Moral Injury

What is Moral Injury?

130609-M-HF949-001“… I started thinking God hates me… I’m not religious or anything, but I felt like there was this hate for me…” – Sergeant Brendan O’Byrne on life after deployment

A new invisible injury is grabbing the attention of military psychologists. The concept of ‘moral injury’ is gaining traction in recent academic literature surrounding the mental health of combat veterans. In his clinical experience with veterans, psychologist Jonathan Shay discovered that Post-traumatic Stress Disorder (PTSD) could not account for all the symptoms veterans presented him with.

In the DSM-5, PTSD is conceptualized as a fear response resulting from the perceived threat of death or serious injury. Rather than a fear response, the concept of moral injury illuminates the importance of guilt and shame. Although many of their symptoms overlap, moral injury is distinct since it results from what a person has done, rather than something that has been done to a person. Litz (2009) defines moral injury as, “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”

While PTSD is an anxiety disorder triggered by an instinctual fight or flight response, Moral injury deals with the uniquely human capacity of moral conscience. As Charles Darwin said:

“I fully … subscribe to the judgment of those writers who maintain that of all the differences between man and the lower animals the moral sense or conscience is by far the most important.”

For example, dogs and humans may both develop an anxious response to repeated nearby bomb explosions. When confronted with actual bombs, this is a useful survival strategy. But if the response continues when the actual threat is removed, this is anxiety (e.g. a slamming door may trigger the fight or flight response). This is how PTSD works at its basic level. It has actually been reported that deployed military dogs also suffer from PTSD: Military Dogs Suffer From PTSD

Human intellectual capacity for ethical reflection, and our placement in cultural belief systems complicate the simple fight or flight response. Moral injury is unique to humans because it is characterized by deep internal conflict, threatening to overthrow one’s sense of identity and communal belonging. Guilt and shame drive the person with moral injury toward isolation, making them feel unworthy of pleasure and perhaps even self-sabotaging or engaging in self-harm. This makes moral injury an empirically dangerous affliction, particularly in terms of suicide risk.

While PTSD can be characterized as an overactive fight or flight response, moral injury is a profound internal conflict. For a powerful narrative illustration of moral injury, see the Public Insight Network.


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