A Vietnam Veteran’s Lament: ‘What Might Have Been?’

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Moral Injury: A Phenomenon as Destructive—And More Deadly—Than Post-Traumatic Stress Disorder

According to Psychology Today, “Moral injury is the social, psychological, and spiritual harm that arises from a betrayal of one’s core values, such as justice, fairness, and loyalty. Harming others, whether in military or civilian life; failing to protect others, through error or inaction; and failure to be protected by leaders, especially in combat—can all wound a person’s conscience, leading to lasting anger, guilt, and shame, and can fundamentally alter one’s world view and impair the ability to trust others.

Unfortunately, the term nor the condition itself is currently diagnostical because neither the government nor the American Psychiatric Association (APA) has recognized it.  In fact, the APA:

“. . . has rejected every diagnostic concept that even hints at the possibility that bad experience in adulthood can damage good character. It has rejected what numerous clinicians following Judith Herman, MD and Mary Harvey, PhD call “Complex PTSD,” but which the APA atrociously named in its field trials, “Disorders of Extreme Stress Not Otherwise Specified (DESNOS).” It has rejected “Enduring Personality Change after Catastrophic Experience,” which is a current diagnosis in the WHO International Classification of Diseases, and “Post Traumatic Embitterment Disorder.”

Jonathan Shay, MD, Ph.D, a pioneering psychiatrist, has developed this definition of the term “Moral Injury” in a 2014 paper of that title:

It has been used in two related, but distinct, senses; differing mainly in the “who” of moral agency. Moral injury is present when there has been (a) a betrayal of “what’s right”; (b) either by a person in legitimate authority (my definition), or by one’s self—“I did it” (Litz, Maguen, Nash, et al.); (c) in a high stakes situation.

Both forms of moral injury impair the capacity for trust and elevate despair, suicidality, and interpersonal violence. They deteriorate character. Clinical challenges in working with moral injury include coping with [1] being made witness to atrocities and depravity through repeated exposure to trauma narratives, [2] characteristic assignment of survivor’s transference roles to clinicians, and [3] the clinicians’ countertransference emotions and judgments of self and others. A trustworthy clinical community and, particularly, a well-functioning clinical team provide protection for clinicians and are a major factor in successful outcomes with morally injured combat veterans.

While MI remains an unrecognized clinical diagnosis, it is something currently being studied and considered for future use (see here and here for example).  Compared to PTSD, for which similar symptoms are manifested, the only real difference is the manner in which injury occurs, and the fact that the proximate causes on PTSD are more objectively quantified; but the fact that one is more provable than the other shouldn’t be the only criterion measured.

See: https://watson.brown.edu/costsofwar/files/cow/imce/papers/2021/Suitt_Suicides_Costs%20of%20War_June%2021%202021.pdf

ADDITIONAL REFERENCES

https://psychcentral.com/blog/a-day-in-the-life-of-a-mental-hospital-patient#1