“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 plan to get certified in ACT. I understand the components of it, however I do not use it often and more than likely not as effectively as I could with proper training. Thank you!
The difference between PTSD and Moral Injury
Moral injury is perhaps more common than we are aware. Particularly in a world with the global conflicts we are experiencing now. I see the value of this topic to be explored even more.
Thank you for providing such valuable knowledge and practical tools. They are incredibly helpful for my work with unaccompanied refugee children under 15, many of whom have endured the trauma of losing their families, and a significant number have experienced abuse during their journeys. While I’m not in a position to sign up at this time, I deeply appreciate the free resources you’ve made available. Your guidance has been a meaningful support.
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Excellent course. I found the case studies especially helpful in linking my own clients’ experiences to the content of the course. For those that do not work with EMDR, a brief understanding on how or why it works with moral injury would be helpful.
Tried to ask chat bot but no help at all – couldnt manage to find sound for almost half hour
trying to find out what is meant by phrase ‘moral injury’
Finding much of talk is very going round the houses although some speakers were more helpful than others
Matt(?) seems to only be talking about pple who have done something wrong
Another guy seems to have slightly wider range of experience/ examples
It wld be good to actually understand this (US?) phrase of moral injury
Haven’t heard phrase in UK
Ruth B defined moral injury as a severe violation of a person’s most deeply held values. I think in traditional religious terms, moral injury is sin with regrets or repentance. Making amends aligns with doing penance. Wyatt Evans did give an example of a soldier who had both PTSD and moral injury and how they were treated separately. One of the main points of this module is that CBT often correctly reframes guilt feelings in PTSD as being false, but that therapists should be careful in case the client actually has failed in their moral responsibility.
There can also be a moral injury that is based on a false assumtion of an applicable moral code. I know of a case that can illustrate this: Decades ago an adult gang leader violently anally raped a young adolescent boy and said to him something like this: “You deserved this. What you did was so bad. Now, remember that you are nothing.” The boy believed those words, at least with a part of his being. He could not then really evaluate the gang leader’s words. Also, the boy had had a prior history of unjust treatment, so this was not something totally new. Eventually the boy – as an adult, after years of dissociative amnesia – remembered enough of the event and the words – and had learned about trauma behaviour – to realize that he had decades ago assumed false guilt and a false identity as a very bad person. He had formed a personpart (EP) to try to manage the false guilt. He finally understood that he had back then formed enormous false guilt by believing that the severity of the punishment by the gang leader was a true indication of how badly he himself had acted. He was finally able to say to himself that although he probably did do something bad to the gang leader, the violent, painful rape could not have been justified by any true, universally applicable moral code. The gang leader had applied a false, only personally justified, moral code.
Thank you, this is so very important! Having found my way working with trauma victims, and military personel, and people with addictions, this aspect was such an improtant part, and I so often found myself floundering in this moral injury arena. Sometimes I would find a way to help this deep, personal and healing aspect, to others I hope they find/found the help from the people and experience that would help them get to that self. I am so glad for this hour program, in my experience, no training ever talked about moral injury. Fortunately, without using those words, I did have personal teachers/trainers from whom I learned this “soul”/spiritual work, healing.
I do want to bring up an area not mentioned in this short broadcast. I have a lot of experience working with clergy, as well as my own religious upbringing, and there is a lot of moral injury under the guise of morality/religious teaching that can cause the same depth of moral injury and pain and dysfunction. Without a language, awareness or methods to help name and talk about these dysfunctions, how can we find ways out of these double binds while helping others find and keep their own true sense of morality. I am thinking that there is a lot of these same binds in the areas of race, cultures, and politics.
Thank you for this excellent module! I believe it is vitally important and I hope for more on this topic.
