The Hidden Trauma of Moral Injury

As you enter the dimly lit space, you sit down in one of 10 chairs arranged in a circle. Others file in and choose their seats, each person facing several others. You wait. Then, you begin to hear the voices of other men and women, invisible to you, speaking from all sides of the space. The voices rise above the ambient sounds and music in the background. First, you hear a young man. His voice is prerecorded, disembodied, but still urgent and compelling. He’s telling you and the others about how he’d witnessed the towers burn in New York City on 9/11, and how he’d pledged not to let anyone do that to our country, ever again. After he’d enlisted, he was deployed to Afghanistan, but there, things didn’t unfold as he’d anticipated. The surprise raids he’d made on peoples’ homes weighed heavily on him. He can’t get it out of his head: what if an occupying army was busting into houses in his home state of New Jersey? The homes and families he’d raided had seemed eerily like his own.

Describing one such raid, he says, “I saw how frightened the kids were as we searched the house and then arrested their father because we’d found a gun. As we took him away in handcuffs, I knew he’d probably be sent to Abu Ghraib.” His voice caught. “Where he’d be interrogated and tortured.”

He said that each time he participated in these raids—numerous times a day, day after day—he couldn’t help but wonder what the U.S. was doing in this faraway land, and why he was systematically destroying families’ lives. His distress deepened as he realized that he couldn’t speak about any of this with any of his fellow recruits: “staying strong” was an unspoken and unbreakable rule.

At one point in the audio, you hear the young man’s voice eerily multiply, as though voices in his head are coming from all directions: What have you done? They were just living their lives. For 10 years I’ve been wracked by guilt. I’ve been out of work. My marriage is on the brink of falling apart. I’ve felt like killing myself. I still can’t get it out of my head.

This scene might sound straight out of a novel, perhaps a psychological thriller. But nothing here is fictional. This is the voice of a real man, sharing a real experience. His story is part of a public art installation I helped to create on the largely misunderstood mental health impact of a specific type of traumatic injury—moral injury. Many voices are heard in this installation, and they sound a common theme: the experience of relentless guilt, shame, and grief for actions, or failures to act, in wartime. Moral injury is often suffered in isolation, and frequently leads to depression, a sense of hopelessness, and sometimes the decision to end one’s life. In fact, moral injury has been recognized as one of the most significant contributors to the high rate of suicide among U.S. veterans, which is currently 17 a day. In the past 20 years, more veterans have died from suicide than in combat.

As a psychologist who’s treated scores of journalists who’ve covered the wars in Afghanistan and Iraq, I’m passionate about our need to better understand the phenomenon of moral injury and how to effectively treat it. Many who suffer it also struggle with PTSD but, importantly, it’s not part of PTSD. Moral injury is not a diagnosis, but rather an ethical and spiritual crisis, a kind of wound to the soul. We see it in veterans and wartime journalists, but also in many first responders, notably healthcare providers during the covid crisis who were forced to choose who would—and who wouldn’t—get emergency care.

Moral injury occurs when individuals feel responsible for, or complicit in, behaviors that violate their fundamental values. It can’t be resolved using conventional trauma treatment approaches, because the suffering is rooted in conscience, not fear. If we’re to truly help people suffering moral injury, we’ll need to rethink some key assumptions about the nature and healing of certain kinds of trauma.

The Toll of Moral Distress

For the past 20 years, I’ve sat in my therapy office listening to troubled reporters and photographers who’ve returned from covering war and all that accompanies it—the atrocities, the losses, the terrible privations. Over time, I began to realize that while many journalists were struggling with post-traumatic stress reactions, a good number were also suffering a kind of moral anguish in response to what they’d seen and experienced. Some were dogged by intense guilt for being able to leave the war zone while their local colleagues had no such choice. Others were burdened by survival guilt after having lost fellow journalists or soldiers they’d come to know and care about. Still others felt unable to report the real extent of war’s devastation, only the spruced-up versions that the military deemed acceptable for consumption by the American public. As one photographer bitterly put it, “I felt I was doing public relations for the military.”

Guilt and shame, of course, are fed by silence. In war zones and other crisis areas, people typically receive messages to “keep it together” and not speak of anything remotely resembling moral conflict. The prevailing mindset is that whatever transpires under high-stakes circumstances—be it on the battlefield or in an emergency-room triage setting—is simply the reality of living with danger and the need to make split-second decisions. Said one veteran about the cost of sharing vulnerable emotions: “You would not be fulfilling your image as a strong soldier. So you live with it alone.”

And the moral anguish can persist, for years and even decades. Dave, a retired Navy Seal commander, told me about his experience fighting against peasant insurgents in El Salvador in the 1990s. At one point, his squad came face to face with one of the leaders of the revolutionary group. “He was just a kid of 17,” Dave said softly. “He was a revered leader of these peasants who were fighting for their survival. The group I was with was reluctant to kill him.” He took a long breath. “So I took my gun and shot him.”

