"Moral Violation" is a term that has emerged in the past thirty years and describes a particular response to events that occur during the course of a service member's military experience. It is closely related to, but also separate from, post-traumatic stress disorder (PTSD). Events that can cause moral injury are also likely to be traumatic, catastrophic physical injury, or loss of another service member. However, moral injuries can occur separately from PTSD.
The concept of moral injury emerged from the work of clinicians with combat veterans who had difficulty adapting to their lives after returning from the conflict. The sentence was coined by psychiatrist Jonathan Shay based on observations made while working with veterans in an ambulance at the Department of Veterans Affairs in Boston. In his book Achilles in Vietnam, Shay introduced the concept of moral violation and defined it as the psychological, social, and physiological result of a betrayal of "what's right" by a government agency in a high-stakes situation. He further describes how military experience, and especially combat, can sometimes change service members' beliefs about what's right and what's wrong.
Later, psychologist Brett Litz and his colleagues refined the concept and described moral violations as an effect of actions that cause dissonance and conflict because they violate assumptions and beliefs about right, wrong, and personal goodness. Morally harmful acts include events such as "… committing, not preventing or witnessing acts that go beyond deeply rooted moral beliefs and expectations".
Moral Violation and PTSD
Moral injury is a group of symptoms that, as mentioned above, are associated with but separate from PTSD. Efforts are made to distinguish between the two and to recognize moral injuries as a common and different syndrome that requires targeted treatment. Several factors make this distinction difficult. One of the difficulties is that an event that meets Criterion A of the Diagnostic and Statistics Manual for Mental Disorders (DSM-5) for PTSD – exposure to death, impending death, actual or impending serious injury – also violates deep-seated beliefs can. For example, an action can be morally harmful if the client believes that it was unjustifiable or should have been prevented.
Identifying moral violations among individuals is complicated by the fact that service members are trained to overcome social taboos against killing or causing serious injury to others. In basic military training, trainees make an effort to overcome an aversion to violence. Bayonet training, hand-to-hand combat, and weapon training with realistic, man-made plastic targets are methods designed to help individuals overcome the natural tendency to avoid violence. In his book "On Killing: The Psychological Cost of Learning to Kill in War and Society", Lieutenant Colonel Dave Grossman quotes a study by military historian Brigadier General S.L.A. Marshall referred to the shot rates of soldiers in World War I. Grossman states that Marshall found that a significant number of rounds fired failed to hit the target, and that many soldiers did not aim at their targets, but shot away from them.
In "Assessment of moral injury to veterans and military personnel on active duty with PTSD: A Review," a 2019 article published in Frontiers in Psychiatry, the authors claim that moral injury is related to PTSD can occur, but a separate one is syndrome.
In particular, a service member or veteran may have PTSD without moral injury, may have moral injury without PTSD, may have both, or may experience events that meet criteria A but have none.
Treason as a core concept
The core aspect of moral violation is betrayal: betrayal of one's own basic convictions, betrayal by others, or both. In my clinical experience as well as in my own experience, moral injury is an essential aspect of military service. The response or behavior of a service member or veteran to moral violations can cause significant stress. Of course, this complicates the transition to post-military life.
While there are a number of major outrageous manifestations of moral violations, such as My Lai in Vietnam and Abu Gharib in Iraq, there are also more subtle manifestations of moral violations. When I was growing up, I was always taught to obey traffic signals, to exceed the speed limit – to be a "good driver". This behavior was "correct". However, when we came to Iraq and Afghanistan, things that were "right" became wrong. There are no stop signs in Iraq and no traffic signs in Afghanistan. A one way street was the way we went. This was not due to the fact that the service members were bullied or did not take care of the safety on site, but because of a safety measure. Then we had to go back to a community of rules and laws and adjust to what was right but seemed wrong overseas.
This is another complicating factor in moral harm. Some behaviors may be acceptable in one environment, but not in another. In an interview for my 2018 podcast Head Space and Timing, psychologist Shira Maguen, a VA clinician who is an expert on moral injuries, describes how a service member can engage in behaviors that are not morally harmful at the time , such as B. Killing or targeting violence on an enemy. These measures are necessary in the context of a combat situation and are even promoted. However, if the service member returns to an out-of-combat environment or relative security, these measures may not be considered acceptable and may therefore be morally harmful.
Combating moral injuries
As mentioned earlier, it is important to investigate whether a veteran suffers a moral injury due to his military experience. Many veterans, like many clinicians, may never have heard of the term, but once they understand the concept, you understand it immediately. When discussing these distinctions with another veteran (not a customer), he said a lightbulb was going out in his head.
This veteran, a navy who served in Operation Iraqi Freedom, was on a roof and prepared the guard for a raid. He saw a movement in the alley below, asked the person to answer with a password, and opened fire on the figure in the alley when he received no answer. It turned out that the person in the alley was a marine colleague who had been injured in the leg. While the wounded marine was finally recovering, my friend was feeling a lot of guilt about the incident. After leaving the military and entering therapy, he was repeatedly told that he was struggling with PTSD. But only when he heard of moral injuries did he understand that what he was experiencing was different from a traumatic stress response.
In the next columns, I will address other critical aspects of the moral violation, including survivors' guilt, the difference between shame and guilt, and the assessments and modalities available to help service members, veterans, and their families, one Measure to get relief from the burden of moral injury.
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Duane France, LPC
Duane France is a retired noncommissioned officer and combat veteran of the United States Army who practices as a licensed professional advisor in Colorado Springs, Colorado. He is the director of veterinary services for the Family Care Center, a private outpatient psychiatric clinic that specializes in service members, veterans and their families. He is also a director of the Colorado Veterans Health and Wellness Agency, a 501 (c) 3 nonprofit that is professionally affiliated with the Family Care Center. In addition to his clinical work, he writes and talks about veteran mental health on his blog and podcast on Veteranmentalhealth.com. Contact him at [email protected].
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