Hi Ruth, Thank you so much. I realize I have repeatedly suffered Moral Injury and realizing this is life changing for me and helps me to understand why it has taken so long for me to start to recover. I have been a burnt out NHS professional, currently running a pet care business for past two years while recovering and before I start a Mind Body Reconnect course in the New Year. I hope that I can start to share my knowledge, experience and care again to others. I cannot therefore afford the gold package but wondered if there are any Scholarships available because I have missed yesterday and the day before due to work and UK timings. Today has been excellent and they are all so relevant to me (and others). I recently paid for Richard Swartz’s IFS and secure Attachment session which was also amazing but genuinely cannot finance more. I would appreciate consideration for a Scholarship if possible. I know you have my email as I emailed you about the follow up to the IFS course. Many Thanks once again for your life changing work, Best Wishes, Carrie Lawson
Thank you for a very helpful and insightful session. As a professional coach working in the area of healthcare and palliative medicine in hospitals that are often resource lacking – moral injury is a constant in much of the client work I do. I love the idea of symbolic amend making – such a powerful tool that I have been privileged to witness in action.
Thank you for these wonderful presentations. The experts offered very useful and helpful advice. As the founder of the Compassion Fatigue Awareness Project, I have been traveling nationally and internationally presenting trainings to help caregivers and responders understand and recognize compassion fatigue. For 23 years, I’ve worked with helpers in just about every helping profession. One profession that wasn’t mentioned in your presentations is animal welfare workers. I have found their level of moral injury the highest of all. Why? They go into animal welfare work to save and nurture the animals in finding forever homes and what do they often have to do? Euthanize them. Animal control officers suffer the highest levels, I believe. Additionally, since Covid, I’ve added several Powerpoint slides on loss and grief. We suffered horrendous losses during the Covid years – loss of traditions, relationships, jobs, and even the loss of meaning in our lives. Often helpers believe they are experiencing high levels of compassion fatigue, stress or burnout, but in reality they are grieving. Again, thank you for helping us understand moral injury and how to approach it.
I wasn’t aware that this was a thing. I can now see, in hindsight, how some of my clients may have been dealing with moral injury. Moving forward, I will be more aware and conduct my assessments from a broader lense. Thank you. This was very informative,
It was really good to hear that things like CBT don’t work well with moral injury because it invalidates possibly very VALID guilt, but can’t eradicate that guilt. I’ve struggled with engaging with CBT for years, and this is probably the reason. Also, I appreciate the knowledge that you DO need to address cognitive distortions that are no longer ADAPTIVE, but MALADAPTIVE, while also working with the person to realign with their core values before the event. I do wonder what that means for people whose moral injuries occurred at a very young age.
Can a patient who’s been molested and sexually abused by different people and did not report it be considered someone suffering with moral injury? From the viewpoint of, “I didn’t report it and maybe it happened to others” and also the viewpoint of “I didn’t speak up to protect myself”.
Great explanation to help clients to understand that they are not bad for what they did, and they can change slowly or do something to prevents others from doing it.
Continue practicing Mindfulness with the Community
So much great stuff in this module – thank you to all. I found the discussion of symbolic amends and the concept of atonement very powerful and challenging. It has so much potential beyond the personal level in cases where a person’s actions have led to societal suffering. As someone who grew up in the context of a civil war, we often heard testimonies of exemplary forgiveness from victims of violence but it has been much less common to hear from those who participated, were ‘caught up’ in the perpetuation of, violence (those, on both sides, who were motivated by deep ideological rationales or the perception that they were “defending” their communities and their cause). I can only wonder how powerful it could be to hear the voices of individuals who have taken the step of seeking atonement and asking for forgiveness, rather than endlessly justifying past actions or, indeed, seeking to bury the past.
I’ve been with the programme for 3 days now and I wanted to mention particular thanks to all of the practitioners taking part. Ruth B, Ruth Lanius and Eboni Webb, in particular, have a real talent for explaining and clarifying what can be quite complex theory. I find the pausing and recapping very helpful. It’s also great to hear examples from the therapy room, particularly questions/dialogue used – this is so helpful to those of us just starting out.
Great, important presentations. Please consider providing clinical resources because I’ve been looking for years (unsuccessfully) for Moral Injury experts/therapists.
Partnering with client’s to reclaim their good.
what about the brain ? its imprints on these experiences ? how to address this matter ?
Thank you for the dedicated efforts it took to organize this program and the wisdom shared by the experts. I’m learning to be informed about differentiating between PTSD an MI and engaging in treatment that is effective for the client. Overall I am learning a lot about trauma treatment and believe the benefits of learning and providing this treatment is key to helping clients heal and have a better life.
