Moral Injury: The Hidden Pains in our Souls and the After Effects of Trauma

Helen L. Horvath, PsyD

Let me begin by saying that if someone you know is diagnosed with Post Traumatic Stress Disorder (PTSD); it is not the same as a moral injury. Treatment for PTSD will not resolve a moral injury. The moral injury, such as sexual assault or relationship with a psychopath, may play into the diagnosis of PTSD based upon a loss of self esteem or loss of a sense of safety. The shame and guilt associated with these factors may create a moral dilemma that impacts the soul.

Think about the fact that on a daily basis we are faced with a series of choices relating to the navigation of our professional and personal lives. We experience doubt, fear, anxiety, joy, happiness, and expectancy of a great life and future. On a normal day with normal people we are able to thrive in our environments as we build a life that overall brings us joy or satisfaction.

Yet, what occurs when our morals, values, perceptions, and beliefs are impacted by others we allow into our world. Do we feel guilt and sadness when we are told that we are not as valuable as we thought? Do we accept, over time, those negative statements that cut at the core of our emotions by those we trust or admire?

Moral injury is a term in the psychology field that impacts all professional fields. Yet, it is most prevalent in the military and veteran communities. Moral injury is defined as actions that go against what we know is appropriate behavior and actions. It is not the "little lies" or "taking pens" from the doctor's office as you sign your medical documents that your Mother warned you about. Rather, moral injury is a deep and abiding overall trauma to the soul. This trauma is based upon extreme and unprecedented life events and the aftermath of those events. These life events are considered moral injury if they go against deeply held moral beliefs and expectations.

In the military, moral injury can occur when a senior leader plays sexual games with his or her troops and expects the troops to go along. Or not reporting a sexual assault that was witnessed or known to occur. Other examples can be found in the war zone when soldiers are asked to kill in order to survive. Only to find out later that the person they killed was on their way to see their wife who had just delivered a baby and was not a terrorist. Or when an order goes against the Geneva Convention. These factors often will lead to serious distress, guilt, shame, depression, PTSD, self-harm, and suicide.

Moral injury often debilitates people as they are prevented from living a full and healthy life. Debilitation occurs due to the damage to the soul of the individual. War is not the only factor that impacts and creates moral injury to the soul. Abuse, rape, and violence have been known to cause moral injury. These are also prevalent factors within the military. Failure to participate in the actions or when the behaviors are reported to the authorities may cause moral injury to occur as a result being ostracized by their military family for going against the organizational morals and values.

Moral injury can lead to self-handicapping behaviors. Self-handicapping is a mental strategy that people use to avoid situations or people in the effort of keeping potential failure from hurting their individual self-esteem. Self-handicaps are obstacles created or claimed, by the individual in anticipation of failing performance - a sort of self-fulfilling proficiency. These become the derailers in the person's life who has experienced moral injury.

It is through the self-handicapping or derailers that a person may experience increased passive and active suicide thoughts and behaviors. Self-handicapping can lead to an erosion of their moral sense of humanity and goodness. People suffering from moral injury generally lose faith and trust in themselves and others. This impacts their sense of hope and ability to see beyond their own situation in that moment in time.

A person does not wake up one day and say "I am going to commit suicide". Rather, there is some sort of moral injury that occurs which weighs heavy upon the soul of the individual who is contemplating suicide. Lethality, in cases of moral injury, is determined by the level of harm to the individual's self perceptions and esteem as a result of the moral injury as it relates to thoughts or actions of suicide. A religious person may believe that killing someone is wrong according to the Ten Commandments; at the same time choose to follow military order to kill someone. Long term, the person may be able to self justify self-harm and threats of suicide as a result of moral injury; just not actually act upon the suicide. Statements such as "my family would be better off without me"; "nobody will notice"; or "I am suffering enough and have caused enough pain..." are some of the statements that may be made. Lethality, examines the potential for suicidal action based upon how a person presents and what statements are actually made.

