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PTSD: National Center for PTSD

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Spirituality Morality


Clergy Toolkit


Morality and Moral Injury

Morality is by nature social. In other words, morality functions to help communities of people stay connected. However, the powerful emotions that people may have as a result of painful events or actions can lead to alienation from others. Painful emotions such as guilt, shame, or contempt (among others) can motivate individuals either to restore broken relationships or to withdraw from their social group. In contrast, positive emotions such as compassion or gratitude function as enhancers of social connections.
In recent years, especially in the context of war, the term "moral injury" has been introduced to identify traumatic experiences that go beyond fear and life threat to include such alienation. Moral injury has been defined as, "[p]erpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations"19. Moral injuries may stem from direct participation in acts of combat, such as killing or harming others, or indirect acts, such as witnessing death or dying, failing to prevent immoral acts of others, or giving or receiving orders that are perceived as gross moral violations20.

A wartime example would be that of a Service member stationed at a checkpoint, monitoring vehicles for weapons and insurgents. Signs are posted for vehicles to stop. A vehicle approaches the checkpoint moving too rapidly, ignoring warning signs. The Service member must make a quick decision as to how to respond that is consistent with rules of engagement. Moral values may include protecting the innocent, as well as supporting one's peers. In the ambiguity of the situation (not knowing the driver's intent) and the need to respond quickly (stop vehicle lest it get too close and explode), Service members must choose how to respond. Moral injury may occur when the outcome of this difficult choice is negative.

Moral injury is not a psychiatric disorder but has many overlapping features of PTSD. An act of transgression is necessary for moral injury, but not for PTSD. Furthermore, a diagnosis of PTSD does not sufficiently capture the experience of moral injury. Consequently, it is important for a mental health provider to assess mental health symptoms and moral injury as separate manifestations of war trauma to form a comprehensive clinical picture, and provide the most relevant treatment. Clergy members can encourage the affected Service member or Veteran to seek out mental health services. Evidence-based treatments for PTSD (e.g., CPT, PE) are helpful if PTSD and moral injury are co-occurring, but may not be sufficient. Interventions specific to moral injury are currently being evaluated.

For more information on moral injury, read the titles below.

Can Killing Cause Moral Injury?

In recent years the psychological and spiritual cost of killing has begun to be documented21,22. One study examined a large sample of Veterans receiving VA PTSD services23. The study found that two elements of trauma exposure (i.e., loss of a buddy, and killing someone) were associated with increased guilt and loss of religious faith. This study also found that guilt and loss of faith were associated with greater utilization of VA mental health services. In fact, these variables accounted for more variance in the use of services than did the overall severity of patients' PTSD symptoms23.

Although killing may be a precursor to moral injury, it is important to note that not all killing in war results in adverse outcomes for military personnel. For example, a military member who kills an enemy combatant in self-defense may perceive that the death was justified. However, if a civilian was believed to be armed and consequently killed, with military personnel later discovering that the individual was in fact unarmed, this may set the stage for the development of a moral injury.

Clergy Response to Moral Injury

Values are beliefs about what is important in life. Personal values are shaped by our family and friends, by observation, and by our life experiences. Religious and spiritual traditions can also help shape the values of many people. When the way we are living is consistent with our values, we generally perceive life as good and may experience satisfaction and contentment. Trauma survivors, however, might have engaged in behaviors inconsistent with their value system during traumatic events in order to survive. For example, a combat Marine might have had to kill someone in self-defense. Trauma survivors may also have failed to uphold their values, for example, by witnessing an assault and not intervening. These types of traumatic events could result in moral injury.

Clergy members can help Service members or Veterans begin to live in ways that express their deepest values by helping them identify the important value that underlies moral tension. Once a value is identified, an individual can choose to live that value in the present moment.

PTSD Information Voice Mail: (802) 296-6300
Also see: VA Mental Health