Questions and Answers about the War Wound 'Moral Injury'

A psychological wound known as moral injury is gaining attention in the aftermath of the wars in Iraq and Afghanistan, with U.S. veterans now being treated for these injuries to the soul — even as medical experts debate whether moral injury is a condition unto itself or a subset of post-traumatic stress disorder.

Some questions and answers about moral injury, and how it compares with and differs from PTSD:

WHAT IS MORAL INJURY?

Moral injury is when veterans feel extreme guilt and shame from something they did or witnessed in conflict that goes against their values, or may even be a crime. The term was introduced in the 1990s by a now-retired Department of Veterans Affairs psychiatrist, Dr. Jonathan Shay, who diagnosed the problem in Vietnam veterans he was treating. Shay has identified two kinds of moral injury: service members blame themselves for something that violated their own moral code, or someone of trust did something that went against a service member's beliefs.

WHAT ARE THE SYMPTOMS?

The symptoms and ensuing behaviors often mirror those of PTSD. Sufferers may experience suicidal thoughts, withdrawal, hypervigilance, agitation and nightmares. Often they are demoralized and behave in a self-destructive way, such as binge drinking, doing drugs and destroying relationships.

HOW IS MORAL INJURY DIFFERENT FROM PTSD?

Those who study moral injury, including Shay and military trauma expert and clinical psychologist Brett Litz, say that PTSD is fear-based, stemming from a life-threatening event, while moral injury is rooted in feelings of shame and guilt. With PTSD, loud noises or chaotic crowds may trigger a flashback. With moral injury, veterans engage in self-torment, punishing themselves with constant self-recrimination.

HOW WIDELY IS IT RECOGNIZED?

While the idea of warriors feeling remorse over battlefield horrors is not new, moral injury has gained more attention in recent years. Some mental health specialists point to it as a reason why veterans aren't improving with PTSD treatments. The VA website includes a page dedicated to moral injury, and the Navy now runs one of the military's first residential treatment programs that addresses the problem.

CAN ONE BE DIAGNOSED WITH MORAL INJURY?

No. The mental health community has not developed an official diagnosis for moral injury. As a result, there is no set of clinical practice guidelines specifically for the condition. However, mental health providers often address moral injury when treating PTSD. Some believe moral injury is a subset of PTSD. Others say it is a separate mental injury that should be clinically defined.

HOW MANY MILITARY MEMBERS SUFFER FROM MORAL INJURY?

Because there is no clinical diagnosis for moral injury, the military and VA do not track moral injury cases specifically. Most service members who are being treated for moral injury have been diagnosed with PTSD. More than 390,000 veterans of the Iraq and Afghanistan wars have sought help through the VA for PTSD.

HOW IS MORAL INJURY TREATED?

The treatment differs from that for post-traumatic stress. PTSD sufferers can find relief with prescription drugs and private counseling that encourages reliving the triggering incident to work through fear. That's not the right approach for moral injury, the experts say. Treatment for moral injury focuses on acceptance and forgiveness. One aspect of it is "adaptive disclosure therapy" — which involves asking patients to reveal their triggering incident to other veterans also seeking to recover.

WHAT PROGRAMS TREAT MORAL INJURY?

The Navy offers a two-month residential treatment program for active-duty service members who have not found success with treatment for PTSD. Called Overcoming Adversity and Stress Injury Support, or OASIS, patients stay at a Navy facility in San Diego, where they participate in group therapy, learn coping skills and may partake in yoga, meditation, volunteer work. The therapy includes writing down and sharing with others what triggered the trauma, writing a letter of apology or reconciliation and crafting a letter to a benevolent figure. Brite Divinity School in Fort Worth, Texas, runs the Soul Repair Center, which is researching methods to assist chaplains and other religious leaders in how to address moral injury.