- Moral injury is different than PTSD. With PTSD, the primary concern is physical safety. With moral injury, it is relational safety or trust.
- Threats to our integrity and identity can cause autonomic dysregulation, similar to physical threats.
- Moral judgment isn't inherently rational; instead, it's often emotionally driven, fundamentally shaping how we think, act, and live.
Wyatt (I’ll call him) was massive. Standing beside him was like looking up at Mount Everest—unwavering, formidable strength, the pinnacle of its rank, the one everyone feared and revered. There was a time when Wyatt felt as epic as this millennia-old mountain. But when we met, he was a black hole—whatever light trapped inside him was being held by a strong force.
That force was his vow: I will never leave a fallen comrade. Until he did, and then that universe blew to pieces.
When Wyatt made his way to me as his therapist, he had spent the previous few years bouncing between feeling nothing and trying to feel something. While on a special ops mission in Afghanistan years before, Wyatt and his team were ambushed due to a major intelligence breach and informant betrayal. The consequences included Wyatt’s best friend—his “brother”—being burned over 80 percent of his body. Watching his brother writhe in pain and suspecting little chance of survival, Wyatt blocked the oxygen tube the medic had installed after she’d left the scene to get more medicine. As he watched his brother take his last physical breath, a part of Wyatt died.
Wyatt didn’t tell this story to me for some time—less because he was too ashamed (although he certainly had a good bit of shame); more so because often, when he tried, he couldn’t find the words. Sometimes his voice would crack, or he’d stop mid-sentence and stare blankly. Other times his jaw would clench, or his mouth would move to speak, but nothing would come out. In my work with people who struggle with moral injuries—like Wyatt—this is not unusual.
Moral injury is a violation of a person’s core moral foundations in high-stakes situations that recasts how they see themselves, others, and the world and causes changes in behavior that signal a loss of trust, connection, self-worth, and meaning. Such violations could result from a person’s own actions, things they witnessed or were made to do against their will, or things they couldn’t prevent. And it’s more prevalent than many would think.
Of the 2.7 million service people who served in Afghanistan and Iraq, reports show that roughly the same number who were diagnosed with PTSD (11 to 20 percent) were also coping with moral injury. Also, the COVID-19 pandemic has thrown into stark relief the presence of moral injury among healthcare workers. New research found that rates of moral injury in healthcare workers during the pandemic were similar among U.S. veterans who served after Sept. 11, 2001.
Trauma research tells us that when people are in a constant state of heartbreak and gut-wrench—as is the experience of moral injury—they will do everything to shut down those feelings in their bodies. But the body also has a “behind the scenes” way of shutting itself down as the means of self-preservation—in the case of moral injury, a possible coping mechanism to maintain wholeness when the awareness of having failed or had failed, one’s core system of meaning and connection is pulling that person apart.
How Moral Injury Lives Inside Us
You've likely heard of the “fight-or-flight” response, also called "hyperarousal" or the "acute stress response," that kicks in when we feel under threat. Fight-or-flight causes our heart to pound, breathing to hasten, muscles to tighten, and thoughts to race—all of which conspire to make us anxious, panicky, angry, overwhelmed, or hypervigilant. Hyperarousal is a primary symptom of posttraumatic stress disorder (PTSD).
Some have likened PTSD and moral injury. PTSD is typically the trauma response associated with threats. But while intrusive images of the past are similar in each experience, with moral injury, memories don’t trigger fear as we usually experience it. Instead, they beget shame, guilt, rage, disgust, emptiness, and despair. With PTSD, the primary concern is physical safety. With a moral injury, it is relational safety—or trust.
Moral injury makes a person question themself, others, life, their God, and their or others’ ability to do right or be good. Moral injury deteriorates one’s character, ideals, ambitions, and attachments. It leaves people feeling contaminated in their being or that something they once held dear has been sullied. “Unworthy,” “beyond redemption,” “gone forever,” and “emotionally dead” are how many people have described the experience.
A lesser known “F” response is “freeze.” Freeze, also referred to as "hypoarousal," occurs in stressful situations when a person’s sense of safety or connection has been severed, and it can neither reconcile nor respond adequately to that perceived threat.
Here’s a fact that not many people realize: Physical threats aren’t the only kind that can be dysregulating. Threats to our integrity and identity can also cause us to “go offline.” New research (my own included) suggests that moral injury could be linked to hypoarousal. Hypoarousal causes people to shut down. They often feel numb, empty, exhausted, hopeless, helpless, depressed, despairing, and stuck. They may disconnect, withdraw, isolate, or dissociate. It can be difficult to think clearly and get thoughts out. It may even result in suicidal thoughts, especially in those with trauma histories.
Like many people who suffer from moral injury, Wyatt was experiencing a number of these symptoms. One day, as he sat like a lump of clay on the couch, I pulled out two big exercise balls and rolled them in front of him. I plopped down on one and asked him to hop on the other.
