Moral Injury-Soul Hurt

Seeking the Military Suicide Solution Podcast, Episode 46:
Dr. Harold Kudler - Historical Perspective on Suicide Prevention

Intro to Moral Injury

Moral injury - Wikipedia

Seeking the Military Suicide Solution Podcast, Episode 46: Dr. Harold Kudler - Historical Perspective on Suicide Prevention
Moral Injury VA Toolkit
Moral Injury Slideshow
Resources for Moral Injury Program Development/Suicide Prevention & Spirituality

Moral injury From Wikipedia

Moral injury refers to an injury to an individual's moral conscience and values resulting from an act of perceived moral transgression,[1] which produces profound emotional guilt and shame,[2] and in some cases also a sense of betrayal, anger and profound "moral disorientation".[3]


1 Definition
2 Historical development
3 Military perspective
4 In healthcare professionals
5 Psychological perspective
6 Social and cultural perspective
7 Spiritual perspective
8 Treatment
9 Moral injury of other professions
10 References


The concept of moral injury emphasizes the psychological, social, cultural, and spiritual aspects of trauma.[1] Distinct from psychopathology, moral injury is a normal human response to an abnormal traumatic event.[1] [4] According to the U.S. Department of Veterans Affairs, the concept is used in literature with regard to the mental health of military veterans who have witnessed or perpetrated an act in combat that transgressed their deeply held moral beliefs and expectations.[5] Among healthcare professionals, moral injury refers to unaddressed moral distress leading to the accumulation of serious inner conflict that may overwhelm one's sense of goodness and humanity. It is important to note that, despite the identification of moral traumas among both veterans and healthcare professionals, research has remained oddly independent between these two groups, and as such, the terminology is not uniform.

Historical development

In 1984, the term moral distress was first conceptualized by philosopher Andrew Jameton in his book on nursing issues, "Nursing Practice: The Medical Issues" to describe the psychological conflict nurses experienced during, "ethical dilemmas." He wrote that "moral distress arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.".[6]

In the 1990s the term moral injury was coined by psychiatrist Jonathan Shay and colleagues based upon numerous narratives presented by military/veteran patients given their perception of injustice as a result of leadership malpractice. Shay's definition of moral injury had three components: 'Moral injury is present when (i) there has been a betrayal of what is morally right, (ii) by someone who holds legitimate authority and (iii) in a high-stakes situation.[7] [8] [9] As of 2002, Shay defined moral injury as stemming from the "betrayal of 'what's right' in a high-stakes situation by someone who holds power."[10]

In 2009, the term 'moral injury' [9] was modified by Brett Litz and colleagues as "perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long term, emotionally, psychologically, behaviorally, spiritually, and socially" (2009, p. 695). According to Litz et al, the term moral injury had been developed in response to the inadequacy of mental health diagnoses e.g., Post-traumatic stress disorder, to encapsulate the moral anguish service members were experiencing after returning home from war.[2] Unlike PTSD's focus on fear-related symptoms, moral injury focuses on symptoms related to guilt, shame, anger, and disgust.[11] The shame that many individuals face as a result of moral injury may predict symptoms of posttraumatic stress disorder.[12]

In 2011, with the inability of current diagnoses to account for moral anguish, research began to encapsulate moral conflict in warriors.[13]

As of 2017, no systematic reviews or meta-analyses exist on the construct of moral injury, although a literature review of the various definitions since the inception of moral injury has been undertaken.[14] [15]

Military perspective

To understand the development of the construct of moral injury, it is necessary to examine the history of violence and the psychological consequences. Throughout history, humans have been killing each other, and have shown great reluctance in doing so.[16] Literature on warfare emphasizes the moral anguish soldiers feel in combat, from modern military service members to ancient warriors.[17] Ethical and moral challenges are inherent to warfare.[18] Soldiers in the line of duty may witness catastrophic suffering and severe cruelty, causing their fundamental beliefs about humanity and their worldview to be shaken.[2]

