Different paths can lead to moral injury following military trauma


Fear for one’s life is considered a normal reaction to a traumatic event, nonetheless it is far from being the only common reaction observed in response to trauma.

In a recent study, Center of Excellence Investigators, doctors: Sheila Frankfurt, Bryann DeBeer, and Eric Meyer, and their colleagues explored the effects of another typical reaction to trauma that has been largely understudied: moral injury.

Photo of Dr. Sheila Frankfurt

Dr. Sheila Frankfurt is an investigator at the VISN 17 Center of Excellence for Research on Returning War Veterans.

Moral injury refers to a psychological harm resulting from either (1) acting, failing to prevent, or witnessing actions that violate an individual’s deepest values and principles or from (2) betrayal by a trusted authority figure in a high stakes situation. These actions and events are called “morally injurious events.”

When memories of these morally injurious events are incompatible with Veterans’ own views of who they are and what they stand for, they may experience intense feelings of guilt, shame and rage. If this inner conflict is unresolved, it may lead to a moral injury syndrome characterized by depression, re-experiencing and avoidance trauma symptoms, substance abuse, spiritual/religious decline, and suicide.

Although the typical focus of moral injury research are “perpetration-based” events, Frankfurt and colleagues’ study tested whether the definition of morally injurious events should include military sexual trauma (MST), as this may be experienced as a betrayal-based morally injurious event.

In their study, Frankfurt and colleagues sought to understand the pathways through which military traumas, like combat exposure and MST, ultimately lead to a moral injury syndrome, characterized by concomitant PTSD and depression.

Analyzing data from more than 300 post- 9/11 veterans, the study found that whether traumatic events were appraised as betrayal- or perpetration-based, explained the presence of PTSD-depression symptoms. For instance, in MST, betrayal explained the association between traumatic events and PTSD-depression symptoms, while in combat exposure events, it was perpetration that accounted for this relationship.

Additionally, Frankfurt and colleagues found some evidence suggesting that the self-focused experience of shame, but not the behavior-focused experience of guilt, further links combat exposure to PTSD-depression symptoms.

Overall the results suggest that moral injury can develop through different pathways following military traumas. Given that in recent years moral injury has been identified as a unique source of distress in Veterans, the results of this study are a promising early step in helping identify modifiable factors that can be used to develop targeted treatments to relieve the burden of moral injury.

For more information about research taking place at the VISN 17 Center of Excellence for Research on Returning War Veterans, visit https://www.mirecc.va.gov/visn17/news.asp.

About the author: Richard W. Seim, Ph.D., is the director of Training and chief of Education & Dissemination Core for VISN 17’s Center of Excellence for Research on Returning War Veterans.


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  1. Tammy Rinaldi    

    Funny, it has been my experience that if you’re looking for morality, don’t go into the service. I’m a 25 year MST survivor. Back in my time, the military did not keep stats on sexual assault and trauma perpetrated on service members because they flat out didn’t want to admit this is a HUGE HUGE problem. Because I demanded justice be served, there’s that MORALITY again, I got treated like I was crazy or guilty of a crime myself. Tried committing suicide TWICE. Fast forward 2 decades later, I finally got vindication when I received 70% SERVICE-CONNECTED disability. My 20+ year VSO said I had one of the most documented cases she had ever seen and frankly we were both stunned my file had not been “sanitized”. Because they did that to a LOT of service members. So after suffering 25 years, all I got was retroactive 4 months compensation. No one dares mention morales and the military in the same sentence to me. I signed a check for my life knowing full well, I may loose it. What I didn’t count on was them taking my soul.

  2. Steven Eckert    

    I am witness to the fact the VA still censors what it doesn’t want revealed. You still can’t trust the VA.

  3. jack kauffman    

    I have been in therapy in the VA system for 28 yrs. in the 90’s my therapist had me talk to a priest about stepping over my moral boundary, he called it the dark side of our humanity that combat vets have to do over and over and then we bury it because we don’t want anyone to know what we were capable of doing. we were raised with a morality, thou shalt not kill. weather we were religious or not, and being in combat we crossed that line over and over. we put it in a box in our mind so that no one would see the evil we were capable of. but it will set and fester and explode when it comes out. we need to talk about it without the fear of being judged for our actions. then we can grieve and release it.

