often unspoken moral need will expand the therapeutic intervention in many far-reaching, even transcendent dimensions of human identity. Thank you.
I’m a trauma recovery peer support who joined this session to understand how to identify moral injury and ways to be of support as peers share their experiences so I could then make a proper referral to a clinician. This session was helpful and I look forward to researching conversation guides to help me have supportive conversations while acting as a bridge to treatment.
excellent
My greatest take away is to help the client to rediscover and reengage value system. Thank you for an excellent sharing.
I plan to begin to gently explore feelings of guilt/shame/blame in my client whose twin has suffered a psychotic break. My client has seemed unable to move forward, has a lot of blame and anger against others who treated his twin badly. Seems to have some aspects of prolonged grief disorder but, having attended this today, may also be experiencing the self-loathing, guilt, shame, etc. of a kind of moral injury for not having “saved” his brother and/or prevented what led up to the mental disorders of his brother.
Hi,
Thanks for bringing up a challenging topic.
Although I am a professional counselor, I am commenting from personal life experience. In my family, there were numerous sets of twins. I was able to observe behavior.
Twinning often carries with it a moral dimension of polarization of opposites. The dilemma your client is experiencing is frequently encountered with twins. It goes deeper than mere sibling rivalry. It is especially difficult when one twin has severe personal health problems. This could be a form of “survivor guilt.”
Possibly, there might be a body of literature to consult about the potential psychological problems unique to twins. This goes deeper than merely making comparisons.
Thankyou very much for this. Missionaries and Development workers need this. Many would have moral wounding
yes! I was thinking, too, about the many pastors leaving ministry work and wondering where moral injury, in addition to the burnout that if often expressed. Does the inability or failure to do all that they feel responsible for lead to the sense of blame, guilt, and shame of moral injury?
I enjoyed all the experts and thank you for sharing your thoughts and recourses. I have new awareness, direction, and tools to support CPTSD and MI.
Was very helpful
Thank you, my take away is use of behaviour activation, the return to values held prior to the event, also found the ideas on teaching in community as a way of personal and collective healing quite helpful.
Very interesting webinar. I was just wondering whether the therapeutic approach would differ for the clients who started doubting their moral character and judgement as a consequence of an emotional abuse. For example, if they internalized the invalidating beliefs from someone else. As Ruth Lainius has put in the webinar, they know rationally that those accusations are not correct, but they do NOT feel innocent.
yes, I think that is the main reason clients who are survivors of trauma cannot let go of feeling responsible
Thank you for offering these excellent sessions. I am a singing teacher in an International School and serve many disturbed children and am now slowly learning the neuro science involved in healing through the expression of singing and music. This session brought me to understand other methods I can integrate to aid young minds to a place of integrity, moral consciousness and safety.
I really like the approach of supporting the patient to assess where their core values were prior to the traumatic experience and what they may look like after trauma. Finding a common denominator and working on it as a base to “fill the gaps” and move forward and step away from the trauma
Thank you for the input
Thank you for another excellent and needful presentation. I cannot imagine how many millions of healthcare workers around the world are experiencing moral injury for participating in the pandemic protocols that were prescribed. Those who aligned with their core values and resisted the protocols often lost their jobs and even their licenses.
How do we address the moral injury that is coerced at a medical system and governmental level? I can only think that if a significant enough number of people in positions of influence and healthcare and politics stood firm on their core moral and ethical values, the coercion to violate moral values would fizzle.
Thank you for bringing up this highly sensitive topic! I believe NICABM is breaking new ground in opening up an often taboo topic in the secular field. Theirvrecognotion of this dimension of actual lived experience will enable them to refer or consult with faith-based counselors and therapists for the expanded betterment of clients suffering from unspoken moral injury that causes them to suppress or compromise their moral integrity.
Very informative and appreciated.
I do find it confusing though, that the structure of the presentation (i.e. the headings/agenda) is rushed through fast at the start, and when it is partly revisited during the session, different subheadings seem to be added or stated differently, and so on, and again all said very quickly.
I suspect this is deliberate, to make it hard to make clear notes while listening and therefore steer people towards buying the package.
One can understand this wish; however for those who can’t or don’t want to do that, the rushing is really unhelpful.
I agree with your comment re: rushed through and heading Abby. It’s good feedback.
And I find content helpful and informative. Thank you immensely.
Rosh:)
This might help. I have learned to schedule time to listen to each presentation at least twice or often three times. Because they offer so many listening opportunities, it is possibleb to do that.