Service members who are deployed into war zones are usually exposed to death, injury, and violence. Military service members represent the population with the highest risk of developing Post-traumatic stress disorder .[19] PTSD was first included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders, the manual classifying mental health disorders published by the American Psychiatric Association, to begin to address the symptoms that Vietnam veterans exhibited after their wartime experiences.[2] As PTSD has developed as a diagnosis, it requires that individuals are either directly exposed to death, threatened death, serious injury, or sexual violence, witness it in person, learn about it occurring indirectly to a close relative or friend, or are repeatedly exposed to aversive details of traumatic events.[19] PTSD includes four symptom clusters, including intrusion, avoidance, and negative mood and thoughts, and changes in arousal and reactivity.[19] Individuals with PTSD may experience intrusive thoughts as they re-experience the traumatic events, as well as avoiding stimuli that reminds them of the traumatic event, and have increasingly negative thoughts and moods. Additionally, individuals with PTSD may exhibit irritable or aggressive, self-destructive behavior, and hypervigilance, amongst other arousal-related symptoms.[19]

Moral injury can also be experienced by warriors who have been transgressed against and thus also in circumstances other than combat. The injury may in those cases include a sense of betrayal and anger.[20] For example, when one goes to war believing that the purpose of the war is to eradicate weapons of mass destruction, but finds that not to be the case, the soldier can experience moral injury. Those who have seen and experienced death, mayhem, destruction, and violence and have had their worldviews shattered – the sanctity of life, safety, love, health, peace, et cetera – can also suffer moral injury.

The exposure to violence during war times make military and veteran population at a higher risk of developing moral injury. According to statistics collected in 2003, 32% of American service members deployed to Iraq and Afghanistan were responsible for the death of an enemy, 60% had witnessed both women and children who were either ill or wounded whom they were unable to provide aid to and 20% reported being responsible for the death of a non-combatant.[2] Similar work has been conducted in a Canadian military context – out of Canadian Armed Forces personnel deployed to the mission to Afghanistan, more than half endorsed a traumatic event that was conceptually linked to moral injury.[21] Specifically, 43% saw ill or injured women or children who they were unable to help; 7% felt responsible for the death of Canadian or ally personnel, and 38% had difficulty distinguishing between combatants and noncombatants.[22] Controlling for other fear-based deployment related stressors, exposure to such potentially morally injurious events have been related to increased prevalence of PTSD and depression in military personnel.[23]

During times of war a service member's personal ethical code may clash with what is expected of them during war. Approximately 27% of deployed soldiers have reported having an ethical dilemma to which they did not know how to respond.[12] Research has shown that longer and more frequent deployments can result in an increase in unethical behaviors on the battlefield.[24] This is problematic considering deployment lengths have increased for the war in Iraq and Afghanistan.[2] [24] During times of war the military promotes an ethical pardon on the killing of an enemy, going against the typical moral code for many service members.[2] While a service member is deployed, killing of the enemy is expected and often rewarded. Despite this, when a service member returns home the sociocultural expectations are largely different from when they were deployed.[2] The ethical code back home has not changed, making the transition from deployment to home difficult for some service members.[12] This clash in a personal ethical code and the ethical code and expectations of the military can further increase a service member's deep-seated feelings of shame and guilt for their actions abroad.

In healthcare professionals

Moral distress among healthcare professionals was first conceptualized in 1984 by Andrew Jameton.[6] The concept was gradually explored over the subsequent 30 years in both nursing and veteran literature, though as above the definitions were slightly different. In the healthcare literature, moral injury refers to the accumulation of negative effects by continued exposure to morally distressing situations.[25] In 2000 the concept of moral distress being generated by systemic issues had been termed, "the ethical canary".[26] to draw attention to the sensation of moral distress signaling a need for systemic change.

In 2018, it was suggested that moral injury can occur among physicians and other care providers which affect their mental health and well-being. The concept of moral injury in healthcare is the expansion of the discussion around compassion fatigue and 'burnout'[27] was first discussed by Dr. Simon G. Talbot and Dr. Wendy Dean.

Physicians in the United States were caught in situations that prevented them from doing what they perceive is the right course of action, i.e. taking care of the patient well. Instead, they were caught in double and triple and quadruple binds between their obligations of electronic health records, their own student loans, the requirements for patient load through the hospital and number of procedures performed.[27] Often, physicians are trained to the 'gold standard' but due to institutional double-binds, can't actually execute that best-in-class treatment.

