Military Moral Injury Psychology Sociology

Veterans Face Traumas Beyond PTSD

Post-traumatic Stress Disorder (PTSD) has become a familiar and frequently used concept in recent years. Although PTSD is a major issue faced by our returning troops, it has become somewhat of an umbrella term we often jump to when considering psychological injuries in the military and veteran population. This article discusses the lesser-known forms of trauma affecting returning military personnel and veterans.


In the DSM-5, PTSD is conceptualized as, “exposure to actual or threatened death, serious injury or sexual violation.” This exposure then produces prolonged distressing symptoms in the individual such as nightmares, flashbacks, or hyper-vigilance. The key distinguishing factor is that PTSD is closely related to a fear response tied to the fight or flight instincts.

Moral Injury

Expanding on PTSD, moral injury focuses on trauma to the moral conscience. Two major definitions have emerged:

1) Brett Litz defines moral injury as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”

2) Jonathan Shay, in Odysseus in America, defines moral injury as stemming from the “betrayal of ‘what’s right’ in a high-stakes situation by someone who holds power.”

Here is a comparison between PTSD and moral injury symptoms as presented in a recent series on moral injury in the Huffington Post:

Huffington Post

Transitional Injury

This is a concept I’ve developed to depict the unique challenges many veterans face upon reintegrating into civilian life. In my research, I’ve found that beyond PTSD and moral injury, as described above, veterans often experience a traumatic transition to civilian life due to the cultural differences they encounter.

Canadian psychologists with the Veterans Transition Program have referred to the problem as a “reverse culture shock” (Westwood, Black, and McLean 2002). Veterans speak of losing their closely bonded “military family” upon leaving the forces and experience a sense of identity disorientation as they attempt to navigate within an unfamiliar civilian world.

From a sociological perspective, transitional trauma is a form of ‘anomie’. Anomie is a concept used by Sociologist Émile Durkheim to describe a society lacking moral regulation. An anomic society lacks the moral signposts that guide individuals throughout their life-course, leaving them without direction to pursue collective goals. In this sense, it is closely tied to moral injury. Rather than alienation resulting from an individual committing a moral offence resulting in self-blame, alienation results when the individual cannot reintegrate into a relatively loosely regulated society that doesn’t provide the same clear sense of purpose and boundaries found in the military.

Sanctuary Trauma

A concept developed by Dr. Steven Silver, sanctuary trauma “occurs when an individual who suffered a severe stressor next encounters what was expected to be a supportive and protective environment’ and discovers only more trauma.” Although this concept is under-recognized, a Canadian veteran has been advocating for its current relevance.

Bruce Moncur wrote a recent article in the Huffington Post expressing that fighting veteran affairs is like fighting the Taliban. He attributes at least half of his trauma to navigating the vicissitudes of veteran affairs. Sanctuary trauma comes from a feeling of abandonment, the feeling that one was merely used and thrown away when becoming injured. As stated in my post on Canada’s ‘sacred obligation’ to veterans, this was reinforced by the meeting with Veteran Affairs Minister, Julian Fantino, that went “off the rails.”

In Brief

Veterans experience forms of trauma beyond PTSD. New labels allow researchers and mental health practitioners to more accurately pinpoint the source of the issue. By knowing the source of the issue, better solutions can be provided.

Treatments for PTSD may include forms of cognitive behavioral therapy. Treatments for moral injury may include existential/ spiritual counseling. Solutions for transitional trauma may be sought in group therapy, programs that teach entrepreneurial skills, or occupational groups that provide individuals with a new sense of mission. As for sanctuary trauma, the solution is ensuring returning veterans feel they are cared for upon their return.

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  1. Wow Steve this blog is what I been telling my shrink is one of the biggest problem we encounter when we come back from war. The system that is suppose to be there for us is not. I toll her we come back from a war to a new war but in this new war we don’t get to shoot back.

  2. I am a fifty-eight-year-old seminary student about to write a thesis on moral injury. After that, I will do a D.Min. and write another thesis on moral injury. Moral injury has the hallmarks of a spiritual problem. PTSD is a problem that medical professionals can help. Moral injury is outside their strict view of therapy and medication. I wish to spend the rest of my life working to educate the public, clergy, employers, and town mayors on the issue of moral injury. In some way, we must begin to cut the suicide rate.