Dave looked down for several seconds, composing himself. Then he looked up at me. “What was I doing there in El Salvador, massacring these peasants?” he asked softly. “We were on the wrong side.” He grimaced. “I still find this painful.”

Sometimes, trauma and moral distress are experienced simultaneously, which can make them challenging to tease apart and recognize as distinct conditions. One veteran I interviewed described how he’d survived a grenade attack on his convoy and then shot and killed the boy who’d thrown the grenade that had killed his comrades. The child he shot was five years old. In the wake of this shattering experience, the veteran suffered the trauma of having come so close to being killed himself, but he was also dogged by the devastating guilt of having killed a child. Even though he could tell himself that the deaths of children were inevitable in war, when he was back in the U.S. and watched his niece and other children playing, it triggered the memory of what Iraqi kids endured due to his country having engaged in a war under false premises—and the part he played in their suffering.

In it Together

As I became more deeply interested in the problem of moral injury and began to attend conferences on the topic, I found myself increasingly uncomfortable with the prevailing view that this ethical distress was located entirely within the individual and should be treated as such. Instead, I began to see moral injury as a disruption of relationship, a wound that a person inflicts, or feels they’ve inflicted, on another person or persons. I began to see that moral healing required not only individual work—the form of most trauma treatment—but also a very particular experience of community. As therapists well know, everyone needs a safe space to speak their truth to others, people who can listen and understand with genuine empathy. Being heard in this way can be tremendously reparative, helping to legitimize a person’s experience and replace the darkness of self-blame and isolation with the light of self-forgiveness and connectedness.

But a bigger relational dimension is at play, too, one that makes speaking up and feeling truly heard equally critical. I’ve come to believe that we need to look at collective moral injury: that is, the larger social and political factors that compel people to commit moral violations in the first place. For ordinary civilians, this requires a difficult personal reckoning. Each of us, I believe, bears some responsibility for the suffering of those pushed to commit ethical injuries in the name of their government, be it in the form of military priorities or social policies. Those struggling with moral distress need to know that the rest of us truly hear what they’ve endured, and recognize that we’ve helped to create and maintain a society that forces many of its citizens to perpetrate or witness immoral behavior. When we acknowledge our part in creating another human being’s moral distress, it can not only help to heal the individual, but also, we hope, spark collective action to address larger societal problems.

I’ve been greatly influenced by others who’ve developed this testimonial approach to promote emotional healing. Chilean psychologists Elizabeth Lira and Eugenia Weinstein found improved mental health in survivors of Pinochet-era torture who shared their horrific suffering to create evidence for a later war crimes tribunal. I’ve been fortunate, too, to personally experience this approach as a listener. At the Philadelphia VA hospital, chaplain Chris Antal and psychologist Peter Yeoman developed a program featuring 12-week discussion groups in which vets shared with each other their experiences of moral injury and were helped to clarify and recover their basic moral values. Afterward, a communal healing ritual took place at the hospital’s chapel, wherein each participant stood at the pulpit and shared their definitions and experiences of moral injury with an interested public. As a member of that audience, I found myself horrified by what these men had endured and impressed by their courage to come forth and speak despite a deep sense of shame.

Once all the veterans had spoken, we civilian audience members were invited up to the pulpit, where we walked in a circle around the men, looking deeply into each one’s eyes and placing our hands on their shoulders. This communal ritual sparked something in me—a sense of genuine connection with these men, and through that jolt of solidarity I felt my own part in their suffering. It evoked for me the many times I’d seen similar pain in the war correspondents I’d treated in therapy and my own sense of helplessness about addressing the U.S. policies that produced the atrocities of war.

I Hear You

The more convinced I became of the healing power of sharing moral injury accompanied by genuine listening and acknowledging, the more I was drawn to creating communal spaces within which these essential processes could unfold. I’d already facilitated a fair amount of collective healing and resilience-building in Kosovo with war-torn communities, via training projects with journalists covering war, and in my own Lower Manhattan neighborhood following the 9/11 attacks. Much of this work focused on exploring experiences of trauma and fostering shared strengths in affected communities. From these projects and others, I’d heard many people talk about trauma that triggered fear and panic, but also about incidents that sparked enduring shame and guilt.

By 2018, I’d decided to create something new to address the moral suffering and radical disconnectedness felt by veterans and wartime journalists—a public art installation called the Moral Injuries of War. Together with a team of researchers and people engaged in the arts, sound design, oral history, and associated fields, we designed an installation wherein, through prerecorded audio interviews, veterans and war correspondents from the wars in Afghanistan and Iraq shared their experiences with members of the public. Afterward, as audience members made their way out of the listening space, they were asked to leave either a written or recorded message about how these anguished stories had affected them. These messages were then passed on to the veterans and war correspondents. In this way, we hoped to facilitate a genuine dialogue between survivors and the public, one that was both personally healing and galvanizing in ways that challenged systemic societal injustices.

