Unseen Wounds: Understanding Moral Injury

Discover the hidden psychological wounds of moral injury and how they profoundly affect our service women. Unpack the foundational elements of moral injury that separate it from PTSD, and learn about the emotional and psychological toll it takes on those in the military. Inspired by the groundbreaking research of Jonathan Shay and others, this episode sheds light on the situations that often lead to moral injury, including betrayal by authority figures and the pressure of high-stakes decisions. Real stories from women veterans bring these discussions to life, offering an intimate look into the struggles and resilience required to navigate these challenges.

Meet Ellie, whose heartrending story of sexual assault and its aftermath sets the stage for a broader discussion on the mental health struggles faced by women in the military. From issues of trust and self-worth to symptoms like anxiety and depression, these narratives reveal the multifaceted impact of moral injuries and their lasting consequences. Through the experiences of women who have faced combat situations, hostile environments, and other violations, we confront the complex reality of moral injury, emphasizing the necessity for understanding and empathy.

Learn about the vital work being done by the Moral Injury Support Network for Service Women Incorporated in North Carolina, an organization dedicated to aiding service women in their recovery journeys. We discuss how community support, prevention, and education play a crucial role in healing, and how your contributions can sustain these efforts. With stories of strength and the promise of hope, this episode highlights the importance of addressing and supporting moral injury survivors through shared understanding and active support.

Chapters

• 0:35 Understanding Moral Injury in Women
• 15:59 Impact of Moral Injury on Women
• 22:17 The Impact of Moral Injury
• 40:26 Supporting Moral Injury Among Women

Transcript

Speaker 1: 0:35

Hi, welcome to the Moral Injury for Service Women podcast. Today I want to talk about unseen wounds, understanding moral injury First. I'm going to do over the next few months I'm going to do a series of podcasts on moral injury understanding what it is, what can cause moral injury, how it affects people, and so on is what can cause moral injury, how it affects people, and so on. The main focus is on service women, of course, but moral injury doesn't just affect military women. It affects any human being can suffer from a moral injury. You don't have to be military, you don't have to be of a certain gender, you don't have to live in a certain place. I mean, moral injury can affect anyone. It is a human phenomenon, which means it's been around since the very beginning of human life. So this month's episode really is about understanding the basics of moral injury. We'll look at some definitions of moral injury, understand how it is distinct from PTSD and also how it is related to PTSD. We'll look at how moral injury originally began to be conceptualized and some of the science behind moral injury. Talk about some real life experiences based on research that I have done with women veterans and other women veterans I've talked to in the course of providing spiritual support, and not just women, veterans but I'll talk about some stories and experiences of men that I've also helped with and that will hopefully help you understand how, get a little deeper insight into moral injury and what it works. We'll talk a little bit about healing and recovery, some of the approaches to healing, about moral injury. We'll do more of this in a later episode, but I'll touch on it later today and then just touch a little bit on prevention and education related to moral injury. So that's what I want to cover over the next few minutes and, as always you can, you can reach out to us Moral Injury Support Network for Service Women Incorporated. You can find us on the web at https colon backslash, backslash misnsorg. You can Google Moral Injury Support Network. Come out right on top. You can find our LinkedIn page. We're on all the social media sites. You can call us at 910-701-0306, where you can reach out to me at droberts, at misnsorg, and I'd love to speak with you more about moral injury or help you with moral injury if you're feeling that you've experienced a moral injury, or provide some training to you and your organization related to moral injury.

Speaker 1: 4:12

So let's look at some definitions of moral injury. At some definitions of moral injury, jonathan Shea, one of the first, if not the first researcher provider to develop moral injury as a concept, defined moral injury as a betrayal of what's right by someone who holds legitimate authority, like, for example, a leader, a military leader, in a high stakes situation. So with Johnston Shays definition you have three key components of betrayal, or four components of betrayal of what's right Someone who holds legitimate authority and a high stakes situation. So I guess that's right. Someone who holds legitimate authority and a high-stakes situation. So I guess that's three. But those are sort of the key components as Jonathan Shay defined it.

