“Moral injury” and those darn peer approaches

moral injury venn

On Being picks up on a fascinating framing of PTSD from an episode of Religion and Ethics Newsweekly:

I really don’t like the term ‘PTSD,’” Department of Veterans Affairs psychiatrist Dr. Jonathan Shay told PBS’ “Religion & Ethics Newsweekly” in 2010. “He says the diagnostic definition of “post-traumatic stress disorder” is a fine description of certain instinctual survival skills that persist into everyday life after a person has been in mortal danger — but the definition doesn’t address the entirety of a person’s injury after the trauma of war. “I view the persistence into civilian life after battle,” he says, “… as the simple or primary injury.”

Dr. Shay has his own name for the thing the clinical definition of PTSD leaves out. He calls it “moral injury” — and the term is catching on with both the VA and the Department of Defense.

We’re turning our attention to this idea of moral injury and the limits of the PTSD diagnosis to explore what happens to a person who has experienced combat.

There are no clean lines separating PTSD from moral injury (which is not a diagnosis) — there is no Venn Diagram, as with PTSD and traumatic brain injury but Dr. Shay explains a fundamental difference by using a shrapnel wound as an analogy.

“Whether it breaks the bone or not,” he says, “that wound is the uncomplicated — or primary — injury. That doesn’t kill the soldier; what kills him are the complications — infection or hemorrhage.”

Post-traumatic stress disorder, Dr. Shay explains, is the primary injury, the “uncomplicated injury.” Moral injury is the infection; it’s the hemorrhaging.

PTSD in service members is often tied to being the target of an attack — or being close in relationship or proximity to that target.

Moral injury, Dr. Shay says, can happen when “there is a betrayal of what’s right by someone who holds legitimate authority in a high-stakes situation.”

That person who’s betraying “what’s right” could be a superior — or that person could be you. Maybe it’s that you killed somebody or were ordered to kill. Or maybe it was something tragic that you could have stopped, but didn’t. Guilt and shame are at the center of moral injury. And, as Dr. Shay describes it, so is a shrinking of what he calls “the moral and social horizon.” When a person’s moral horizon shrinks, he says, so do a person’s ideals and attachments and ambitions.

This contains echos of their recently re-aired Bessel van der Kolk interview (on trauma not being a cognitive experience):

This is not about something you think or something you figure out. This is about your body, your organism, having been reset to interpret the world as a terrifying place and yourself as being unsafe. And it has nothing to do with cognition, with, you know, you can say to people, “You shouldn’t feel that way” or “You’re not a bad person” or “It wasn’t your fault.” And people say, “I know that, but I feel that it is.”

It was very striking in our yoga study because we see yoga as one important thing that helps people who’ve been traumatized because they get back into their bodies. How hard it was for people to even during the most blissful part of the yoga practice called Shavasana, what a hard time traumatized people had at that moment to just feel relaxed and safe and feel totally enveloped with goodness, how the sense of goodness and safety disappears out of your body basically.

Addiction treatment catches a lot of grief because it’s not “medical enough” and relies on these goofy groups of fellow alcoholics. What’s Dr. Shay’s prescription for recovery from PTSD?

The On Being post notes that Shay believes the treatment of moral injury happens in the community:

Peers are the key to recovery — I can’t emphasize that enough. Credentialed mental health professionals like me have no place in center stage. It’s the veterans themselves, healing each other, that belong at center stage. We are stagehands — get the lights on, sweep out the gum wrappers, count the chairs, make sure it’s a safe and warm enough place…

4 thoughts on ““Moral injury” and those darn peer approaches

  1. I like how the graphic breaks down the symptoms to specific cognitive injuries. I feel by the seperating of the two, interventions would have a better success ratio. Because the individual receives the care that’s needed.

    I think there’s more to moral injury than just a “betrayel of what’s right,” though. Some veteran’s carry “Survivor’s Guilt,” by just living through the reality of war and returning home. While volunteering at the V.A. during hot steamy high humidity days, the weather was triggering memories/flashbacks of combat decades in the past. Depression due to living through an incomprehensible survival while their buddy returned in a body bag, was shared with me on the oncology ward.


      1. Thanks for the Shattered Assumptions insight. Thinking back on the conversations I had the Shattered Assumptions Theory could a possibility of what those vets were living with for decades. Their resiliency is amazing. I want to know how they did it for that length of time.


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