PTSD stems from an actual or perceived life-threatening or body threatening danger.
Moral injury stems from exposure to acts that violate one’s moral code.
Moral injury stems from a betrayal of one's core values or “what’s right” due to a high-stake situation where snap decisions must be made by the individual, a person in authority, or an organization. This can occur when a military unit is overrun forcing difficult choices to be made, medical providers having to triage care when limited resources are available, a family member is forced to decide if life sustaining treatment should continue or end for a loved one who is incapacitated, ect.
Thus, morally injurious events are traumatic; however, they are a unique type of trauma related to wounding of the Core Identity, big “S” Self, or Soul vs the body. Moral injury scars are complicated due to the deep spiritual / psychological wounding to the Self leading to emotions of confusion, uncertainty, guilt, shame, worthlessness, and self-loathing due to the wounding and betrayal of core values.
People struggling with moral injury may ask themselves:
Was I (we) justified in my (our) actions?
What did my friends die for?
Why did I survive, and they didn’t?
Did I make the right decision (s)?
What did I participate in?
Am I a good person?
Can I be forgiven?
Will my community accept me if they ever find out about what I participated in?
A study of emergency responders and combat Veterans found that morally injurious experiences were positively correlated with suicidal thoughts, behaviors, and substance use. In the exploratory model of the same study, morally injurious experiences that could be defined as atrocities of war (e.g., failed to save the life of someone in war, saw and/ or participated in the death of a child) were significantly associated with suicidality, even after controlling for the effects of PTSD.
Moral injury resulting from transgressions one committed, acts one failed to initiate or accomplish, and transgressions committed by others were positively associated with suicidal thoughts and behaviors among a sample of combat-wounded Veterans. Higher levels of overidentification with one’s perceived failings strengthened the association between moral injury and suicidal thoughts and behaviors.
Moral Injury is a very serious wound to the consciousness.
Current treatment for Moral Injury focuses on trauma informed guilt reduction (TRiGR). I think we can do better. Even the name of this type of treatment, in my opinion, sounds counterproductive. Guilt is synonymous with blame, which is why treatment attempts to improve symptoms by increasing internal feelings of forgiveness are ineffective at best and re traumatizing at worst.
When the word “forgiveness” is used, the polarity of blame will always be activated in the consciousness; and with blame will always be an electrically charged implication of wrongdoing and guilt. Let me say that again, using terms and treatments aimed at forgiveness, or guilt reduction, will always activate the polarity of blame in the subconscious and therefore will always be difficult to heal.
When it comes to Morale Injury, attempts at forgiveness will activate deeply charged feelings of guilt, thereby bypassing the grief process, and providing little to no actual relief of symptoms. In my experience and opinion, it is skipping some very important steps and ends up being just a conceptual, cognitive, intellectual mask; covering ever growing, deep internal emotions of pain, sorrow, and self-loathing.
Treatment focused on grief is a necessary part of the process. One must grieve that they were ever put in the situation in the first place. Grieve that they did not have time or support to help them make a different choice. Grieve the wrongdoing. Grieve the outcome of the choice. Grieve the loss to the other AND the Self related to the choice. Grief is a step that cannot be skipped. It is only through grief that one can expand their healing to acceptance. Acceptance is what is required to heal. Allowing the TOTALITY of ALL THE DETAILS and VARIABLES of what happened. “It happened. I cannot change that. What I can change is how I RELATE to what happened. Can I allow that I made the best choice I could at the time? Can I allow the Reality that If I could have made a different choice I would have.”
Acceptance is a mental exercise. Forgiveness is a behavior. Cognitive Behavioral Therapy (CBT), which is based in the Hermetic Principles, teaches us thoughts lead to emotions which lead to behaviors. Behavior does not come before thought. Acceptance is the mental exercise that pulls one out of emotions of pain and sorrow to clarity, peace, and calm which are the electrically charged emotions needed to initiate behaviors of forgiveness.
Mental Health is a dedication to Reality at all costs. Eventually all defense mechanisms, protectors, exiles, managers, delusions, repressions, ect dissolve into Reality when one is on the path to self-healing and self-awareness. Allowing and acceptance is the way. Allowing what is affords us to see the situation with clarity. Allowing what is provides the middle path by which the totality of the Reality can be experienced.
Below is a Tao parable that makes this point:
“A farmer and his son lived on a farm in the countryside. They owned a beautiful horse they cherished deeply. The farmer entered the horse into a village contest and won first prize along with some money.
When his neighbors gathered to congratulate him, they said enviously, “How lucky you are to have such a remarkable horse."
To the neighbor’s puzzlement, the farmer responded, “Who knows what is good or bad.”
Not long after, some thieves heard about the prize-winning horse and stole it during the night.
The neighbors came by to express their sympathy for the farmers loss and again were confused by the farmers calm response—“Who knows what is good or bad.”
The next week the spirited horse escaped from the thieves and miraculously returned to the farm—with several other spectacular wild horses. Again, the astounded neighbors commended the farmer on his incredibly good fortune, but his reaction was unchanged—“Who knows what is good or bad.”
Not long after, the farmer’s son fell off one of the horses and broke his leg. Compassionate neighbors again expressed their heartfelt sorrow.
“Who knows what is good or bad,” repeated the farmer calmly.
A short time later, the King’s army passed through town requiring all young and able-bodied men to be drafted into the War, but the farmer’s son was passed over due to his badly broken leg.
By this time, the neighbors brought some food and simply came to enjoy a meal with the farmer and his son. They expressed neither joy nor concern for the farmers current circumstances because they knew how he would respond.”
CITATIONS
Boscarino JA, Adams RE, Wingate TJ, Boscarino JJ, Urosevich TG, Hoffman SN, Kirchner HL, Figley CR, Nash WP. Impact and Risk of Moral Injury Among Deployed Veterans: Implications for Veterans and Mental Health. Front Psychiatry. 2022 Jun 6;13:899084. doi: 10.3389/fpsyt.2022.899084. PMID: 35733800; PMCID: PMC9207252.
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