You are correct. these are excerpts from lengthier presentations. I have listened to many of their short presentations and am accustomed to their presentation style.
Also note that each presenter has a body of their work that can be accessed. This includes books, full-length presentations.
Think of it as a smorgasbord or buffet table. It is possible to return for seconds for free!
This was a great webinar. I learned that my trauma is a mixture of PTSD and moral injury, the latter being the harmful core values taught to me by my family who are deep into shame from the church, misogyny, racism, and poverty. I internalized a lot of their moral injury on power over others to feel worthy and safe and it directly battled my core values that are opposite of that. So I built an identity of self-contempt to be accepted by a community that was harmful and it has carried to this day with an inner critic who loves to abuse me when I fail at something I should be able to do. Add in the CPTSD of the abuse my family did to me and my inner psyche is at constant war between morality, worth, fear, and rage. This webinar really cleared some issues for me. Thank you.
Moral injury is very prevalent in veterinary and shelter medicine. Sadly, veterinarians – the most empathic of humans towards animals – face repeated trauma due to having to euthanise often healthy animals as part of their roles, often due to an owner’s lack of funds to treat simple conditions.
This has been a very useful presentation to assist me with supporting these clients, and myself – a former veterinarian who found myself unable to continue in my job due to burn out. Thank you for making these presentations available to us, sadly income does not allow me to purchase the package, and the free access streaming is greatly valued.
Hello,
Thanks for your insight and sharing. The same goes on with human beings at all stages of life whose family members choose not to provide basic care and allow them to be denied treatment, hastening premature death. That is why it is good NICABM is taking a forward-looking, anticipatory approach to counter the collective trauma of mass cultural PTSD due to moral injury.
I have really appreciate the insight of Dr Ebony Webb in all of these modules. Here, the mention of the idea that for some trauma survivors, there is no identity before the trauma, so re-covery is more a process of dis-covery. For early sexual abuse survivors, there often is no before the trauma. Opening up a world of discovery instead of trying to find something that never existed is an important reframe that can also facilitate agency in exploration and choice-making.
Having tragedy of the war in Ukraine, our people bleeding with bodies and souls. It is so important to receive tools for PTSD and moral traume differencialtion and hints of ineffective and prommising intervations. Some approahces form previous session were already successfully implemented, so we will offer leant in thes modul to our patients and coworkers. THANK YOu for your generosity and highly proffessional positioni
Hello. This is a personal observation, not a professional. It is regarding the deep moral injury people in the Ukraine experience that people in the U.S. cannot fathom.
A family member personally went to the Ukraine to rescue a very elderly mother in-law who has never been to the U.S. and speaks no English. They had to go through enormous bureaucratic hurdles to get her out just days before her village was destroyed.
She has no ability to grasp any ray of hope. She is surrounded by children, grand-children, etc., who reside in the U.S. Yet her only thought is of what she left behind.
Hi I am working with social workers, social work students and apprentices. Burn out is a huge issue, thank you for sharing a wide range of strategies that I can use to support them through their supervision.
moral injury is a concept that I did not know even existed. Thank you for these webinars. From where I am, moral injury is never acknowledged, infact if you are morally misaligned or injured, you suffer in silence.
Wonderful presentation. I am now more educated and informed about the distinctions between moral injury and PTSD. I will pay more attention while listening to my clients, discerning cues and adjusting the treatment appropriately. Thank you all. Dr. Monique – Vancouver BC
Thank you for the presentations. I’m using quantum physics modalities to treat my patients, I wish western medicine would mesh with us. Thank you Pharm.D. EEM-CLP, MAP practitioner in the works
I am unsure how this may work with prisoners. Would the same concept apply when using CBT interventions in an institution when healing cannot necessarily be applied in the institution?
Consider working with prison chaplains to find ways to slip in methods. Inmates often are very receptive to this deeper level of spiritual healing for themselves as child victims of neglect, abadonment. abuse or violence, who may have grown up to become perpetrators.
Some of the most rewarding pastoral counseling work I have observed was with male inmates. Once we addressed their own unmet childhood wounds, mostly from lack of father-figures, they were able to emotionally and spiritually mature to take responsibility for their adult lives. Doing this work introduced a spiritual dynamic that had been missing. This enabled them to heal and find peace and self-acceptance.