Slowly, I started bouncing. Neither one of us spoke. A few minutes later, I saw his ball bend and then rise. A few minutes after that, we were both moving in rhythm, still, neither of us saying anything. It was like a Samuel Beckett play–Theatre of the Absurd–only in reverse: Silence preceded the irrational or illogical speech, which preceded the logical argument. Suddenly, Wyatt burst out,
“F*ck… Can’t live … God, so gross!” His neck snapped back. And his face wrinkled as his hand flew to his mouth. We stopped bouncing. Wyatt shook his head and then dropped his head into his hands as sobs quietly crept out. Finally, he looked up, the avalanche of tears having stopped, leaving this mountain of a man. He said:
“My buddy told me once, after another brother met a similar fate, that he’d never want to live like that. And I didn’t want him to live that… I just couldn’t stand looking at him like that… What if I did it for me, not him?… Then I’ve betrayed him too, and no better than the Taliban informant.”
You Have to Feel and Deal in Order to Heal
One of the challenges about healing from moral injury is how we frame the story—and often, the foundation of that story rests on a person’s beliefs. Many therapeutic approaches talk about cognitively reframing beliefs, meaning we tell ourselves to think differently about them. This can certainly be helpful in some circumstances.
What doesn’t get talked about very often is that beliefs (and moral judgment) aren’t inherently rational. As Jonathan Haidt, a moral psychologist and professor of Ethical Leadership at New York University Stern School of Business, pointed out, people generally do not engage in moral reasoning; rather, the conclusion is coughed up by an unconscious emotion—and this can fundamentally shape what we think and believe, how we act, and the stories we live by.
Like any difficult emotion strongly felt, sometimes that experience can cause our nervous system to go “offline.” In Wyatt’s case, one of the prevailing emotions he experienced was disgust. He was disgusted at the betrayal of his unit by the informant and the deadly consequences it wrought, especially for his best friend. He was also disgusted by what his best friend looked like after the explosion, and he fought with himself for having had, in his words, that “cruel, I’d-rather-leave-you-than-look-at-you” repulsed response. Wyatt was further disgusted at life generally, and God specifically, for putting him in a situation that forced him to kill—not an enemy, but his “brother.”
Shame and guilt are two of the emotions most often associated with moral injury—and Wyatt had both in spades. Interestingly, disgust is thought to be the primary emotion from which shame and guilt emerge when they can neither be validated nor reconciled. Going right back into the field and “swallowing [everything that happened] in one rancid existential gulp,” as Wyatt said, is the definition of invalidation and not reconciling.
Interestingly, disgust links to morality; moral judgments are thought to become more rigid and entrenched from experiencing disgust. For Wyatt, killing his best friend was the height of violating what he considered morally sacred—leaving a fallen comrade behind. And should others, like his buddy’s wife, family, friends, comrades, the military, etc., discover the truth of what he’d done, it could very well result in an unbearable annihilation of the relationships that mattered to him most. It makes perfect sense why then Wyatt would be feeling his own and others’ betrayal so intensely—and why his body had resorted to shutting down, causing him to withdraw in the way that it did.
“Get over it” is a self-talk technique often employed to combat unpleasant feelings. “Think happy thoughts” and “Don’t be sad” are a few others. The problem is that a befuddled nervous system can’t easily understand this rational, higher-order cognitive functioning language because that part of the brain is shut down. The nervous system prefers “somatic speak”—for instance, the silent sensory stimulation of a bouncy ball.
This brings us back to Wyatt and me bopping up and down in my office like two characters in Theatre of the Absurd—yet each seemingly ridiculous rise and fall was helping to arouse his system and bring him out of the shutdown he was experiencing.
This explains why he blurted out what he did. And why, a few minutes later, he could think more clearly, even somewhat differently, about what he’d done and the circumstances surrounding the tragic wartime events. And why, eventually, with practice, he could find new and better words to put to those thoughts and feelings than any he had previously.
And how, in time, with the help of trusted conversation and an embodied writing therapy that I developed specifically for moral injury, Wyatt came to understand how the experience of all that had happened and all that he believed—past and present—was living inside him and how it was affecting the story he told himself and others about that fateful night and his “non-life” existence ever since.
Eventually, he could craft a coherent narrative that felt right and real about the events and everything he’d experienced since, as painful as it was in parts. This coherent narrative—having it, living it, and sharing it with trusted others as he was able and chose to—was the thing that allowed him to truly begin to live again.
Dr. DeMarco is an award-winning writer, and a therapist, clinical ethicist, and trauma researcher specializing in moral injury and moral distress. She is the author of the Psychology Today blog “Soul Console: Healing from Moral Injury” and one of Medium’s Top Writers for Mental Health and Health, respectively. Her writing has appeared in national and international publications, including the New York Times, POLITICO, The Boston Globe, Psychology Today, and The War Horse, among others. She’s also been featured as a trauma, health, and spirituality expert for MindBodyGreen, Integrative Practitioner, Lifehacker, Bloomberg/WNBP Radio, Partners HealthCare, and the American Heart Association. Her new book Holding Onto Air: the Art and Science of Building a Resilient Spirit is now available.
DeMarco, M. (2020). The PTSD-like Affliction That’s Traumatizing Health Care Workers. Elemental. https://elemental.medium.com/the-ptsd-like-affliction-thats-traumatizin…
Nieuwsma, J.A., O’Brien, E.C., Xu, H. et al. Patterns of Potential Moral Injury in Post-9/11 Combat Veterans and COVID-19 Healthcare Workers. J GEN INTERN MED 37, 2033–2040 (2022). https://doi.org/10.1007/s11606-022-07487-4