Having worked for many years as a clinical/forensic psychologist, trauma-informed theory, research and approaches have both attracted my deepest attention and guided my work. As I listened today, faces of several patients came very much into focus… thank you for that guidance.
I continue to work with EMS, allied heath professionals, law enforcement and military veterans… the discussions today have animated my readings on MI and also provided some language to work with several religious leaders I know who are concerned about ethical dilemmas they encounter in their pastoral work. Many thanks, and continued strength for the work we do.
I missed the beginning, but it made sense listening to the case examples of how to help the client to give back abstractly via volunteer work, doing education, etc.
Thank you for this opportunity to learn about these approaches to treating Moral Injury. I appreciate the distinctions between PTSD and Moral Injury, and learning the contraindications of some PTSD treatments in the context of Moral Injury. I also appreciate the way NICABM consistently brings in the Body. Helping clients to locate trauma in their physical bodies, where it resides, what it feels like, looks like, what are the textures or sensations of trauma held in the body is SO CRUCIAL to allowing trauma to move through instead of getting stuck in the body.
I am an avid promoter of NICABM and their free resources. I am constantly sharing these resources on social media, and even word of mouth in my own community. These resources have completely changed the way I interact with people in my community, changed how I interact with people in my career spaces, and has helped me recognize and release my own childhood trauma’s.
I highly recommend NICABM courses and resources.
I agree completely on the viewpoint of bringing the body into the conversation. It is one thing to try to bring about healing/acceptance/recognition to the mind, but the body holds on to things much longer and, from my experience, cannot begin the above processes without the discussion and work done on where in the body the emotion is being felt/held.
Thank you so much. This explained a concept I was unaware of – moral injury instead of PTSD.. What a breakthrough in increasing awareness of the importance of appropriate ways to treat this!
I have studied under your organization for 4 years. I GET IT NOW! GENERATIONS OF MORAL INJURY ON TOP OF MORAL INJURY IS THE EPIDEMIC ❤️ this explains the lack of results in therapy❤️ This explains the self condemnations that have stunted countless generations of truly beautiful people with tortured souls ❤️ this explains the special needs rise ❤️ why meds don’t work ❤️ why a survivor cannot bear to hear… it wasn’t your fault 💔➡️❤️
I have struggled with a relentless pattern of shame and deep energetic self recrimination, for most of my adult life, regardless of the number of modalities I have both personally engaged in, to help myself, and thus learned as a clinician to help my clients. This has all been without the biographical material in this lifetime (nothing in my behavior I can point to) that would substantiate this kind of experience. This is the first time I have come across this concept of moral injury in such a detailed, fleshed out way. It has stirred my curiosity about a few things: 1) what might be happening when a parent or grandparent has sustained a massive moral injury, and that energetic structure is passed on to their descendants, without the descendants knowing about this content (but feeling the potent energetic and psychic structures that house them in ongoing shame and self recrimination, etc.) and 2) what could be the role of stains on the soul of this sort, from past life time actions that might have a similar effect? I am humbled by the complexity of our human paths out of pain, trauma and suffering and into life’s innate blessings and gifts of basic goodness like aliveness, relatedness, creativity, etc. My own path has involved working with potent generational traumas on both sides of my family (including years of persecution, torture/attrocity and genocide on one side), severe attachment trauma wounds and an adult trauma psychologically replicating some of these core complexes, such that it fragmented my being. It’s been an indescribable road of healing that’s been required to find coherence individually, and energetically with the larger webs of interconnectedness that affect us. In all these years, I have not considered the impacts of my one parent and both grandparents, re this concept of moral injury. When I think about this from what I have viewed in your program, I have a deep sense of wondering arise, could this be a huge missing piece for me and my family of origin? I am intrigued to see how this unfolds. Thank you so kindly.
Hi Angela – I’m in Berkeley. Thank you very much for your comment, especially the past-life piece and the transgenerational, energetic effect parents and grandparents can have on us. I remember someone once saying, “We internalize our parents’ emotional states.” That rang so true for me. In my case, as a third generation immigrant, it was paranoia and intense mistrust of others, as well as terror around being abused and taken advantage of by others, feelings I have struggled with my entire adult life until receiving skilled somatic trauma therapy myself. And for me, Twelve Step recovery was most powerful and successful in helping to eradicate the moral injury I suffered from due to actions of my own as an adult under the influence of a number of life-threatening addictions which, oddly enough but most commonly, were attempts to actually save or preserve my own life. Direct and symbolic amends were immensely effective in this regard. As you said so beautifully, the complexity of our human paths out of pain. Thank you for sharing….