Speaker 1: 5:11

Now Litz and his fellow researchers came along. They conceptualized it as perpetrating, failing to prevent, bearing witness to or learning about acts that transgress deeply held moral beliefs and expectations. So in that definition we get a little better sense of the different ways that moral injury might happen. One is perpetrating. You could morally injure someone else or moral injury yourself by perpetrating some moral wrong against someone else. And so there are, there are plenty of people who perpetrated, who are perpetrators and they also feel more moral injury, as well as their victims, who do Failing to prevent, if you know that some immoral things are happening, some bad things, something's going to happen that's going to some trauma or tragedy that's going to happen, that's going to some trauma or tragedy that is going to happen to someone else, or something that someone's going to do to someone else, and you have the chance to prevent it. You don't, um, you can cause a moral injury to yourself because you fail to prevent, and there were.

Speaker 1: 6:37

There are plenty of women veterans I've talked to that feel that they could have maybe done something to prevent a sexual assault happening from them or happening to a friend or someone else they know. Or one woman was a sergeant major and after a long career she really struggled with the idea that, as a leader, I should have done more to help and support other women or to prevent them from being sexual assaulted. There's in many cases a person may think they're able to prevent a moral injury, but they're really not. They were actually disempowered during the whole time and that's why they didn't prevent it. But looking back, it's very easy to think, hey, I could have done something, I should have done something, and then have a lot of guilt and shame because of it.

Speaker 1: 7:35

Along a similar vein, you can be someone who bears witness to a moral injury. You see something that happens that you can't prevent and it really wounds you and bothers you. Many, many soldiers I've talked about in deployments. A great example of this is in the pullout of Afghanistan, where many soldiers had to witness the tragedies of what was happening to the Afghani civilians and they were prevented from doing anything about it and they're bothered extremely. They are holding a lot of guilt and shame now because of it.

Speaker 1: 8:20

You can actually just learn about acts that transgress deeply but held more beliefs and expectations and that can cause a moral injury. Because just hearing about it, hearing what someone else is going through or has gone through um can be extremely difficult to deal with. And we see this with care providers. You know counselors, psychologists, social workers, chaplains, etc. That do a lot of counseling with people who have suffered greatly, and just hearing about it can then morally injure the counselor because he or she begins to realize really bad things happen in the world. They're not preventing things and sometimes they feel completely helpless to help the person who has suffered these things. So that can lead to a moral injury.

Speaker 1: 9:18

So just in a nutshell, looking at those definitions, you have a tragedy that occurs to someone that is, either that is a betrayal or it's trans and somehow transgresses deeply held moral beliefs and expectations. It could involve perpetrating, failing to prevent, bearing witness to, or you can be the target of, some kind of like a sexual assault or a betrayal by chain of command, a betrayal by a leader or supervisor, betrayal by a spouse, a betrayal by a doctor or supervisor, betrayal by a spouse, a betrayal by a doctor or a chaplain. You can be betrayed in a deeply deep way like that bothers you, so deeply that we would consider that a moral injury. So what I try to do is just again think about it in those terms of is there trauma? Did it violate a deeply humorous belief? Does a person now have difficulty coping with or fitting this trauma into their worldview? And that likely is a moral injury.

Speaker 1: 10:52

So moral injury has both psychological and spiritual dimensions. So, as a spiritual problem, moral injury is associated with guilt, shame and spiritual crisis. Um, because guilt being something, feeling bad for doing something to someone else, or, um, shame, just being feeling bad about who you are as a person, because something happened to you or because you did something to someone else. It's a little different than guilt in the sense it's not so much about what you've done or haven't done, but more about what you are now as a person, your value as a person, and so on. And then spiritual crisis. Some people, after a potential morally injurious event, begin to feel like where was God in all this? How come God didn't help me? Is there a God now? Even people who have been deeply religious for a long time after a moral injurious event, can begin to question all their religious beliefs.