As of 2018, moral injury has been studied in medical students working within the NHS.[28] In her TED talk in October 2019, Dr Sammy Batt-Rawden argued that doctors come to psychological harm as a result of not being able to give patients the care that they need in an under-resourced NHS.[29]

Since the beginning of the COVID-19 Pandemic in 2020, healthcare workers in the United States in particular have been faced with decisions like rationing care while hospital policy and insurance constraints remain, without support or training on how to psychologically process the toll these decisions can take. Driven by changes in health care reimbursement structures, systems were “optimized” to the point that they were continually running at what felt like full capacity, with precious little slack to accommodate minor surges, much less one the magnitude of a global pandemic. As such, COVID-19 has only exacerbated an already deeply challenged system.[30]

Psychological perspective

See also: Moral psychology and Perpetrator trauma

Brett Litz and colleagues define moral injury as "perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations."#2 Litz and colleagues focus on the cognitive, behavioral, and emotional aspects of moral injury, positing that cognitive dissonance occurs after a perceived moral transgression resulting in stable internal global attributions of blame, followed by the experience of shame, guilt, or anxiety, causing the individual to withdraw from others.[2] The result is increased risk of suicide due to demoralization, self-harming, and self-handicapping behaviors.[2]

Psychological risk factors which make an individual more prone to moral injury include neuroticism and shame-proneness. Protective factors include self-esteem, forgiving supports, and belief in the just-world hypothesis.[2]

Social and cultural perspective

As of 2018, research by anthropologist Tine Molendijk[31] has shown that as unresolved conflicts at the political level create potentially morally injurious situations for soldiers on the ground, "experiences of institutional betrayal" and "a resultant search for reparations" by veterans can also be part of moral injury.[20] She claims, both public condemnation and public heroification of veterans may contribute to moral injury, given that both are generally experienced by veterans as alienating distortions of their war experience, meaning that both may entail an "injustice" being done to the experience.[32]

Spiritual perspective

Rita Nakashima Brock and Gabriella Lettini emphasize moral injury as "…souls in anguish, not a psychological disorder."[4] This occurs when veterans struggle with a lost sense of humanity after transgressing deeply held moral beliefs.[4]The Soul Repair Center at Brite Divinity School is dedicated to addressing moral injury from this spiritual perspective.[33]


According to Shay, the process of recovery should consist of "purification" through the "communalization of trauma." Shay places special importance on communication through artistic means of expression. Moral injury could only be absolved when "the trauma survivor... [is] permitted and empowered to voice their experience....". Fully coming "home" would mean integration into a culture where one is accepted, valued and respected, has a sense of place, purpose, and social support.[10]

According to Litz for this to occur, there needed to be openness on the part of civilians to hear the veterans' experiences without prejudice. The culture in the military emphasizes a moral and ethical code that normalizes both killing and violence in times of war.Litz and colleagues (2009) have hypothesized a modified version of CBT that addresses three key areas of moral injury: "life-threat trauma, traumatic loss, and moral injury Marines from the Iraq and Afghanistan wars."[[2] Despite this, decisions made by service members who engage in killing or violence through this cultural lens would still experience psychological and spiritual impact.[2]

It is hypothesized that treating the underlying shame associated with service member's symptoms of PTSD is necessary and it has been shown that allowing feelings of shame to go untreated can have deleterious effects.[12] This can make the identification of moral injury in a service member difficult because shame tends to increase slowly over time.[2] Shame has been linked to complications such as interpersonal violence, depression, and suicide..[12] In 2015, Gaudet and colleagues wrote that interventions are lacking and new treatment interventions specific to moral injury are necessary, and that it was not enough to treat moral injury in the same way that depression or PTSD are commonly treated[2] In spite of the lack of research on the treatment of moral injury, factors such as humility, gratitude, respect and compassion have shown to either be protective or provide for hope for service members.

Treating moral injury has been described as "soul repair" due to the nature of moral anguish.[17] While moral injury can be experienced by people other than military service members, research has paid special attention to moral injury in military populations.[2] Seeking professional mental health help for moral injury may present with some challenges, particularly for military personnel. Moral injury is frequently associated with socially-withdrawing emotions, such as guilt and shame. These emotions may further reduce the likelihood of individuals reaching out for help in the fear of being rejected or judged by others. Additionally, military personnel may be hesitant to seek help due to actual or perceived career repercussions. Recent research on this topic showed that among active deployed military personnel, those who were exposed to potentially morally injurious experiences were more likely to avoid military mental health services and instead seek help from a professional in a civilian health care system.[34]

Moral injury of other professions

The concept of moral injury has more recently also been discovered among police,[35] and likely exists among firefighters as well and other forms as first responders work and should include such Emergency Medical Services, legal defenders/lawyers, and Child/Adult Protective Services.[36] Professions with non-human subjects such as veterinarians are also beginning to be studied.[37]

Robotics and artificial intelligence

Main article: Machine ethics

See also: Robot ethics and Ethics of artificial intelligence

At the intersection of moral psychology and machine ethics, researchers have begun to study people's views regarding the potentially ethically significant decisions that will be made by self-driving cars.