The questions turn into key components of behavior. You may ask what steps can we take in the various industries, within our families, friends, and other community members to heal the souls of those harmed by moral injuries? What is the key to creation of a "safe harbor" for the survivors of moral injury?

First and foremost the survivors need to have a sense of hope. That in order to heal their souls; survivors must stop blaming themselves for "not knowing better"; "following blindly military orders"; or "continuing participation in an action or behavior" that causes them to feel partially responsible for their own moral violations. The survivors' views are skewed as they attempt to look back in order to understand why they behaved or justified behavior in a certain way that violated their own social morays and beliefs. This self-blame creates the derailers that can lead to suicide as it makes the moral injury more difficult to accept as a result of accepting the moral transgression as a "normal behavior".

Secondly, once the self-blame is addressed and resolved the work continues in the psychological bandaging and repair of the "soul wound". The "soul wound" is an impartial look at those behaviors and actions that stand in the way of creating a new whole person. The survivor will never be the "same" person before the moral injury; yet, they can become a new and productive person.

Repairing a "soul wound" requires an understanding of what was experienced in order to overcome the self-blame that stands in the way of healing. Understanding events and moving forward past our self-blame are key segments of the recovery process from moral injury. The survivor must be able to tell their story from their point of view with great acceptance by the listener. It is after the story is told that the listener is able to dissect the story to reframe the story into a viable and structured view of the events - one event at a time.

A moral injury is a form of disconnect between a person's key psyche and underlying and hidden psyche factors such as beliefs, values, ethics, and morals. The underlying beliefs are the ones that are developed during strategic times of difficult choices. The underlying beliefs and key psyche beliefs may not be congruent and creates internal confusion. For example agreements to act in a certain way that goes against morals and values. The moral injury occurs when the trauma experience is not reconciled with the moral choices and behaviors. Basically, the incongruent behavior becomes the moral injury disconnect.

"Soul repair" of a "soul wound" should begin in the psychological frame of where the individual is currently at in their beliefs and values. These are then tied to the story to create a meaning outside of the dysfunctional views that go against the survivor's morals and values. This type of work should be accomplished by a professional with degrees in ministry, psychology, or social work to ensure that the signs of lethality and suicide are recognized and addressed.

Many survivors of moral injury feel or think they are dehumanized. They may feel or think that they are not worthy; that they are "less than" others in their circles of influence; or that their experiences will forever tie them to the moral injury. That their future choices will always be guided by their past choices and moral injury. These survivors may think that they have lost human dignity.

When working to repair a "soul wound" through a "soul repair" process; it is critical to seek out people and experiences that are diametrically opposite of those that we have encountered in our journeys. We need to help those with moral injuries become reconnected to a "normal" societal view of morals, values, and judgement. The reconnection is attained by introducing others who are empathetic, accepting, inspiring and meaningful.

Through this process of reframing and redefining we are able to help the survivor create a life that re-humanizes them. This is done through empathy, caring, compassion, and nurturing behavioral examples. This takes the survivor towards the goal of creating dignity. Again, this occurs as a result of seeking out people and experiences that help better define and work towards the creation of a "soul repair".

If you have experienced a "soul wound" and moral injury; please do not neglect your soul and spirit. Do not keep your wounds hidden; speak to someone about your moral injury. It is generally through conversation that your injuries are acknowledge and managed. Through art, play, writing, spiritual meetings, and dialogue the moral injury can become a new path that can have positive effects on your life and the lives of others.

? Remember, Never Give Up!!? We look forward to your comments.

Note: September is National Suicide Prevention Awareness Month—please feel free to share your comments and thoughts at the end of this article. One life lost is one life too many.

If you have thoughts of suicide, please choose life and speak to someone. Call:

Suicide Prevention Lifeline: 1-800-273-8255

Veteran Suicide Lifeline: 1-800-273-8255 and Press 1

Options For Deaf and Hard of Hearing: 1-800-799-4889