Speaker 1: 12:01

From a mental health perspective, moral injury can lead to emotional dysregulation, depression, anxiety and suicidal ideation. It can affect other areas of a person's life too, including his or her finances or physical health. So the thing with moral injury is that it has many tentacles and it can affect a person in many ways. And it can affect a person in many ways. Many people with severe cases of moral injury also reported homelessness, substance abuse and a range of physical ailments. So it has this radiating effect on your life. When you find it difficult to mentally and emotionally spiritual cope with life, you can end up disabled. In a way, you can end up losing your sense of identity, losing your sense of self, losing your self-esteem, and then it's very difficult to work at a job, take care of yourself physically. A job take care of yourself physically. It's easy to get into substance abuse and this kind of thing. And so now, post-traumatic stress disorder may accompany moral injury, but they're not exactly the same phenomenon.

Speaker 1: 13:21

Psd is a diagnosis in the DSM but moral injury is not. Dsm lists eight criterion for PTSD, including stressors, symptoms, alterations and arousal, reactivity, impaired functions and others, while in my symptoms I might include moral concerns, betrayal, lack of trust, loss of meaning, religious struggles and others. And so PTSD doesn't necessarily capture all of those elements, especially the religious and spiritual concerns. They do share a distorted PTSD and moral injury do share a distorted blame of self on others, guilt and shame. So those are common both with moral injury and PTSD, and in often cases somebody who's morally injured also has PTSD. But it's not necessarily true that all cases of PTSD cause or relate to moral injury, because PTSD can come from a variety of factors, including you could be in a horrific car accident, end up with PTSD but not have a moral injury, because you might realize like hey, it's just something tragic that happened, it wasn't anybody's fault, et cetera. But if you or a loved one was killed in a car accident and the person who perpetrated that was a drunk driver. That might also include moral injury. So that's how the two can be related to each other.

Speaker 1: 14:59

Let's look at, uh now, shay, as I mentioned, one of the early, if not the very first, person to conceptualize moral injury. He did it. Who performed, often saw horrific things, performed horrific things in the course of combat or in the course of those deployments. And it wasn't just that they had PTSD, there was something else going on deep inside of them that made it difficult for them to cope, that made it difficult for them to recover. And so, after some research, after really talking to them, conducting some his own research, he conceptualized this concept of moral injury, and others have built on it since then.

Speaker 1: 15:59

Let's look at a couple of real world examples. Let's talk about a soldier named Ellie. This is a fictional name, but the story's real. She was repeatedly raped by a military supervisor over a period of several months as a junior soldier. She was afraid to report it. Ellie suffered a great deal from depression, her work performance suffered and she became a bad soldier. Quote unquote. Her friend became very disturbed by what was happening to Ellie and begged her to do something about it. Eventually, ellie's friend became so distraught of what was happening to Ellie that Ellie's friend took her own life and in this so in this case we look at both women suffered a moral injury from what happened to Ellie.

Speaker 1: 16:47

Now, another example is a friend of mine served as an airborne ranger during Operation Enduring Freedom and Operation Iraqi Freedom. As a tip of the spear, he and his buddies were often engaged in direct action against combatants. At times, the intelligence reports they received from their commander was sketchy at best. In one particular operation, the rangers were told to attack a building and kill everyone in it because there were only enemy soldiers in the facility. The soldiers entered the building using satchel charges and grenades, spraying bullets everywhere. When the dust cleared, they saw dead women and children without weapons. Other incidents like this occurred.

Speaker 1: 17:30

During their tours, the soldiers assuaged their guilt with heavy doses of alcohol and illicit drugs. When Joe returned home, he was diagnosed with PTSD and given heavy medication to help him sleep. The drugs did little. It was not until a chaplain introduced him to the idea of moral injury and helped him accept forgiveness from God that he started to feel better about his life. So two real world, two examples. You see the trauma, you see the guilt, you see the shame in those things and the difficulty coping like the airborne ranger, just medic, just ptsd. Now we have found I'll get into this a little later that some modalities with help with ptsd can also help with moral injury to some degree, but everybody's individual and so that's not always the answer.

