Veterans, civilians, and the sometimes-overlooked wounds of conscience, values and trust

When people think about psychological injuries associated with military service, they usually think about PTSD. But there is another idea that I think deserves much more attention: moral injury.

Moral injury can occur when we do something, fail to prevent something, witness something, or experience a betrayal that seriously conflicts with our deepest values and beliefs about what is right.

It can involve guilt and shame, but also anger, grief, disgust, loss of trust, or a profound sense that something about ourselves—or the world—has changed. For some people it raises spiritual or existential questions: What kind of person am I now? How could people I trusted have allowed this? What do I believe anymore?

You Don't Have to Have Been in Combat

Much of the early work on moral injury came from the military, for understandable reasons. Military service can place people in situations involving responsibility, loyalty, authority, life-and-death decisions and actions that would be almost unimaginable in ordinary civilian life.

But you don't have to have been in combat—or even have served in the military—to experience moral injury.

A health-care professional forced to provide care under conditions they believe are unsafe can experience it. A first responder who couldn't save someone can experience it. Someone who remained silent when another person was being harmed may carry it. So can someone who was seriously betrayed by an institution, employer, religious community, profession or person they trusted. Research on moral injury now extends beyond veterans to groups including health-care workers, first responders and civilians.

Sometimes the wound isn't simply “something terrible happened to me.”

It is closer to:

“Something happened that violated what I believed was right.”

That distinction can matter enormously in therapy.

Moral Injury Isn't Quite the Same as PTSD

Moral injury and PTSD can certainly occur together, but they aren't identical.

PTSD often involves fear, threat, intrusive memories, avoidance and a nervous system that remains prepared for danger. Moral injury may centre much more heavily on guilt, shame, anger, betrayal, forgiveness, trust and meaning. Someone can experience significant moral injury without meeting the diagnostic criteria for PTSD.

That means healing sometimes requires more than simply reducing anxiety or processing a frightening event. We may also need to explore what happened to someone's understanding of themselves, other people and the values by which they want to live.

Veterans Also Have to Navigate the System

There is another difficulty I see for veterans: getting help can itself become a complicated undertaking.

There can be Veterans Affairs benefits, disability claims, assessments, treatment authorizations, insurers, medical providers and different programs to navigate—often at precisely the time when someone has the least energy for bureaucracy.

For some veterans, experiences with large systems can also intersect with the original injury. When someone already feels let down by leadership or an institution, having to repeatedly explain or justify an injury can be particularly difficult.

Therapy shouldn't become one more system a person has to fight with.

Finding a Way Forward

One resource I've found particularly interesting is The Moral Injury Workbook by Wyatt R. Evans, Robyn D. Walser, Kent D. Drescher and Jacob K. Farnsworth. It uses principles from Acceptance and Commitment Therapy (ACT), with an emphasis not simply on getting rid of painful thoughts and feelings, but on reconnecting with one's values and developing a meaningful way of living alongside what cannot simply be undone.

I like that approach.

Healing from moral injury doesn't necessarily mean deciding that what happened was okay. Sometimes it wasn't.

It can mean developing a more compassionate and complete understanding of ourselves, making room for grief or anger, examining responsibility honestly, reconnecting with other people, and deciding how we want to live now.

And that last question feels particularly relevant in the times we're living through. Many people—not only veterans—are struggling with polarization, war, institutional distrust, injustice and events that challenge their assumptions about other people and the world.

We can't control all of that.

But we can examine what matters to us, what we want to stand for, and how we want to participate in the world around us.

Sometimes that is where healing begins.

— Rory Batchilder, M.Ed., RP, CCC
Registered Psychotherapist & Canadian Certified Counsellor
Former Canadian Naval Officer