The installation debuted in 2019 at the UNFINISHED festival at the National Museum of Art in Bucharest, Romania. Many who attended said that through listening to the voices of veterans and journalists struggling with ethical dilemmas, they’d had a visceral experience of the nature of war. Since then, the program has been presented across the U.S. to audiences of veterans, refugees, immigrants, and ordinary citizens.

Most recently, in June 2023, Moral Injuries of War was presented as an interactive performance at the National Sawdust space in Brooklyn, New York. The two-night experience was sold out, with over 140 people in attendance each evening. The event involved a preparation for listening and responding compassionately to the audio installation as well as to veterans who attended in person and engaged in a facilitated public conversation about their war experiences.

In addition to these powerful testimonies, both prerecorded and live, we also heard moving responses of audience members to what the testimonies evoked in them. One person responded: I grew up in a small, working-class town where Memorial Day was devastating because every family had lost multiple people in some war. Living there, you get the sense that humans are disposable—as we heard in many of the stories tonight. One of the ways I’m engaged with that now is by being a lawyer for intimate partner violence survivors, specifically people whose relatives were in the military and came home and committed violence. The violence that comes after war when people don’t have tools to deal with their trauma is something I grew up with in my own family system, in my own community.

To date, over 3,000 people have participated in Moral Injuries of War presentations, either in person or online. We’re now looking to take the interactive performance to even larger venues.

We’re All Implicated

You may remember Dave, the man who shot a 17-year-old revolutionary leader in El Salvador, who went on to share his story for the installation. He’d been the perpetrator of violence, which is obviously a powerful generator of moral distress. Less appreciated is the anguish that can be caused by witnessing violence and not being able to stop it. That’s why the installation included the voice of an African American man from Alabama who’d found himself in an excruciating situation while serving in Iraq in 2013. He and his squad had been sent out to a small village, where they’d come upon an Iraqi military contingent engaged in a massacre of the local civilian population.

“We were told to stand down and not intervene,” he says. “I’ve never been able to make sense of this—just to follow orders and not question, especially in a situation . . . like this.” He takes a long breath. “It’s disturbed me to this day. I finally feel the need to speak about it in public.”

The ambient background music swells and now the circle of listeners hears another voice, and then another. A female journalist speaks of her deep sense of helplessness in the face of the suffering of local civilians who were terrified and bewildered by all that was going on, and her grief about the terrible loneliness of the young combatants themselves. She says: “Again and again, I saw them breaking into tears as they spoke with their loved ones back home.”

One soldier ends his story with a direct message to his circle of listeners: “I’m not asking you to take away my pain,” he said. “I’m just asking that you realize that you’re implicated in my pain.”

The Heart of Moral Repair

When we suffer moral distress, we typically get lost in convictions about our badness, our unforgivable failures as human beings. What’s harder to grasp—but vital for sufferers to take in—is that moral distress actually springs from our essential goodness, which is bound up in our caring relationships. When we find ourselves in situations that disrupt natural human connection—when we’re pressured to cause others harm, or when we witness harm and do nothing—we plunge into a form of radical distress. In these crises, we’re faced with a kind of Sophie’s Choice, wherein we have to make the excruciating decision to either protect others or protect ourselves, in some cases with life-or-death consequences. When we choose ourselves, often under duress, the ethical part of us suffers. And our souls drop into darkness.

That darkness may lead to depression and thoughts of ending one’s life, or it may trigger a kind of self-protective freezing of the spirit, a sense that one is unworthy of being loved, which then leads to the abandonment of care and compassion for others. For some, it causes a severe relational split in which only certain people are felt to be deserving of one’s care, while others aren’t human enough to warrant it. Racism and xenophobia can spring from such a fracture. Thus far, our culture has done little to facilitate a collective reckoning about the moral violations of war, and it grapples even less with the moral abuses of racial injustice and countless other assaults on human equality and dignity.

The heart of moral repair involves guiding the soul out of its dark place and into the light again. This is hard and harrowing work: for some people, it takes years to heal their splintered spirits and recover wholeness. Others never do. But the invitation for therapists is clear: we need to help morally distressed people experience their essential goodness, which includes a process of breaking through isolation and sharing their experience, feeling fully heard and acknowledged, and finally, witnessing others share responsibility for the larger social ills that have contributed to their moral distress. We need to approach moral pain not as part of a mental disorder, but rather an injury to the soul. It’s a rupture. It certainly can be a trauma. But to heal, traditional trauma treatments won’t be enough. More is needed: such as access to spaces where those struggling with moral injury may receive peer support or facilitated groupwork, and programs where veterans can engage in dialogue with members of the public. At its core, healing moral distress is about love and accountability. Let’s lead with that.

ILLUSTRATION © ADOBESTOCK/ADAM