Speaker 1: 18:36

Okay, let's talk about how moral injury affects people. Many studies have identified guilt, shame, depression, anxiety, sleeplessness, hopelessness and PTSD-like symptoms in morally injured people. We conducted a study Moral Injury Support Network conducted a study of about 50 women, veterans who had suffered moral injury experiences and we looked at the effects that they had as a result of it. Many of those cases over half the cases of moral injury came from sexual assault. But that wasn't the only source of moral injury. It also included hostile work environment, gender harassment, retaliation for reporting or asexual assault or other violation, and there were many other things that led to moral injury in our participants, and so you know it affected them in a variety of different ways.

Speaker 1: 19:55

More than 40 of the women identified symptoms in two categories emotional and mental health problem and so when you look at emotions experienced included fear, anger, rage, hatred, grief, and you know, we all can experience those emotions from time to time. But for these women, like that was those kind of emotions stayed with them and they had a very difficult time shaking them. They just felt like they walked around angry, raging hatred, fear all the time, fear all the time. Later, after an initial strong emotional response to the experience itself, then sometimes they would experience a sense of hopelessness and some of the women you know, after a time they lost their ability to feel at all, especially after they didn't receive the help, support, justice or counseling that they needed. For some of these women, this diminished emotional capacity never returned to them and it affected their relationships from then on. So with significant others they had a really difficult time because they were emotions were either frozen or unavailable or, as I mentioned, for some of the women it was a constant sense of fear, anger, rage, et cetera, and some women completely lost the ability to have an intimate relationship with another person and remained single and isolated. After that they left the military and they just you know, in some cases got a place in the woods somewhere and just stayed away from people, avoided them as much as possible, because they lost all sense of trust of other people. They were fearful of other people. They had the inability to relate to other people.

Speaker 1: 22:17

Kaylee was sexually assaulted and what she had to say about the emotional after effects was well, that's really hard. I don't really have emotions because when you get into that fight, flight or freeze, I froze and that kind of froze everything. I have a really hard time with emotions. Mary was forced by her supervisor to get an abortion and she had this to say it was a mixture of fear and resentment of my leadership. You know resentment for what they were able to do. You know, at the time make I felt, make me do it. In other words, made her have an abortion and she was a very young soldier at that point, just basically out of basic training and a fear of their control over me.

Speaker 1: 23:03

But the hazing and bullying continued for the rest of my time there. So afterward I also had the regrets of this. Didn't stop anything. Really. I had a very difficult time with respect. Everything became very robotic, having to perform at 150% so that they don't find any crack in the armory to target me again. So everything became very obsessive and my therapist to this day is still trying to dig up memories. I have very little recollection of a lot of my time stationed there. So not only did she have, you know, this fear and resentment and this anger with her chain of command, but she also had some mind numbing and mind um, like checking out dissociation, um and so that she really those memories are still in there but she really can't access them because of what happened to her.

Speaker 1: 24:12

Mental problems included for our participants, included PTSD, anxiety, depression, suicidal ideation, diminished memory capacity, as we just saw with Mary, and confusion. Diminished memory capacity, as we just saw with Mary and confusion. Trey said the effects of her sexual assault were long-term. Well, it started me on this huge spiral and I think I'm still in it. Right now. I'm 100% disabled, 100% for PTSD. I mean I've got some other things but I can't work.

Speaker 1: 24:47

Laina went through her traumatic experiences and she was able to keep working years later like an ambush in the dark. Her buried experience hit her. Something happened at the job I had. I worked with kids that just really knocked me down. I couldn't work anymore. Just depression and anxiety, just a lot of the nightmares. I couldn't name what was going on, just drinking, just things that aren't me. So she got into a job. There was some pressure, stress. It involved working with kids and it triggered her and she just couldn't do it.

Speaker 1: 25:25

We found that loss of self-worth was the second most common symptom for women. In our study, women who experienced sexual assault, gender harassment, retaliation for reporting or not giving in to sexual advances. Many of them did not report anything, but just because they didn't report it and because they refused the sexual advances of a leader, a commander, supervisor, etc. Then they became the victim of retaliation. Other incidents led to a loss of self-value, including hearing of other sexual misconduct, combat and hostile work environment, and there were a few women who violated their own morals and I talked about this at the very beginning Like they failed to do something they thought they should do and later had a lot of guilt and shame over it.

