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Moral Injury: A Primer

by Caleb Miller

Military professionals are relatively familiar with general mental health and PTSD; a newer concept, “moral injury,” has been growing in popularity for the past few decades among top leaders, counselors, psychologists and chaplains. Since the month of May is Mental Health Awareness Month and June is PTSD Awareness Month, I would like to highlight the concept of moral injury as it has emerged in the military lexicon by answering three questions.

What is it? Why does it matter? How can we address it?

The short answers:

  • Moral injury is a violation of deeply held values and ideals in high stakes situations. It results in profound distrust of others (particularly leaders) and overwhelming feelings of guilt and shame.
  • Moral injury matters because it affects a substantial majority of the military population whether they realize it or not.  
  • Addressing moral injury as an organization requires honest self-assessment, patience, and an intentional, multi-disciplinary approach. Effective recovery takes a long time and often a second opinion.

A disclaimer in what follows: these are the impressions of a battalion chaplain who scoured the From the Green Notebook archives to see only a few mentions of moral injury. I do not write as an expert on the subject, but rather as someone with a practical sense of the basic trends and best practices.  

I write with the hope that those who may someday serve or lead in extremis can be better prepared for moral injury and go into the worst moments of their lives with clearer, realistic expectations – and in the meantime consider painful realities and moral dilemmas closer to life in garrison or at home.

I also write with the hope that those who are still trying to make sense of something they did or witnessed  – but who seem to be hitting a dead-end with one form of counseling or treatment – may yet find a breakthrough with another approach.

What Moral Injury Is… and Isn’t

Moral injury is a new way to differentiate and describe an old phenomenon: a violation of deeply held values and ideals in high stakes situations, resulting in profound distrust of others and overwhelming feelings of guilt and shame. Parallel descriptions exist as far back as Greek tragedies (Odysseus and Achilles) and biblical narratives (the concept of “sin”).

The theory behind moral injury is perhaps contentious but can be demonstrated time and again in a simple proposition: every human being possesses deeply held beliefs about right and wrong.

Moral injury is sometimes confused with PTSD or forms of depression. These disorders are often linked and produce similar behaviors (whether in the form of withdrawal or outbursts of anger), but they are not the same. PTSD shows up in a person’s experience as a reflexive response to stimuli. Depression manifests as a season of mental pain or emotional turmoil. Moral injury shows up in a person’s life as sorrowful regret or a crisis of faith – a sense of shortcoming or compromise that outstrips our ability to cope.

Stated another way: where PTSD continually threatens a sense of safety or agency, and depression continually threatens a sense of hope or purpose, moral injury continually threatens a sense of trust and honor. PTSD is closely linked with anxiety. Depression results in a feeling of emptiness or dread. Moral injury is tied to cynicism.

We can inflict moral injury upon ourselves, or others can inflict it upon us. It can result from an act, an event we witnessed, or something we were told to do by an authority figure. Dr. Jonathan Shay, who coined the term after working with veterans of Vietnam, observed that moral injury often causes us to adopt a hostile posture toward others; we begin to expect nothing but, “harm, exploitation, and humiliation.” Anyone in this category sees only retaliatory options: “strike first; withdraw and isolate oneself from others… create deceptions, distractions, false identities, and narratives to spoil the aim of what is expected.”

Why Moral Injury Matters

As with any buzzword, temptation persists to turn moral injury into the latest explanation for anything and everything. 

We should be careful. 

The link between moral injury and suicide or toxic leadership is not firmly established. It is easy to think of ways moral injury would contribute to those problems, and a correlation is almost certainly there, but correlation does not equal causation. Experts are divided.

Even so, moral injury is pervasive. I do not believe it is a stretch to say that all those who have enlisted or commissioned in the armed forces will encounter it in some form. Combat veterans often experience it in their reflections on the darkest days of deployment, but many who never go OCONUS will encounter it as well. “High stakes situations” includes all sorts of scenarios: discipline issues, sexual harrassment and assault, arrests, scandals, rumors – failures real or perceived. Those in the Guard or Reserve components should keep in mind that first responders, law enforcement, hospital/prison staff, and social workers often find themselves susceptible to moral injury, too.

As leaders increase in rank and responsibility, the high stakes situations increase and the risk of moral injury increases. 

Understanding and addressing moral injury is also important due to its relationship with veterans of Vietnam, Operation Enduring Freedom (OEF), and Operation Iraqi Freedom (OIF) – operations that proved to be protracted and without clear purpose. Wars echo the conflicts that came before, if for no other reason than the leaders who served in prior conflicts have been promoted as the subsequent conflict breaks out. If history is any indication, any future conflicts will be led by veterans of Afghanistan and Iraq at the highest levels.

