“A Stain on the Soul”: Why Moral Injury Requires A Different Treatment Plan Than PTSD
with Bessel van der Kolk, MD; Judith Herman, MD; Rachel Yehuda, PhD; Ruth Lanius, MD, PhD; Matt Gray, PhD; Wyatt Evans, PhD; Bill Nash, MD; Megan Schmidt, PsyD; Ruth Buczynski, PhD
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Vasisi and how mtoaddreesery useful In PTSD we mare mbale tomdealm with Guilt which is not guilt-i.e. not intended.
Aprticuylarly with vets- moralmshame haslongmbeen recognised-how to recognise itduring conversaM.D tion with a client and what to do about is useful indeed. Thanks David Muss
Thank you. I have been dealing with two clients with moral injury and it is difficult to find information on it outside of military context. I also would love the contacts of presenters in this workshop.
fullerclare@gmail.com
Thank You, a great presentation and raising of my awareness of this topic. It will help me in my work and contact with resistors of child abuse.
Thank you for making these modules open to non/practioneers. One of the best today.
How can a significant other find a therapist who has worked with Moral Injury for military Special Operations personnel?
Very helpful!!!
Is there any way to get the contact information for Dr’s Gray, Evans, and Nash?
I would like to refer someone for therapy to deal with moral injury but this man can’t find any therapist willing to work with him because he has been defamed enormously in online media and even therapists believe he is somehow a “bad” person and won’t work with him. Do you have a suggestions for how to find a therapist?
thank you!
Donna Dryer, MD
ddryer@orenda.org
An IFS therapist, I’m sure, will consider working with him. I would take your inquiry to the IFS institute and ask for a referral.
Today’s takeaway is that helping the community zooms out from helping oneself and back in again. After career playing defense in corporate relations, now working in areas that help others heal, through creativity and through community engagement in reconciliation processes, from local to international circles. This series helps lived story to be foundation to inform potential for others, while extending hope that still struggling with intense personal reactivity decades later can be seen as personal MI beyond PTSD. Covid meant 2 years of virtual visit thought therapy instead of EMDR as initially sought, will return to seek somatic options then apply to workplace, global, family and beyond. Much appreciated.
There was nothing said about the moral injury of health workers who were told to follow the rules about COVID and the injection. The first rule of medicine is “Do no harm”. So many in the medical field were told to do things that were not in alignment with their moral code. It was all off limits and even discussing it seems to be off limits. Many got the shot to keep their jobs, advised and gave the shot to their patients, or quit and had to face a difficult future. This is very much a moral injury. My husband is a physician. He was lucky to be on the verge of retirement, but I can see the injury that it has done to him.
Excellent presentation. This module was very helpful in understanding the differences between PTSD and moral injury. I’m sure the methods to assist clients will be useful.
Your presentations are wonderful, and they make eminent sense to me. I value the correlation with brain physiology and the positive effects you’ve experienced with patients. My question is, what has been the scientific validation of these approaches in terms of randomized controlled trials. Or if felt to be unethical to do that, what comparisons can be made between these new strategies and older ones. In what percentage of these cases are patients able to lead normal lives, however you define that. I believe you are at the forefront of how to improve human interaction, not just in those who have been traumatized at times during their lives, but for those of us who sort these things out for ourselves to lesser levels all the time. In the future, these are skills we should equip our children with from very early on, when the right brain emotional regulation network is being formed. But how to get that knowledge to the parents and caretakers of those children to form those bonds of trust. If that emotional regul
Thank you. The information from Matt Gray, Wyatt Evans, Bill Nash was new to me and educational. The clients my organization seeks to help often experience “moral injury” regarding what Matt refers to as “lethality.” This relates to decisions they made about situations that society does not recognize as moral pain or injury. Therefore, they are deprived of opportunities for recognition and healing. I will try to share with my colleagues that as counselors we need to be informed about this dimension of recovery needed.
I appreciate the idea that making amends (e.g. symbolically) can be one of the key parts to aiding healing from moral injury. Speaking as a registered nurse, thank you.