I am pastoral counselor who have worked with abusive men, I am sure men in prison are quite receptive to exploring their experiences of being victimized. I think takes the focus off their victimization of others and provides them excuses for their behavior. Prisons are interesting places. Those in prison have limited ability to determine their decision making. Research indicates that treatment needs to first deal with their abusive behaviors and take responsibility for them over time, change their belief system and behavior over time before exploring their childhood.
Two different, seeming opposite approaches, to working with the same issue, Joanne and Elaine. Interesting to read their differing comments. Thank you, both
I will pay closer attention to clients’ focus on extreme guilt and shame to identify moral injury. The difference between PTSD and Moral injury gets misplaced sometimes…
Moral Injury needs a treatment modality different than PTSD.
Thank-you very much for your presentation, it helped me to understand my own moral injury I have been working with over the years….Underneath Fear Lies Loneliness, Underneath Loneliness Lies Moral Injury, Underneath The Moral Injury Lies….Unattended Sorrow….Addressing Unattended Sorrow Contributes Towards Healing The Moral Injury(Child Exposure To Neglect/Abuse/Needs Not Met), The Visceral Held Issues PTSD(Child Abuse & Adult Trauma). The take away from your presentation is the last section of the presentation ”After Moral Injury” addressing Morality And Re-Claim Self Identity Back &Re-engaged Into Repair/Social Connection.
What Arises For Me Is The Choices To Be Made With Who Do I Repair Relationship With Or NOT (The Perpetrator re Child!!Adult!!) And
Forgiveness/Acceptance And Give It A Place In Heart Body Mind, Embody The Resilience And Rest In Visceral Ease & Joy . Thank-you For Your Kind Free Presentations & Download Materials You Offer The World. God Bless You NICABM, May The World Be At Ease And Peace! CWRI
Found differentiating between PTSD and Moral trauma and the differences in approaches very helpful! Had never given this much thought in the past. Also assessing value systems and moral injuray may be helpful as well in instances of abuse and neglect with children and parents who suffer burn out or multi-generational abuse. Foos for thought regarding burn out in clinicians working with high risk/high need populations.
I am certified as a trauma treatment professional I myself have a complex case of ptsd and moral injury in which I continue to experience continuing reinjury emotionally and morally that stems from unproved and court charges of animal cruelty that has charges dropped or dismissed but am continuing to be unable to resume my three professions as Episcopal priest as well as registered cat breeder and having my credentialing with Blue Cross being threatened even though my certifications and licensure have remained intact and unrelated misdemeanor charges not involving patients. I had massive media publicity 6 years ago about to be expunged in court records but I still have not been able to recover my cats though have a permanent registration as breeder with CFA. My doctoral dissertation published by Cistercian Studies is about our culture’s devaluing Nature in 1976. I listened to this module 3 on distinguishing PTSD and moral injury and can see both intertwined in my case and I can see symptoms of both without the guilt because I was charged for what never had a Bill of Particulars and am impaired in my professions without conviction and continuing to experience reinjury. The highlight of the season is the return of a breeding pair of catbirds.
From this presentation I can see that there are many more forms of both than I have imagined and that I have most of the tools already–including mindfulness as well as reframing and plodding on to confront one impediment at a time. My take away is to encourage patients in persistence to pursue personal resilience and self affirmation. My personal core values were target of the charges and media and the public shaming was the goal. They prevailed in courts.
This moral injury has been present for healthcare hospital workers who have been forced to choose between performing abortion procedures and leaving their jobs. I’m certain the Colorado law to provide gender-affirming care (to “support” medications and surgeries for trans teens) goes against many mental health and medical worker’s values. Our political systems create laws that cause moral injury and upheavals in staffing, but gain politicians a vote.
Totally agree, it’s horrible and very traumatic. I do not morally agree with what law says I have to do in my profession which has made me move towards another…. but that’s a slow process with inflation and traumatized children post family abuse has given to me.
Thank you. There is currently a case pending before SCOTUS on this very issue. If you want to learn more and review some of the “amicus briefs” submitted by medical doctors who agree with you, go to the website for the Justice Foundation.
Bravo to NICABM for allowing us to voice concerns about this morally divisive topic that contributes to collective cultural and social/behavioral trauma.
A milder form of moral pain/ injury that I frequently see clinically is in parents who have been ( often rightly) accused of poor or neglectful parenting which has done their child harm. The adult child is accusing or estranged. I try to help these parents recognize that it is impossible to undo the harm of the past, but that the only “true apology“ that is likely to be acceptable is a sincere investment in being a good parent now in terms of what an adult child needs. This may mean, as you suggest, becoming compassionate with themselves and understanding why they were not able to do better at the time, but in the present, not making excuses or denying responsibility for the past… and instead developing the new skills that they need as a good parent of adult children.