You should read topics concerning transgenerational trauma, systemic representation and family constellations.
I can see young children in dysfunctional families almost always having a sense of moral injury because of the erroneous childhood belief that THEY caused the disruption in the family and THEY were responsible for its resolution. I would like to explore further how that affects them as adults and any special considerations for treating adults who carry moral injury over from their young childhood? For example “I made my Mother protect me from the alcoholic . . . I ran to her for protection . . . and now I cannot accept that in me . . . how could I do that to her?”
Thank you for all the hard work.
I appreciated the focus on differentiating symptoms that may show up in PTSD and moral injury and particularly the notion that guilt is an adaptable and expected protective defense in the context of moral injury.
As we know, it is often the case that folks with unresolved childhood experiences of suffering go on to victimize others. I often encounter people who are experiencing PTSD symptoms stemming from their own histories of being traumatized as well as from their own experiences of violating their own moral codes, or sense of self as a “good person”, and injuring others. In these contexts it is not an accidental misfire from a soldier in combat who received incorrect coordinates but rather, for example, a person who grew up in a violent home and community environment who then goes on to willingly engage in multiple instances of gang violence.
I would be curious to hear some of the presenters here reflect on that intersection and specifically on how to apply the interventions here when the symptoms are so intermingled.
I’m not a practitioner but I want to thank you for providing these professional insights on dealing with one’s severe mental traumas. I hope the session becomes a starting point for many people to recover and be able to feel their values in this world again.
This is my third time listening to this rich, dense presentation. It directly relates to my client base who often were forced into acts of violence and perpetration. I appreciate Dr. Ruth’s compass in navigating us through each mini-presentation so that we understand the connecting therapy modalities that are referred to. I encourage all listeners to listen often and use this as a resource for going deeper with each of these researchers. a shout out to Dr. Eboni Webb. Her skillful and engaging presentation style, her rich, resonant voice, her depth of compassionate experience, affords her the ability to become a national spokesperson for many diverse client bases we might encounter. Thank you, NICABM. This series introduced us to several new presenters. I will be purchasing the book of Dr. Wyatt Evans and perhaps other resources. Even if I do not purchase Gold today, the program will be available in the future as well.
The very last piece of the guy who went into wrong lane as result of alcohol – how we can turn a trauma all be it lives taken into a blessing for others – he going to schools. How often the traumas in our own lives resulted in us doing the work we do as therapists etc.
GREAT point, Helen!
This was very valuable. Acknowledging is the word that comes to mind. Letting a person speak without jumping to a potential solution. It’s the revealing and being heard that matters.
Very helpful to review the contraindicated techniques between PTSD and MI
This session made me consider that some of my more complex clients may be suffering from moral injury, which is contributing to their presentation, and not being adequately addressed. Thank you for expanding my horizons. It has also been validating regarding my efforts to find to find the right tools for the client, even when I feel at a loss. It encouraged me to continue to validate the clients thoughts and feelings even if I don’t see their application to the situation.
It also revealed why I left a career I was passionate about as a midwife, and never sought further promotion. I knew my own values were very different to the system I was working in, but hadn’t quite connected the dots. Thankyou.
Thank you so much.
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Supporting a client through the experience of shame, guilt and self condemnation when they have engaged in actions / decisions that violate their own and societal moral values that has left them in ‘no man’s land’, isolated and alone. Charting a pathway through that territory with a client allows them to reconnect with sense of self, other and community – a sense of belonging.
I also wondered about when a client feels the moral codes they have committed their lives/careers to have been breached by others and the organisation they work for. Their hatred, rage and condemnation is directed towards the ‘other’ and they feel themselves directly threatened- also leaves them alone, disengaged with family, workplace and community in unchartered territory. This is also an experience that can be associated with traumatic stress and moral injury. We, as therapists often need to work with clients in these circumstances to re-connect and re-attach to humanity (self/other), not identifying with moral superiority and/or inferiority. I will look forward to adapting the tools we have gained today to apply to interventions with this cohort of clients as well. Thanks again.