1 Haleigh, A. Barnes; Hurley, Robin A.; Taber, Katherine H. (23 April 2019). "Moral Injury and PTSD: Often Co-Occurring Yet Mechanistically Different". Journal of Neuropsychiatry and Clinical Neurosciences. American Psychiatric Association. 31 (2): A4-103. doi:10.1176/appi.neuropsych.19020036. ISSN 1545-7222. PMID 31012825.

2 Litz, Brett T.; Stein, Nathan; Delaney, Eileen; Lebowitz, Leslie; Nash, William P.; Silva, Caroline; Maguen, Shira (December 2009). "Moral injury and moral repair in war veterans: A preliminary model and intervention strategy". Clinical Psychology Review. 29 (8): 695–706. doi:10.1016/j.cpr.2009.07.003. PMID 19683376.

3 Molendijk, Tine (2018). "Toward an Interdisciplinary Conceptualization of Moral Injury: From Unequivocal Guilt and Anger to Moral Conflict and Disorientation". New Ideas in Psychology. 51: 1–8. doi:10.1016/j.newideapsych.2018.04.006.

4 Rita Nakashima and Gabriella Lettini, Soul Repair: Recovering from Moral Injury After War (Boston: Beacon Press, 2012).[page needed]

5 Maguen, Shira; Litz, Brett. "Moral Injury in the Context of War". PTSD: National Center for PTSD. U.S. Department of Veterans Affairs. Archived from the original on November 11, 2019. Retrieved December 13, 2015.

6 Jameton A. Nursing practice: the ethical issues. Englewood Cliffs, NJ:Prentice Hall, 1984[page needed]

7 Shay, J.; Munroe, J. (1998). "Group and milieu therapy for veterans with complex posttraumatic stress disorder.". In P. A. Saigh; J. D. Bremner (eds.). Posttraumatic stress disorder: A comprehensive text. Boston: Allyn & Bacon. pp. 391–413. ISBN 978-0-205-26734-7.

8 Shay, J. (2002). Odysseus in America: Combat trauma and the trials of homecoming. New York: Scribner.

9 Shay, J. (2010). Achilles in Vietnam: Combat Trauma and the Undoing of Character. Simon & Schuster. ISBN 978-0-684-81321-9.

10 Shay, Jonathan (2002). Odysseus in America: Combat Trauma and the Trials of Homecoming. Scribner. ISBN 978-0-7432-1156-7.[page needed]

11 Farnsworth, Jacob (2014). "The role of moral emotions in military trauma: Implications for the study and treatment of moral injury". Review of General Psychology. 18 (4): 249–262. CiteSeerX doi:10.1037/gpr0000018. S2CID 146548836.

12 Gaudet, Camille; Sowers (2016). "A review of PTSD and shame in military veterans". Journal of Human Behavior in the Social Environment. 26 (1): 56–68. doi:10.1080/10911359.2015.1059168. S2CID 141882386.

13 Drescher, Kent (2011). "An exploration of the viability and usefulness of the construct of moral injury in war veterans". Traumatology. 17 (1): 8–13. doi:10.1177/1534765610395615.

14 Hodgson, Timothy J.; Carey, Lindsay B. (19 May 2017). "Moral Injury and Definitional Clarity: Betrayal, Spirituality and the Role of Chaplains". Journal of Religion and Health. 56 (4): 1212–1228. doi:10.1007/s10943-017-0407-z. PMID 28526912. S2CID 4921453.

15 15 Nazarov, A.; Jetly, R.; McNeely, H.; Kiang, M.; Lanius, R.; McKinnon, M. C. (2015). "Role of morality in the experience of guilt and shame within the armed forces". Acta Psychiatrica Scandinavica. 132 (1): 4–19. doi:10.1111/acps.12406. ISSN 1600-0447. PMID 25737392. S2CID 25264428.

16 Grossman, Dave (2009). On combat: the psychology and physiology of deadly conflict in war and in peace. Illinois: Warrior Science Pub.[page needed]

17 Brock, Rita (2013). "Soul repair: Recovering from moral injury after war". The Right to Heal: Holding the US Accountable for the Human Costs of War.[page needed]

18 Blinka, Dee (2016). "Moral injury in warriors and veterans: The challenge to social work". Social Work & Christianity. 43 (3): 7–27. EBSCOhost 117407870.