Thank you so much for this series of latest insights. I especially liked the systemic and thereby community aspects of Moral Injury and that you make it much broader than “just” in Military activities. I had found that myself, and applied that insight in coaching women. The validation of my insight from your institute is very helpful. I found it very helpful the distinctions that you made especially about the accuracy of the experiences of guilt, in people who experienced moral injury by their own acts, and that in fact, their experiences of guilt IS a sign that their moral identity is still alive and intact. I see Moral injury in regard to Mothers for instance who flee a violent relationship and have to leave their kids behind, while they fear femicide; or doctors and nurses who have injected so many people with the Covid vaccines as being safe, without informed consent and are now faced with all these scientific research that reveals excess death by myocarditis and other injuries through the “vaccines”. I also have a deeper understanding now, of moral injury, and why so many officials are afraid to step forward and discuss immoral policies and actions in their institutions. I think that we might consider that experiences of moral injury too, working in an organization, being aware of crimes committed to innocent people and fraud committed, yet not being able to address it or leave the organization, as your colleague who works for the UN mentioned, their first moral obligation is with their family. Which can lead to a huge crisis in consciousness. In my coaching, I always bring the broader cultural context to the table for my clients, and this class has deepened my understanding of the cultural aspects of moral injury and new insights into questions to ask and different approaches to the coaching journey. Thank you so much.
Excellent presentation! I appreciate the distinction between moral injury and PTSD, as well as other variations of trauma. I also appreciate the differences noted between combat-related trauma and that experienced in fields of health-care, and even education. I would also like to see addressed, the moral injury that arises from deeply embedded religious/ spiritual beliefs and cultural upbringing. Guilt and shame are two powerful dynamics that influence the pursuit of mental health and wellness.
This I took away from this session about moral injury:
Evoke the experience of that emotion, allow the person to experience the pain during a session. So what about trying to spread that emotion through self-touch throughout the body?
Social presence, connection, compassion – the importance of this in community healing
Practical interventions – to let the person explore certain actions like hugs or symbolic amends-making
Not to try to reason things out, expecially in the beginning.
Anger that comes from lack of acknowledgement of the persistence of anguish surrounding moral injury
I appreciate how persons expressed themselves- based on infotmation they got here by summarizing key concepts from the presentation. Thanks much for sharing your various take aways. They were helpful
My greatest take away from this session was the comparison made between PTSD and Moral Injury. This explanation helped to clarify my thoughts on how we tend to treat clients with PTSD; instead of exploring the facts that it could be something else; like moral injury.
I sincerely found meaning when the areas of focus for dealing with someone with moral injury were mentioned: Attachment, relationship, trust, identity etc. I strongly believe too that community approaches will help clients a lot- it was also mentioned that creating a moral community would be effective.
Before watching this video I never saw the negative effects on Health workers- they too can face moral injury.
Thanks much for giving me the opportunity to share in this informative course.
Reneé Mair
I appreciate this in depth, thoughtful discussion. I work more in evaluation (data collection) and organizational consulting services within traumatized youth & caregiver” Soul work” in all it forms, I think is what you’re describing, and it’s so valuable for individuals, not only who feel moral injury, or been on the receiving end of it, but also for those who are researchers and non-clinicians. Thank you for the program.
This segment was particularly helpful for me as I’m dealing with a client who is experiencing significant moral injury. This directed me toward more appropriate interventions and validated the direction I’m headed. Until this training, I had never heard the term moral injury so it also provided a framework for her treatment.
Thank you for making a distinction between guilt/shame and moral injury!! This was very insightful.
Thank you for an interesting presentation. I was struck by the idea of a person affected by MI finding some healing in preventing harm to others in some way – eg teaching young people about drinking and driving..
I loved the idea to specify the core values, that helpsthe patient to recognize himself and have selfesteem .
Also the givng back to community, restore the balance .
Thank you for making a distinction between guilt/shame and moral injury. What you did with this video IMHO was begin to teach the blind all the differences they found when experiencing an elephant [an old joke had one blind person at the elephant’s head discover the trunk and describe it as “very like a hose,” and the next blind person describe the leg as “very like a tree trunk,” et cetera. I believe there were five “blind takes” on what an elephant is actually like. Being sympathetic to blind folks’ developing understanding of what’s around them IS COMMENDABLE but HAS to end with NOT ONE of those great “takes” got the ESSENCE of the elephant. For me, the SMELL of elephant poop [invisible and ineffable] is the very definition of a “circus” WITH elephants! Things can still be missing without inclusion of SENSES that are not always 20/20 if sight [some blind people have “light” or “parts of the visible spectrum”] or within certain megaherz if sound, etc. === don’t want to go on and on, just make the point that no matter HOW HARD WE TRY, we’re only “improving on whatever we START with. We’ll likely NEVER really finish describing an elephant! In the joke, the TAIL of the elephant was the END discovery. I bet little kid blind folks would discover the SMELL under the tail or SLT. Kids are fearless, lol!