    I would love to talk to anyone that wishes to write to me. steve40004 at gmail dot com

  3. Thank you for taking to time to read my posts and follow my blog. I really appreciate it. I love seeing my fellow veterans express themselves in more ways then grunts, acronyms, and catch phrases (not that there is anything wrong with that, as I catch myself spouting random moto-speak as well). I also really appreciate the views on what’s it’s actually like for us over there, when we come back, and the like. I hope you don’t mind, but just in case any of your followers want to check out my ramblings I’m going to drop my link below. Stay sage out there gents and ladies.

  4. I’ve been studying PTSD and TBI for nearly 10 years and I’m still learning. My husband is a combat veteran and seeing it first hand and what it can do to people is a learning experience.

  5. Like many conditions in medical science, as time goes by, we hear that there are various subtle differences, such as with dementia and autism. So, what was referred to as “shell shock” in WWII and before, is now becoming better understood–and, no doubt, that understanding will also evolve over time.

  6. “Sanctuary trauma” seems to describe what many women endure after escaping from violent partners or surviving rape: dealing with law enforcement and the court system can be infuriating, traumatic, and even abusive. Do you think there’s a similarity here?

  7. Of course the best solution is prevention. That our so-called “leaders” continue to “lead” soldiers into traps like Vietnam and the Mid-East wars, is an enormous betrayal, not only of supposed American ideals, but of both citizen and soldiers’ trust. Then the VA betrays yet again by treating PTSD victims like garbage.

    A great deal of injustice is done because of authority figures’ abuse of power. Experiments have shown that people are more likely to commit acts they know are wrong, if those actions are ordered or sanctioned by an authority figure. Then, there’s the peer pressure, or the pure terror of being in a kill-or-be-killed situation.

    How many vets have told me, “I want to support the troops, but I think the war is wrong?” Too many to count. I wish those who have “been-there-done-that” would take a stronger stand against these stupid wars, for everyone’s mental health.

  8. It’s not that we aren’t aware it’s just that the public are too scared to delve and question what happens to our veterans. We make the governments therefore we all need to accept the issues and not pretend to be kept in the dark. We must demand for new measures to help our heroes who are doing their jobs without questions. We must ask
    The questions and force the right answers.

  9. Steve, thanks for another enlightening article on the struggles veterans face on returning to civilian life after war. We are destroying the lives of decent men and women – and their families – with our endless wars 😦

  10. I wish I could like this a thousand times. This is the research that needs to be posted in every newspaper in America. It’s criminal what’s being done to our veterans. Thank you for this post. I may come off as angry in this comment, however, I’m humbled and speaking from a place of gratitude.

  11. I quite like the idea of ‘moral injury’ but I’m not sure it fits very well into the box that administrators use to assess injury or trauma. Let’s face it, costs are kept down by trying to make it as difficult and painful as possible to claim anything. What’s not to like about diagnosing it as a moral problem. See a priest. Get guidance. Do not pass go until you’ve got a recognisable disease with physiological markers. As Durkheim pointed out anomie and an increase in suicide are related. No surprise there. And no surprise administrators are screwing veterans. That’s their job. Cut cost. Or you’ll be cut off too.

  12. For those who’d experienced PTSD, not just in war, they would need to go through catharsis, and it’s a very hard process to get through, especially when the person is in the midst of the breakdowns, because the person can’t see the light at the end of the tunnel, but so long as the individual keeps on working on healing up from the traumas s/he endured through, then, PTSD can be overcome, for the veterans, as well as everybody else, but this is a very long and winding process.

  13. I have multiple clients for therapy who experience moral injury following extended time spent in prison and doing things (gang initiation, etc) that is directly opposed to their moral beliefs. It generally overlaps with their PTSD symptoms from the traumatic acts themselves, like you noted.
    This was well-written and thought-provoking. Thank you!

  14. It seems to me that what you describe as transitional injury might also fit the transitions that survivors of clerical sexual abuse struggle with (coming to terms with life post-church and for some, post-faith); of course for many compounded with a form of sanctuary trauma.

    Do you know if anyone has looked at the idea of transition injury in that context?

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