19 Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, D.C.: American Psychiatric Association. 2013.

20 Molendijk, Tine (2019). "The Role of Political Practices in Moral Injury: A Study of Afghanistan Veterans". Political Psychology. 40 (1): 261–275. doi:10.1111/pops.12503.

21 Nazarov, A.; Fikretoglu, D.; Liu, A.; Thompson, M.; Zamorski, M. A. (2018). "Greater prevalence of post-traumatic stress disorder and depression in deployed Canadian Armed Forces personnel at risk for moral injury". Acta Psychiatrica Scandinavica. 137 (4): 342–354. doi:10.1111/acps.12866. ISSN 1600-0447. PMID 29504125. S2CID 3822173.

22 Nazarov, A.; Fikretoglu, D.; Liu, A.; Thompson, M.; Zamorski, M. A. (2018). "Greater prevalence of post-traumatic stress disorder and depression in deployed Canadian Armed Forces personnel at risk for moral injury". Acta Psychiatrica Scandinavica. 137 (4): 342–354. doi:10.1111/acps.12866. ISSN 1600-0447. PMID 29504125. S2CID 3822173.

23 Nazarov, A.; Fikretoglu, D.; Liu, A.; Thompson, M.; Zamorski, M. A. (2018). "Greater prevalence of post-traumatic stress disorder and depression in deployed Canadian Armed Forces personnel at risk for moral injury". Acta Psychiatrica Scandinavica. 137 (4): 342–354. doi:10.1111/acps.12866. ISSN 1600-0447. PMID 29504125. S2CID 3822173.

24 Mental Health Advisory Team (MHAT-IV). (2006, November 17). Operation Iraqi Freedom 05- 07. Retrieved December 18, 2008, from

25 Rushton, C. H. (2018). Moral Resilience: Transforming moral suffering in healthcare. New York: Oxford City Press.

26 Sommerville, M. (2000). The ethical canary: Science, society and the human spirit. New York, NY: Viking.[page needed]

27 Talbot, Simon G.; Dean, Wendy (26 July 2018). "Physicians aren't 'burning out.' They're suffering from moral injury". STAT.

28 Murray, Esther; Krahé, Charlotte; Goodsman, Danë (2018-10-01). "Are medical students in prehospital care at risk of moral injury?". Emergency Medicine Journal. 35 (10): 590–594. doi:10.1136/emermed-2023-207216. ISSN 1472-0205. PMID 29945983.

29 Batt-Rawden, Sammy, The empathy switch, retrieved 2020-03-03

30 "Beyond burnout: This surge of Covid-19 is bringing burnover". STAT. 2020-11-25. Retrieved 2021-01-28.

31 Molendijk, Tine (2021). Moral Injury and Soldiers in Conflict: Political Practices and Public Perceptions. Routledge. ISBN 9780367546359.

32 Molendijk, Tine (2018). "Moral Injury in Relation to Public Debates: The Role of Societal Misrecognition in Moral Conflict-Colored Trauma among Soldiers". Social Science & Medicine. 211: 314–320. doi:10.1016/j.socscimed.2018.06.042. hdl:2066/194973. PMID 29980118.

33 "Soul Repair : Brite Divinity School". 2014-06-20. Retrieved 2015-03-04.[non-primary source needed]

34 Nazarov, Anthony; Fikretoglu, Deniz; Liu, Aihua; Richardson, J. Don; Thompson, Megan (2020-12-31). "Help-seeking for mental health issues in deployed Canadian Armed Forces personnel at risk for moral injury". European Journal of Psychotraumatology. 11 (1): 1729032. doi:10.1080/20008198.2020.1729032. ISSN 2000-8198. PMC 7067158. PMID 32194921.

35 Papazoglou, Konstantinos; Chopko, Brian (15 November 2017). "The Role of Moral Suffering (Moral Distress and Moral Injury) in Police Compassion Fatigue and PTSD: An Unexplored Topic". Frontiers in Psychology. 8: 1999. doi:10.3389/fpsyg.2017.01999. PMC 5694767. PMID 29187830.

36 Martin, Colleen E.; Tran, Jana K.; Buser, Sam J. (January 2017). "Correlates of suicidality in firefighter/EMS personnel". Journal of Affective Disorders. 208: 177–183. doi:10.1016/j.jad.2016.08.078. PMID 27788381.