Very much with you Bec when you say, I believe, also applicable in a more general sense, ‘Being sympathetic to blind folks’ developing understanding of what’s around them IS COMMENDABLE but HAS to end with NOT ONE of those great “takes” got the ESSENCE of the elephant.’ The bigger picture and the wider context, if one is aware of, can add dimensions to our impact on the individuals and civilization as a whole. Ultimately, are we not working both at a micro and macro levels?
Hi Caroline,
I sympathise with what you are saying. However, it seems like your passion spills over to attacking the whole thing. And when that happens, it causes people to react, rather than think about what you have said.
I do sympathise because I have known mothers to suffer terrible regrets later on in life.
Inspired me to check on subtler levels in my somatics and embodiment coaching and work more differenciated, for example around relational topics and past decision making in clients. Like separation/ leaving a child for own safety reasons, „fleeing“ life settings as a habit while somehow having a sense of „one should“, when it often involves others, etc.
Think this must not only address the „big boom“ but can also address more subtle levels of internal stressors.
Thank you so much. I’m grateful for having access to your highly informative work from the other side of the globe. One REQUEST though:
Could you please make sure that all of your experts are adequately equipped technically to produce GOOD SOUND QUALITY & without disturbances? For a listener who’s not a native speaker sound quality plays a pivotal role in being able to make out what’s being said.
Very helpful and useable point. Thank you for voicing this for the benefit of all.
I agree! And I am a native speaker!
Agree
This was so helpful! Case studies were helpful as well.
I felt there was too little information about community approaches and creating a moral community.
Again, well done!
Moral injury from failed big entrepreneurial or life projects – individuals who are morally committed to justice, equity, but who due to circumstances that they could not anticipate, carry the guilt, the shame and the will to dye due to failing of an academic or financial investment, where they think is a failure and morally wrong towards family, friends and people who trusted them. Can we address these kinds of situations as moral injury, ptsd, or burnout?
This is an interesting question. In my experience the moral injury as discussed can also be a result of failing others due to overwhelm / childhood trauma / burnout or ptsd and the resulting physical / mental block to fulfil the duties towards family, friends and people who trusted them.
In any of those cases it would be valuable to evoke the experience of the emotion, allow the person to feel the pain and stay with it for some time while being witnessed by a practitioner that expresses compassion and resonates / acknowledges the emotion and anguish.
Perhaps letting the person explore the nature of the pain and where it occurs in the body, holding that area and then guide the person to hold other areas in the body to distribute the pain, making it more bearable.
Very helpful suggestions for helping people feel they can contribute to the moral well-being of society, going forward; even when it’s not possible to reverse the harm they perpetrated by their own choices or behaviors in the past.
I think it’s so interesting. Freud talked about the ego, id, and superego. We don’t talk about the id any more, but capture similar aspects of mind by talking about the amygdala, other “lower” brain structures, procedural memory, etc. We capture similar aspects of mind as “ego” by talking about the cortex, etc. But ideas capturing similar aspects of mind as superego–the idea that a moral sense and its vicissitudes are an intrinsic part of our makeup–not so much. I think this workshop was a reminder to pay attention to the importance of values and the ethical sense, for people suffering from transgressions, but also others.
Thank you Paula for providing this bridge to a past context in a more informed, current framework of ‘the importance of values and the ethical sense’! Yet, the essence, essentially, remains one and the same human being in need of being human fully.
Being a doctor I have witnessed and was also involved possible preventable death in hospitals i know moral injury very well in myself and my colleagues
And I know without community support and sometimes therapy many of us would have committed suicide because of the heavy burden of responsibility and the feeling of moral failure. There is often something which could have been done better or more. It is no wonder that MI is more prevalent in Healthcare
Indeed Heike, thank you so much for your honestly stepping forward here. I have experienced that as a health policy official and that’s why I left the government many years ago and started a coaching practice. It feels very validating right, that these experiences are now named here as moral injury too. Wishing you all the best with your healing and transforming your experiences.
!!
Thank you for such a clear, informative and practical session. I shall be more mindful of exploring clients’ core values as an ongoing thread running through my sessions with them.
Kathleen
I am a teacher in a university in Mexico. I have many students going through very hard situations and this information has helped me to have more ideas on how to help them, starting from understanding the nature of guilt. Thank you very much for this wonderful information!
What a beautiful illustration, I find your example very helpful.
With the picture of the stick and the carrot, the individual’s moral compass
being the carrot (the goodness that is strived for), and
the nature of guilt being a stick (one of many avenues that one may attempt
to measure up against). Thank you for sharing.
