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.
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.