I also also agree fully with the need to retain guilt and shame as adaptive social capacities. The “internal” negative reinforcement that helps us stay in good relationship with those around us.
Excellent presentation , poignant examples to illustrate distinction
I engage in a group EMDR colleague consultation monthy, and will bring this valuable hour to my group,
;with key distinctions between PTSD and Moral Injury as we explore cases. This touches another depth of emotional memory which is most often embedded our work. Thanks again to all at nicabm!
Regarding the treatment goals, “Who and What am I responsible for?”/“Responsibility to Other”: I wonder if there is a particular standardized prevention curriculum that is currently being used in our schools/other child-focused organizations to strengthen these moral positions within our children and teens so as to provide our nation’s next generations with the tools they need to recognize they do have a responsibility to the “other”.
Thank you! This is so profoundly relevant for myself and my son. Every experience he’s had in 17 years of psychiatric abuse relates to moral injury. Me as guardian and parent and being court ordered to force my child to take drugs that have caused so much harm. It’s absolutely against everything I believe. And the totally unjust police assault of my special needs child (and myself three times), and how they are never involved in responsibility for their actions which perpetuates the abuse. I am so grateful for this information and this way to identify what’s been happening. It makes a huge difference. I am definitely interested in doing this entire conference. Thank you
This program is helping me to release unresolved trauma that I have “taken on” empathically from family and those who abused and morally violated my person. I have not understood how to do this and it has led to much illness and the inability to function naturally and create from an authentic, self-realized place. It has always helped me to see things from another perspective and I can now see their behavior from an expanded perspective which creates deeper compassion and so the experience of love in my being. The careful and responsible information given in these interviews has been very powerful in helping me to make amends with myself and release and restructure the consciousness experiencing itself through me. I realize this sounds detached, but I look at this as a great step in understanding that I do not have to choose to live like this any longer. I feel I can now bring an ever greater expression of my whole being and creative intelligence to my clients and the moments onward. Thank you!
I think this module tied in very strongly with my existing experience formerly in addictions counselling. Validating, creating safety to sit with emotions and look inward to notice and allow sensations, making amends, aligning with values acceptance. non-judgement. I agree that community approaches work well, and mutual aid. I like in this module the exploration of moral identity. “Who am I morally responsible for?” “Who is depending on me?” I will add this aspect into my work from now on. Very interesting to hear about possible causes of moral injury. Have definitely had clients affected by incest and leaving younger siblings vulnerable to abuse from the perpetrator that abused them.
Thinking about a recent client and the comment in webinar about showing compassion for them and something they had done ( I hope compassion would always be present but probably, on reflection, not in this case) and how I could have thought about this even where I’m getting something back which was that it wasn’t as bad as the rest of the family had said and something it had touched in me, I should have shown compassion in order to help them deal with their emotions. This will help me in future work. Thank you.
CC closed captions are absent in Module 3 and Bonus Psychedelic Assisted Psychotherapy videos. CC were OK in Module 2.
So enlightening. I work with doctors and burnout and have a background in trauma with military folks. I have often noted how medical professionals in both realms tend to be some of the most difficult to treat and this is the first time I’m receiving practical applications and understanding of why regular trauma interruptions don’t always work.
I’m wondering if loss of faith in humanity can also be a part of moral injury? It is another side of what I often see. Thank you!
Finding where guilt is felt in the body and what shape, texture etc and when was this experienced previously etc. very valuable alongside love, connection, acceptance – so much to think about
It sounds like MI could be such a painful experience, that one may engage in different strategies to prevent oneself from experiencing it, such as victim blaming. The patient understanding the harm that they have caused, in that sense, may actually trigger MI. It is like a two-step process.
I appreciate the confirmation for allowing clients to realize that their response to trauma is many times a normal response, how any normal human being might respond. I have found this to be the doorway to healing in many cases. Thank you.
Thank you for offering these sessions. This work brought me home to a place of integrity, moral consciousness and safety.
Thank you for an excellent presentation.
Takeaways – core value exploration and community interventions – the differences identified in processing moral injury as opposed to ptsd were also really helpful and can be put into practise straight away.
Very interesting, But English is not my best language (
It was very helpful understand that making emmends can be ‘simbolic’, as well as the relevance to engage with values to overcome the moral injury. Many thanks.