Thank you for this great module. I have enjoyed all of them so far and I will be better at assessing and evaluating as a result. I now feel the need to improve upon my intake assessments and ongoing assesssments by triaging for moral injury whenever a client presents with PTSD.
I’m wondering about a continuum of moral stresses that can result in moral injury as opposed to a singular event?
Yes! I am thinking about incest throughout a child’s life-time.
I understand my bully wounds of receiving bully treatment from class mates and being a bully during childhood to my brother.
i made myself less entire life non deserving
Thank you for such a great overview of moral injury vs PTSD. I found the working case examples helpful in deepening my understanding of what it is, what are the barriers to treatment and how to overcome these. Thank you
As always, invaluable! I love these. You help me to change the world, one person at a time. Thank YOU for what all of you do.
Dr. Wendy Mincer, Dallas, TX
The issue of moral injury may also address feelings of people that are in prison. Some experience self loathing because they have done something that not only them, but others in society find morally wrong.
It is wonderfull, that you adress this topic!!
it seems to me, i struggle with this very often with mothers, realizing that they did not manage to prevent hurting deeply their child. and seeing how they – for example – are not able to get on their on feet. land in psychiatric institutions. and beeing accused by children, friends and society having been too selfish..
what do you think about this aspect of this topic?
Dear Esther,
You did not ask me, but I’d like to respond nonetheless;
I think your point is very relevant, to the point of being
absolutely pivotal in making a tidal wave of real change for society.
Thank you,
Peneleapai
Esther, I see this dilemma in the role of statutory sw/child protection. We have to ‘meet the person where they are’ to make progress and with a moral injury dimension – so personal and tightly locked away sometimes, where is that! Work to convince parents that they have the most valuable relationship with their children -which they can build upon, takes so much time to unravel… It must seem such an impossible hope for some. Drug dependency, choosing partners badly, exploring the lessons from childhood care…such a complex journey to navigate. Self compassion and forgiveness and courage to try again are not easy to find. The idea of normalizing past decisions and yet looking for a more effective path is important. The idea of living with guilt and not being eaten up by it… knowing you are at your core a loving responsible and RELIABLE parent in spite of where you had been brought to in the past.
Resources are needed in the recovery and rehab stage of any assessment and planning , and all too often without this we have a ‘revolving door’ scenario. This webinar reminded me of the importance of the support circle understanding the moral injury impact and its self-destructive dimension. Work for Protective Parents and the other supporters to bolster the whole system is required and sometimes we fall short on providing it.
Ruth, Really found this session interesting — should be common sense, but the clear difference of flow, where PTSD arises from an external threat and moral injury results from an individual’s choice to violate his/her own personal values set the scene perfectly. Wish I could have seen more of this, but I am really grateful for the opportunity to get what I can fit into my schedule at no cost.
Quite frankly, approaching 81 in eight weeks and finishing up three years of DMin seminar work next month has been physically and emotionally draining. I’ll never be an expert, but when folk come to me for spiritual help/guidance, I feel better able to speak with compassionate understanding. Having a clearer sense of what certified counseling is doing for “my folks” who have the benefit of such and to see how sensitively NICABM moves in new directions that consider the whole person and his or her whole environs. Thanks for your leadership in the field. Carol
Carol – I happen to also be 81 and REALLY LOVED that you are still “traveling the road” like the Good Samaritan, helping WHO you can but NOT taking on the entire burden of the injured person’s troubles. The FIRST G.Sam [though I’m not a biblical scholar] bound the wounds, put the victim in a place that took care of food and shelter, but went off on his camel saying he’d “check back.” Samaritans today are [so it seems] told, “you took on the PERSON for the rest of his LIFE, so don’t walk away, you Brother’s KEEPER you!” WTF?
The word “keeper” is the tricky part here. IMHO it can keep Samaritans from offering help AND contribute to “infantilizing” those who might at least begin to help themselves even if they have to crawl on their bellies like snakes to get where they need to go. Sometimes the line HAS to be drawn between “just enough help” and “you broke him, you bought him.” [clear as mud, I’m sure! But I LIKE the “cut of your jib”!] You go, you 81 y.o. “girl” you! HEARTS 2U!!!
Carol, I especially resonate with ‘how sensitively NICABM moves in new directions that consider the whole person and his or her whole environs’! I believe that there is a particular need for whole environs, as you put it, both theologically and in behavioral medicine. A clearer big picture always helps.