37 Moses, Lisa; Malowney, Monica J.; Boyd, Jon Wesley (2018). "Ethical conflict and moral distress in veterinary practice: A survey of North American veterinarians". Journal of Veterinary Internal Medicine. 32 (6): 2115–2122. doi:10.1111/jvim.15315. PMC 6271308. PMID 30320478.

Seeking the Military Suicide Solution Podcast, Episode 46: Dr. Harold Kudler - Historical Perspective on Suicide Prevention

This podcast from Military Times examines the alarming rate of military and veterans suicide, offering new insights based on research and effective clinical and peer support practices in suicide prevention. Hosted by Duane France, a retired Army combat veteran, author and mental health counselor, and Shauna Springer, a psychologist, author and nationally recognized expert on initiatives to benefit the military community, the podcast aims to move beyond awareness to identify actionable strategies that can impact the rising suicide rate among service members, veterans, and their families.

Intro to Moral Injury

1. Introduction to Moral Injury Moral Injury Symposium PRESENTED BY: Geoff Millard Policy Associate INSTITUTE FOR VETERAN POLICY

2. History VETERANS MENTAL AND EMOTIONAL DIAGNOSES • NOSTALGIA/HOMESICKNESS - late 1600s to early 1700s in France, Germany, and Austria • ESTAR ROTO - late 1600s to early 1700s in Spain means “to be broken” • SOLDIERS HEART – U.S. Civil War • SHELL SHOCK – WWI • COMBAT EXHAUSTION – WWII • STRESS RESPONSE SYNDROME – first appears in DSM I 1952 - some early Vietnam veterans did get this as a diagnosis • VIETNAM SYNDROME – early 1970’s • PTSD – 1980 DSM III adds PTSD • PTSD & MORAL INJURY today…

3. Definitions PTSD Post-traumatic stress disorder is generally defined as an anxiety condition that can develop after exposure to a traumatic event or ordeal in which grave physical harm occurred or was threatened. Veterans with PTSD and/or depression face a broad range of physical, cognitive, behavioral, emotional, and social challenges. DSM-V

4. Definitions MORAL INJURY Like psychological trauma, moral injury is a construct that describes extreme and unprecedented life experience including the harmful aftermath of exposure to such events. Events are considered morally injurious if they "transgress deeply held moral beliefs and expectations." Thus, the key pre-condition for moral injury is an act of transgression, which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or culture-based, organizational, and group-based rules about fairness, the value of life, and so forth. MORAL INJURY

5. Overlap between PTSD and Mental Illness

6. Veteran vs. Civilian Suicide COULDTHIS BE EXPLAINED BY MORAL INJURY? Veterans are times more likely to die by suicide than the general population.

7. Activism / Advocacy as Treatment

8. Where Do We Go From Here? 1. Create a public dialogue with the community around moral injury. 2. Provide opportunities for veterans to design and participate in programs on moral injury. 3. Explore a diagnosis of moral injury to include service connection. 4. Explore treatment options for moral injury. 5. Fund research on moral injury and it’s overlap with PTSD & TBI. 6. Consider the impact of moral injury before we go to war.
Source: eMail

Resources for Moral Injury Program Development/Suicide Prevention & Spirituality

Wanted to share the basic program development tools that will be helpful as Veterans Legacy considers its plan for developing a Moral Injury Program. Hope this is helpful!

I. Moral Injury VA Toolkit

II. Moral Injury Slideshow

More than 200 veterans, educators, students, behavioral health providers and faith-based caregivers attended our Moral Injury and Veterans Symposium earlier this month; by way of presentations, panels and facilitated discussions, attendees shared both perspectives and personal narratives, and helped others to become culturally and trauma-informed advocates for veterans.

For those who weren’t able to attend, we’re presenting a summary of three takeaways from the sessions. We hope to continue the conversation and promote understanding of this profound wound.

1) What is moral injury?

A relatively new phrase but not a new concept, moral injury is the grief, shame, and guilt that results from violating your personal code, going against a fundamental sense of right and wrong. Combat and theatre veterans in particular struggle with the moral and ethical ambiguities of war, especially with regard to the pride of their military service combined with the shame and dishonor of what they’ve seen while serving. It can also manifest as a result of such well-documented themes as survivor’s guilt and institutional betrayal.