There is an understanding of the psychological issues associated with trauma that show up in a different way for Spiritual Healers. An example of such “manifestation”, i.e. easier to understand psychological states, is the imagery that comes with Journeying and Pure imagination. As a student of several spiritual paths and depth psychology I realized that these methods can be extremely useful without the repeated traumatization that comes with revisiting the experience itself. The only condition needed for safely administering these methods is an awareness on the part of the patient that there is something array with their state, that they need help, and are willing to partner with the healer to get to the bottom of the issue itself. Repressed memories, excessive feelings of guilt, shame, and self-blame can all be addressed through imagery. An important element, I found, in any healing journey. Thank you to all the contributors for bringing the issue of trauma to the forefront to any practitioner whatever their methodology.
We were taught about moral injury as part of our military/veteran focused CMHC degree. I saw it in action while I worked at the VA, but in an unexpected place- with a veteran who had served time for sexual misconduct with a minor. He was able to go from “I will never be able to forgive myself” to “Oh, maybe someday I will” when we could conceptualize what had happened as a moral injury and used ACT and spiritual integration to address it. I’m now interested in how IFS could be extremely effective in treating moral injury as it focuses in on those parts that have been exiled due to injury. Thanks for this!
I loved the idea of makiing amends and appreciating the moral personality and moral values of a person. Giving them strength to be the moral person they feel they are again.
This helped me to recognize that with the sexual abuse support group that I help co-facilitate, I do need to be aware of moral injury. If it does occur, I do need to be aware not to challenge her moral injury presentation. And, being more aware of moral injury helps me to make a more accurate referral. I also appreciate knowing that for many, this will be a time of discovering their values.
I am very grateful for the whole series I can be part these days that contribute to expanding my knowledge and skills how to make my treatment of patients with PTSD more effective. I am appreciating the
NICABM and its team of experts to share their best knowledge and practice. Today it was very meaningful for me to hear about the new part I was missing- about moral injuries and how to address them in my practice and help people prevent from long term burnouts and experiences that are remaining in their deeper self beyond their trauma triggering as if another level of self traumatization. Thank You also for careful guidance how to develop my treatment steps in a helpful way, this is very exciting to come back and hear about the hopeful possibility of people claiming and re-living their human life.
Zdravim Hanka. Velmi sa tesim kazdemu psychologovi zo Slovenska, ktory je studentom NICABM a seminarov o traume🤍 Organizujem v SR/CR Trauma konferenciu vramci novapsychologia.sk, ak by ste dostali impulz ostat v spojeni, budem rada;) Marci (Mgr. Marcela Hrapkova)
Thank you for all the hard work in preparing this webinar. It shows! Here are several suggestions for this module if it is subject to editing for future presentations:
1. I think providing more case examples would be helpful.
2. Self-forgiveness is often a sticking point in the resolution of traumatic moral injury. To some, self-forgiveness is not possible as it can be perceived as exoneration, rather than acceptance of human inadequacy and mistake-making, albeit at an elevated level. Bob Enright has written a lot on forgiveness and treatment for moral injury might want to include some of his work on this at U of WI.
3. “Moral” might be examined in the context of not only one’s core beliefs and values, but also one’s spiritual self, and relationship to God, if the patient acknowledges any such meaning. In my experience, most do. Thus including the input from a chaplain/rabbi/minister/priest might be valuable on a number of different levels.
Thanks again for a job well done.
Thank you for your comments, they were very thought provoking. I especially took on your comment regarding exoneration. I have sometimes used the phrase, “This is an explanation, not an excuse”, but now I will take that a step further and explore “exoneration” where applicable.
Hi Vincent,
Thank you for the feedback!
We greatly appreciate hearing your input and will certainly take this into consideration.
Enjoy the rest of the program!