Moral injury is a very useful term. The population group I researched titled “Lives unseen: Unacknowledged trauma of non-disordered, competent Adult Children Of Parents with a Severe Mental Illness”. (Although easy to read, support for some during the reading of it would be advisable) probably suffer from moral injury. People can find it by simply googling that title. I also wrote articles I’ve been invited to write by a psychiatrist on trauma and grief some which may indirectly related to moral injury. As soon as the NSW psychiatrist publishes each article I modify it slightly then put it on medium.com for free for the general public. (People just need to put in my full name Suzette Misrachi followed by medium.com). Thank you for this great presentation! I learnt a lot.
Thank you so very much 🙏
I am not trying to be condescending, unkind or diagnostic, but it sounds as if your are hurting. Please take care of yourself.
With Concern
That is so sincerely expressed, and compassionate. Perhaps NICAMB’s spokesperson could have done with some of that approach in responding to the distressed comment.
When a patient was shamed from birth, would that register registeras trauma or as moral injury?
I think yes to moral injury. But it begs the question why they were chronically shamed….what else was going on at home? If the child was not safe and the secure attachment broken, then I suggest PTSD is also hiding in there.
The vast majority of women who choose to end a pregnancy do not suffer moral injury, that’s why.
In order to suffer moral injury, one must feel that an act is against one’s morals. Perhaps you might purchase the gold package and listen to this material again as it appears you did not pick up that key point of the entire presentation.
Just because an act is against your morals does not mean it is against others’ morals.
It is clear if you chose such an act it would be likely to cause you moral injury, but this is not the case for all others.
Regarding your accusation of NICABM being “silent” on your single example, there were countless other possible examples which were also not mentioned.
I am hoping to help my friend see the need to get more indepth therapy to help her get to the bottom of her fears and imaginations. I would really like to help her get to the place where she can recognize her guilt and know how to deal with it. And beyond all that if I can get her to realine with her moral values, I think we will both have a better life, because as of now we both live stressful lives because of self blame and self disgust.
Martha, you will do it! You gut sense is worth hearing… Your hope will see manifestations that you long for both of you!
Thanks for this presentation! I really like the idea (from Wyatt) of bringing guilt into the room non-judgmentally, see it with an element of compassion and what it actually says about you to feel that guilt after doing a ‘bad’ thing. I am an EMDR practitioner mainly and do chairwork as well and could incorporate this idea into these frameworks. I have a client who has worked in Customs at sea in Australia and his role ended up being to turn back boats full of desperate asylum seekers. He can do all the other things suggested in this training (identify his values and act on those by connecting with and prioritising his kids, putting his family first, looking after an asylum seeker in our remote community) but he just can’t get past the thought that “Our government did terrible things to those people and I was part of that”.
Maybe he doesn’t have to get rid of the guilt, but befriend it. Thanks again!
Thank you – I liked the idea of making amends with community groups to prevent future harm, and taking an action like a hug to gradually restore connection with his children.
Thank you very much for this wonderful segment.
Very helpful in working with parents of kids with special needs too.
The session mentioned medical profession as an environment conducive to moral injury. I’d like to add another:
Teachers, especially SPED classroom teachers. They typically burn out by their 5th year in an environment which is chronically under-resourced by budget and staffing. They have to endure a daily full semester like this, year after year of service employment doing less than they believe their students deserve or they’re ready/able/willing to deliver but for the chronic lack of school district support.
Another category of environments conducive to moral injury is people with business or religious beliefs being in societies or companies who routinely require behavior which violates one’s morals or fundamental beliefs. Perhaps some of them choose to be whistleblowers.
Can a person have moral injury if it is the trauma and what others have done to them through out life? thanks I know i have PTSD but maybe I have moral injury also.
If you have endured bad things happening to you by others, then I expect this external behaviour is at odds with your own values. Sounds like moral injury to me. Take care of yourself x
Thank you for this excellent session!! I found myself thinking about another huge group of sufferers of moral injury that includes siblings…siblings subjected to often witnessing repetitive abuse / mistreatment of other siblings or a parent by another parent, another sibling, etc, or bullying in schools.
Also, isn’t it quite common for this witness to often become an abuser later on, though this wasn’t the point of this session yet in my opinion, deserved mentioning.
Thank you for another very enlightening session.
Exactly this is such a good point. The shame, anger and confusion if a survivor goes on to project these unprocessed feelings onto an innocent can be unbearable. I think we tend to only see a narrative that people who perpetrate wrong or harmful behaviour are always without conscience but I think there can be tremendous shame when perpetuating learned immoral behaviour.