Moral injury overlaps with trauma, which is why counselors see overlap with moral injury and PTSD—and why we as a nation need to consider the impact of moral injury before we go to war. Note there is no current diagnosis of moral injury in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders), and the VA was not fully funded for mental health counseling before the U.S. invasions of Iraq and Afghanistan.

2) In their own words: Survivors of moral injury

“The last 10 weeks of my tour, I was ‘in the rear with the gear and beer.’ Suddenly the lead squad opened up on the first villagers they saw and killed them instantly. The epiphany came when I realized I was walking in to a village to murder people. It changed the way I looked at my life, the military, society, the world, even my parents. I decided the (Vietnam) war was wrong. I didn’t condone it, but I didn’t stop it.”

“Throughout my deployment, I saw myself in the Iraqi people and began to resent myself for simultaneously being ‘the invader’ and the ‘defender’—in their personal space defending my own.”

“Two fellow Marines died on my watch. I buried those feelings. I just recently started talking about it again. Every time I tell the story, I lose a piece of myself and I still feel that guilt. Someone thirty years older than me still has issues with this. Does it ever really go away?”

“Even in a position of power, having to figure out how to implement a new directive from Congress that I considered to be out-of-touch with what was happening on the ground, I felt the moral injury to have to make management decisions that I did not necessarily agree with. It’s a similar struggle when preparing the next group for deployment—you want to be supportive, but you also know what they are going to be up against, and it’s hard to send to them into that.”

3) Moral injury can get better

Moral injury is not something that one naturally “gets over” or “grows out of.” Throughout life, triggers can bring back moral injury as if it were yesterday. That doesn’t mean, however, that veterans should not seek help or that counselors cannot apply best practices. The goal should not be to get rid of grief, but rather to cope with it. When moral injury comes to the surface, acknowledge what it is and see it for what it is. Staying connected to support systems and relationships is crucial: romantic, family, children, and those you served with. Don’t shy away from talking about it.

For those seeking to help veterans afflicted with moral injury, working with trauma survivors is walking a delicate line. One of the most effective methods is to simply be present, build a rapport and to listen authentically. And listen with a “third ear”—most often the things that people don’t tell you are at the root of their trauma. Treatment takes time, building up each session until veterans are able to recount their traumatic experience all the way through at their own pace.

Final thought: Activism and advocacy serve as unofficial treatments for moral injury, which is why veterans have been at the forefront of social movements throughout history. One veteran who spoke at the Symposium credits joining the anti-war movement with saving his life; another found healing by returning to Vietnam to help build schools and establish hospitals.

In other words, none of us are done serving.

Special thanks to Swords to Plowshares’ Institute for Veteran Policy, the University of San Francisco’s Peace & Justice Studies Program, and the Leo T. McCarthy Center for Public Service & the Common Good.

III. Moral Injury in Military Members and Veterans Handbook

Karis L. Callaway and C. Richard Spates

Subject: Psychology, Clinical PsychologyOnline Publication Date: Jun 2016DOI: 10.1093/oxfordhb/9780199935291.013.69

IV. TEDex Virginia Tech -- The Moral Injury of War video -- Eric Hodges, USMC --


Chaplain Services We are available for spiritual support for inpatients, outpatients and via telehealth for Veterans throughout the health care system. To reach the Chaplain Ofce, call (503) 220-8262, ext. 57021 Monday through Friday 8 a.m. to 4:30 p.m., excluding Federal Holidays, or non-emergent calls. For emergent calls call (503) 220-8262, ext. 0, then ask the operator to connect you to the on-call chaplain phone. Classes and Groups

¦ Chaplains lead a variety of groups at the Portland and Vancouver campuses. To learn more call (503) 220-8262, ext. 57021 or visit the Veteran education and group directory online at, ;

CONTACT: VAPORHCS -- CHAPLAIN SERVICES -- presenter that I met at the Veterans and Military Suicide Prevention Conference (November, 2019) was an Iraq War veteran. Gregory J. Widmer, M.Div, Integrated Health Chaplain Contact information: 360-737-1435,

¦ Topics include: Women’s Group, Mental Health Group/Residential Rehabilitative Treatment Program (RRTP), Grief and Loss, PTSD and Moral Injury Specialized Spiritual Care

¦ We ofer spiritual care in areas such as Home Based Care, Hospice, Palliative Care, Transplant, Substance Abuse, Pregnancy and Infant Loss, Moral Injury, PTSD and Women’s Health.

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