Excellent comments especially regarding networking with faith-based spiritual direction. This suggestion bridges a gap between fields of endeavor because most clients I work with are much more likely to seek and receive pastoral care rather than psychological care. Pastoral care is accessible and available and socially acceptable. Psychological care is often none of these for typical clients seeking relief from lives of trauma. Traditionally, there has often been mutual mistrust and exclusion between these fields. This does not serve patients or clients. For example, psychotherapists refer to recommending the practice of “mindfulness.” The typical client is far more comfortable with the concept of prayer. In my practice, within faith-based charitable organizations, I must be very careful to avoid suggesting or introducing practices from religions that are foreign or alien to the client. To do so would risk introducing an additional moral injury. I must work within the clients’ range of spiritual understanding and reconnect them with their original foundational resources that initially created their personal moral compass.
This session in particular has tapped an unmet need and a “nerve” in therapists’ comprehension. Thank you, Dr. Ruth and NICABM, going forward, for having the courage to include references to the traditional religious practices and beliefs that are foundational to Western Civilization. This will resonate with clients who were child victims whose unhealed traumas eventually forced them into acts of perpetration. This causes them to experience two kinds of moral injury. One is the trauma caused by the psychological moral injury they have internalized. The second results from the subsequent perpetuation.
Mindfulness teaches “mindlessness” or how to empty our minds. Whereas, the rich religious traditions of the West such as Christianity and Judaism allow us to fill our minds with uplifting concepts and beliefs. Psychology and pastoral care can walk hand-in-hand and must not be viewed as mutually exclusive lest we further compound moral injury.
I had a client suffering from moral injury because she could not prevent her son from partnering and having a child with a woman who was mentally unstable and who ticked all the boxes of a covert narcissist. This client, who was competent and non-disordered, grew up with parents who had a serious mental illness. Moral injury was what she, as a mother, was suffering from because she could not prevent harm to her son. It was a trigger left over from bearing witness to the abuse she witnessed, as a child, towards her siblings by her abusive and mentally unwell parents. I will try to write about this. I write for psychiatrists and once they publish each short article I then put it on medium for the general public for free. I also did some research into the unacknowledged trauma of “Competent Non-Disordered Adults Of Parents with a Serious Mental Illness” (CaN-ACOPSMI) – very easy to read. People just need to Google my name, Suzette Misrachi, to obtain it for free. Often people with such a background experience moral injury, in the context of psychologically and emotionally absent parents, go on to become deeply and profoundly parentified. It may have also been their way of resolving their moral injury. A bit like, the example given of the man who had a head on collision with a busload of 8 student who were killed as a result. Except, in the instance of a mother, she could not go off and do presentations to other similar parents as a way of avoiding the same “collision” or accident of not warning her son from partnering with a mentally unstable covert narcissist. How to deal with such a scenario?
Today, there has been a very helpful session.
For instance, the session differentiated between two types of trauma, i.e. PTSD, and Moral Injury (MI)
And, the session also provided insights, not just of different and appropriate treatments for the two types, but also of why more traditonal trauma treatments used in PTSD military cases, are less appropriate to MI.
In short, today’s session has armed clinicians, saved them embarrassment and frustration, and potentially, expedited diagnosis and solutions for a patient.
I particularly found helpful the last example or case study offered, where one of the clinical team unpicked an apparent PTSD and military case, identified a MI element, and articulated some solutions. Thank you, c
I appreciated the repeated mention of Depression. So much of trauma work focuses on regulating anxiety, fight/flight, dissociation, self-medication – getting back into that Window of Tolerance “from the top, down”, as it were: not nearly as much focus on pulling oneself “up” from anhedonia, fatigue, burnout, apathy, withdrawal.
I found the model of ‘renengaging with the person prior to the transgression’ very powerful, something we can do for ourselves within and for the person we work with. Also, not dismissing self-blame resonated with Paul Tillich’s ‘courage to accept acceptance’.
Moral Injury is healed from giving back to others. Strangers . Independent of class , color or creed.
The person experiences an impulse to respond and in doing so trust occurs with discrimination and loving kindness.
That is so true, the conditions for recovery must be accessible in everyday relationship.
Thank you so much for this free lecture. It is such a good demonstration between PTSD and Moral Injury. Very good to have the distinction so clearly explained by the experts. And, the examples given to work with moral injury.
Lynette
great question!
I am so grateful for the explanations defining differences between Moral InJury and PTSD.
Also the way to alter therapies to fit the different conditions