  4. Richard G Kensinger    

    I am a former AF ER medic during the Vietnam Conflict. I’ve witnessed horrific physical wounds but now as a clinical psychologist I see the plethora of so-called “invisible” wounds such as TBI, PTSD, clinical depression, and compacted grief. I am not familiar w/ moral injuries.

    I am also quite concerned about escalating suicides in combat vets and non-combatant active duty members. I conduct research on the impact of repeated combat trauma, and have several articles published in this regard. I provide free clinical consultations to Viet Vets particularly.
    I support an array of clinical interventions inc. ongoing group therapy as it recapitulates the essential psychosocial unit: the squad.

  5. John L. Donnelly    

    The writings of Nancy Sherman, philosopher and psychiatrist, who teaches at Georgetown University have been extremely helpful to me as a Vietnam veteran who has suffered, and continues to suffer, from “moral injury”. Her books, “The Untold War”, “After War” and “Stoic Warriors” helped me to better understand my particular version of PTSD. I recommend them to all combat veterans and those who treat them.

  6. Richard Baker    

    I have been working with a Psychiatrist and a Psychologist for a few years with my PTSD issues, and have discussed often about this being one of the roots of my issues. Here at the VA hospital in Indianapolis, I have not only been working with the mental health team but also with the Chaplain’s office with this issue. Working with the mental health department and the Chaplain’s office, along with medications, has provided some relief from the PTSD, but I don’t think it will ever go away. By the way, I am a Vietnam veteran, so this has been around for a long time.

  7. Jerry D Parrish    

    We, the veterans, do not diagnose ourselves well at all. The spouse needs to be involved in most of the diagnosis we go through. They see us for what we are and we see us for what we want to see.
    We do not see the hurt we inflict on other people, spouses do.
    We usually start getting the symptoms “after” we retire.
    We work night and day and stay busy and the symptoms stay hidden from us. Then we retire and suddenly it all comes crashing down on us and we don’t know what happened.

  8. Robin Edwards    

    After reading the article, I was able to finally “name” all of mixed and draining emotions I experience. I wish they would have delved deeper in the study for those whose battling dual moral traumas. MST & Combat, this is a daily double dose of moral trauma and conflict for more veterans than people realize. It’s a start

  9. NICK GIAMPA    

    This describes exactly what I’ve been feeling/complaining about for years. Never able to really put a finger on it until reading this article. Now that it is defined, what can be done to remedy it? Is there a remedy?

  10. August    

    A lot of veterans can never get treatment due to the VA’s mandatory “Release of Medical Information” forms that veterans are required to sign. Why can’t the veterans get help & treatment without the VA telling the entire entire world their most personal issues?

  11. Anthony Shaw    

    Morals are Major keys, Laura . Thank you for your post as i feel a sense of corruption by serving the same government that allows lies to soilders who look up to the upper command chain. I gotten raped by a older seargant because his wife was having issues, and seargant * forced me and humiliated me, told me to do it or id be domoted. Morally and Mentally ill struggling to stay strong through the last few months not knowing my failure to admit to myself the shame and guilt of disgust back in 2010. I tried to commit suicide at the cemetery. The captain saw me as failing to be on time … truth is probably busy training I had a Trumatic brain injury. I would show up to information that was not scheduled, as well as not show up to schedule formations . when being just charged by medical dental vision and psychiatric, one sergeant and me with the psychiatric test , I was under the impression that they were looking out for my best interest. They put on my DD 214 stuff back then I didn’t understand but now I know. Captain at Fort Sill prior to discharge explain that in months my status will automatically upgrade from general to honorable . Right now it is 2019 , yet, found myself using substance call me talking to myself tumors in my body , haunting thoughts for instance just know I just parked my car I am morally beat myself up for an hour at a time off the highway. This also led to a lot of doubt personally in The United States System. On march 28th 2019 i also have a sentence date from Pima County supreme court in the state of Arizona versus myself in a Legal battle. My intentions were harmless But now I feel like I had went from hero (320 pt scores) to zero i’m possibly could be facing jail time, in this state I have no family over a year now. Still I continue to harm myself because of morales that were instilled in me. I am what i am black or white, but because of the color of my skin even though I ignored it, i had bigger things to worry about, still affecting our Civilization.

  12. Laura Egudi    

    I guess i was not so crazy after all. That is exactly what i been labeling my experiences, moral injury. Wow. What do i do with this info. Im so tired of the ups and downs.

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