Addressing Moral Injury

When considering how to address moral injury in a military setting, a by-phase approach is useful: before and after. [Since addressing moral injury during a high-stakes situation is next to impossible (prevention will depend on this preparation, and recovery will depend on how the injury is handled in the aftermath), I will focus on before and after.]

First, to address moral injury before it occurs requires prolonged preparation. The act of preparation at the individual level is as hard, perhaps even harder, than any attempt at recovery – it is aimed at an unknowable future, rather than a concrete experience or decision. Preparation requires serious consideration of the fact that all wars, even the most justifiable and noble, include utterly painful realities like the deaths of children or the effects of war and tragedy upon fragile people; the violation of firmly held ideals in complex situations; countless failures to act in the heat of the moment.

In previous years it was trendy to present leaders with case studies of varying complexity to instill an ethical decision-making process. These are of great value, but not as a directly preventative measure against moral injury. They do not really allow personnel to train as they fight. In high stakes situations, time and detailed information is usually scarce.

What may be of more use is to focus on forming habits, paying closer attention to the moral decisions we make every single day, often without even a second thought. Some diagnostic questions for all of us:

  • What are my deeply held beliefs about right and wrong?
  • How do my day-to-day actions line up with those deeply held beliefs?
  • Are there any orders which, if I were asked to perform them, would violate my beliefs?

Some further diagnostic questions for leaders:

  • What are the deeply held moral impulses of those in my organization?
  • Do I incorporate moral principles into my decisions? Or do I thoughtlessly filter simple matters through convenience, and complex matters through legality?
  • If my own deeply held beliefs about right and wrong were different, would my leadership practices change in any meaningful way?

These questions, if answered honestly and thoroughly, are uncomfortable because they touch on an easily-ignored aspect of readiness. But the discomfort is nothing compared with the ugliness and pain that may result from leaving them unexamined until they are tested to the point of breaking.

After a morally injurious event has occurred, a deep sense of regret and betrayal sets in, culminating in cynicism that any resolution exists. For leaders on the lookout for sources of help, I have found some success in triaging along the lines of these categories: grief, shame, guilt, and comorbidity.

First, there are those grieving. Nearly all need to feel heard, and for some this quest to be known to another individual will eventually be enough. These individuals have usually witnessed something that violates their conscience but were not directly involved. They need to be allowed space to mourn and process – not in some flippant way, but in a way that truly seeks to understand the complexity and pain involved in the experience. Here counselors gifted with helping patients through grief will be most effective.

Next, there is shame. These individuals need assistance regaining the hope that they will ever trust any peers or leaders again. The moral injury resulted from the decisions and acts of others, and they are personally invested in the aftermath. Some have consciences which have been seared by betrayal at the deepest level. For these cases, because of the need to restore trust, I have seen the most success with a Marriage and Family Life Counselor (MFLC) or some form of group therapy, where servicemembers hear from others who feel similarly betrayed in a controlled setting.

Then there is guilt, on display in those who search for a form of reconciliation, absolution, or atonement. These individuals can pinpoint exactly what they regret. Perhaps once they have killed another human being they have mentally placed themselves in another category. Perhaps they blame themselves for something they could have only indirectly controlled. In these situations, I have seen the most success with faith-based counseling or talking with a chaplain – even for those who do not consider themselves particularly spiritual or religious.

Finally, there are those experiencing moral injury alongside another condition like depression or PTSD. Individuals in this category are best served by seeking out clinical psychiatrists and psychologists who can prescribe medication.

Are there other ways to parse out and triage moral injury? Absolutely. This is “a way,” not “the way” – scribbles in the proverbial green notebook, not a peer-reviewed article. But it is presented to highlight a problem set and demonstrate the multi-disciplinary aspect.

In conclusion, moral injury is distinguishable from yet intimately connected with other sources of mental pain and emotional turmoil plaguing service members and veterans. It is important for leaders to be on the lookout for this phenomenon throughout their organization, but particularly with combat veterans. Finally, though the challenges associated with moral injury are considerable, there are many interrelated resources available for short and long-term support – aimed not just at coping, but healing.

For more information:

Moral Injury – PTSD: National Center for PTSD (va.gov)

The Shay Moral Injury Center, Moral Injury | Volunteers of America (voa.org)

CH (CPT) Caleb Miller is currently a student at the Chaplain Captains Career Course at the U.S. Army Institute for Religious Leadership, Fort Jackson, South Carolina. He has previously served as the chaplain for the 100th Brigade Support Battalion, Fort Sill, Oklahoma, and the 10th Psychological Operations Battalion, 7th Psychological Operations Group, Jefferson Barracks, Missouri. 

The views expressed are the author’s own and do not reflect the official position of the US. Army Chaplain Corps, the Department of the Army, or the Department of Defense.

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