Shirah Vollmer MD

The Musings of Dr. Vollmer

Moral Injury

Posted by Dr. Vollmer on May 20, 2013


Moral injury, a concept implying that one’s behavior goes against one’s morals, both individually and collectively. Behavior in one setting. like murder, is considered evil, but in the context of war, taking a life, is understood in a different way, and yet, it brings up the possibility of profound guilt, which, in my mind, is almost identical to moral injury. The idea that one can feel good about a behavior in the moment, but upon reflection, can have crippling regret, is the power of the human psyche to re-evaluate one’s actions with superego ideals, leading to despair, with the challenge of subsequent forgiveness. Suicides are high in our post Iraq and Afghanistan veterans, and so it is possible, but not proven, that this high rate of self-destruction, is due, at least in part, to a particular crisis in moral injury. Perhaps the behaviors of our returning soldiers, in retrospect, is too painful for words, too outside the concept of forgiveness. So, the question is whether the term “moral injury” furthers our understanding of these veterans, or whether it is redundant, given our established diagnosis of PTSD. I think “moral injury” focuses on guilt, whereas PTSD focuses on hyperarousal. Both are key components to the disabling psychological trauma which many of these veterans experience. “Moral injury” adds on to the multifaceted way in which those who have gone through an experience, so outside of mundane human activity, are left with a mind filled with confusion and anxiety. Understanding this suffering, perhaps by crystallizing a part of it under the term “moral injury” is one step further to helping those who suffer alone, join a community of empathic souls.

7 Responses to “Moral Injury”

  1. Shelly said

    Awesome. But where exactly do you place those people who looted from stores during the LA riots? Do we give them therapy because they feel guilty for what they did, or arrest them? Did they suffer from PTSD or moral injury?

    • Moral injury is about guilt, either at the time, or in retrospect, whereas PTSD is about hyperarousal. The looters mental state is what is in question. One would have to interview them to determine their symptoms, if any, after the looting episode to see whether PTSD and/or moral injury was relevant to them. Breaking the law requires consequences, but human suffering can be addressed by psychotherapy and psychopharmacology. This is not an either/or proposition. Thanks.

  2. Eli said

    Thanks Dr, Vollmer, for the clarification between the hyper-arousal that belong predominately to PTSD, and the guilt and regret that belong to Moral injury. I am actually treating a patient in a clinic with a veteran.The guilt and moral injury consumes him daily and he basically uses mania and obsessional thinking as a defense against the the ingrained guilt that he suffers from. the guilt basically disabled this patient completed he was diagnosed with schizophrenia paranoia type. I’m wondering what your thoughts are as regard to psychotherapy on such a patient?

    • Hi Eli- my first thought is to question the diagnosis of paranoid schizophrenia. Guilt and trauma can create psychosis but this is not the same as schizophrenia. Working with him in psychotherapy can clarify this issue. Thanks for participating in this discussion.

  3. Ashana M said

    I think sometimes we feel guilty when we have actually done wrong and other times when guilt allows us to avoid confronting our helplessness. It is sometimes less terrifying to believe we had control but made the wrong choices than to recognize that we had no control in situations of life or death. Our fragility and mortality as human beings is more than most people are able to honestly accept. When we choose to feel guilt for other than real moral reasons, we are remarkably good at confabulating a supporting structure of evidence to convict ourselves of our imaginary wrong.

    Unless our war veterans really were involved in carrying out war crimes, I doubt very much there is real moral injury involved in veterans’ feelings of guilt. I would guess it is mostly a guilt borne out of avoiding powerlessness. PTSD isn’t just about hyperarousal, but about learning. The new knowledge embedded in trauma that needs to be accepted and understood involves our real powerlessness. It sometimes also involves accepting the maliciousness and harm human beings are capable of.

    • Hi Ashana,
      Thank you for your comments. I do think that the particulars of a war time situation creates a mental state, in some, that is troubling in a way which is hard to articulate. Moral injury gives them a language to explain themselves. I am not sure people “choose” guilt, but I suppose you mean this is an unconscious choice. Thanks again.

      • Ashana M said

        It would probably be more accurate to say it’s the result of automatic processing and relies on a heuristic that favors acknowledging evidence that supports existing beliefs rather than evidence that creates cognitive dissonance. So, rather than revise a belief about the limits of one’s own power and durability to better accommodate the facts, there is a tendency in traumatized individuals to see evidence of moral wrong-doing when there may not really be any. I’m sure wartime has its own unique features, but it seems that nearly everyone with significant trauma symptoms feels guilty. Sometimes there is real moral wrong-doing involved, but more often there isn’t.

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