Speaker 1: 26:30

Diane, deployed as part of a hospital unit for humanitarian assistance to a place that she never expected to see combat. Her unit was unexpectedly attacked and she described her experience like this I wound up having to be on the perimeter. My senior nurse not the colonel, but the E7 I worked under said she gave me a sidearm and a rifle and said I want you to go over there on the perimeter and whatever you see, that isn't ours, kill it. I said I'm not that person. She said I don't care if you are or not, you've got to get over it and do it. I shot into the night. I don't know if I killed anybody or not. To be honest with you, I think I did because I wasn't an expert. It's part of my life I don't talk about. I think war is a moral injury. Frankly, at this point in my life I'm a pacifist. I don't even kill bugs. If somebody was coming at me with a gun and I had a gun and I don't own weapons, but if somebody was coming at me today and it was that of self-defense would I kill them? No, I'd probably shoot their kneecaps off and let justice do its thing. I don't know.

Speaker 1: 27:38

After firing at would-be guerrillas or people who weren't surgeons, those people that killed over half the women lost their ability to trust others due to their MI experiences. This issue showed up in the same kind of moral injury encounters I just mentioned sexual assault, gender harassment, retaliation. The women stated that their loss of trust came as a result of being assaulted or let down by someone that they were supposed to trust, such as a supervisor or a friend. Women also lost trust in people and the military institutions when they failed to believe or support the survivor. Again, many of these women remain largely alone. Of course, the loss of trust, reduced self-esteem and emotional problems are likely to lead to relationship problems. Many of the women lost their marriages. Some marriages were dissolved because their husbands were cheating on them and that either created a moral injury or exacerbated the moral injury the women already had.

Speaker 1: 28:50

Nearly half the women seriously considered taking their own lives or actually made a suicide attempt. Renee was raped and she had this to say about how it affected her work and the suicide attempt she made I would never let them beat me. It was the only thing that kept me from killing myself. I would not let them tear down the uniform or make me slump and walk and give in. No, I did not. What I did do was attempt suicide. I took two weeks off and I planned it. When I got back I realized I was never going to win. I couldn't break my mother's heart. I couldn't tell her. Who are you going to tell? Nobody believed me. Nobody believed women. Even today, they're still struggling.

Speaker 1: 29:35

Shame, guilt and self-blame also figured prominently in the lives of moral injury survivors, even when an objective observer might determine that the survivor had no reason to think they were somehow to blame, women tended to find themselves guilty for what happened to them, and I talked about that at the beginning of the show that failure to prevent can cause moral injury and for many women they later on thought I should have done something to prevent it, when really they probably didn't have a chance to do anything about it because of the. Either the attacker was much physically stronger or they were some kind of supervisor, they had legal authority over them. Whatever the case was, they were really disempowered to do anything for it. Intellectually, women could tell themselves they were not to blame, but they could not seem to shake the feeling that it was somehow their fault. Other times seem to shake the feeling that it was somehow their fault. Other times perpetrators and their co-conspirators, supervisors and other blamed women are gaslighted them.

Speaker 1: 30:42

Faith, a Hispanic woman, experienced shame and guilt due to racism. Well, initially I wasn't an equal opportunity specialist. I was military intelligence this is Faith's story and I was one intelligence this is Faye's story and I was one of a few women of minorities that were within that. Most of the people that I got with early on were there was a white environment, let's just say. And so I got lonely at times. I didn't know how to describe it, but I felt it was because of who I was it. But I felt it was because of who I was. I was made to feel ashamed of being Hispanic because I was the only one at a time being in a room there was only me, the only Hispanic person. So I became lonely. But at the same time I've kind of tried to assimilate with that and not my culture, kind of leave my culture behind. So loneliness and shame, I think, were the biggest things in the beginning. It was a lot of loneliness, low self-esteem and the shame of who I was and who I was born to. Um, so being Hispanic in a very white environment and obviously having the white people not try to really ingratiate themselves to her, not try to really help her feel like she was part of the team, regardless of a race, and that her race and culture was important and and should be honored and so on and things like that.

Speaker 1: 32:08

But we see that moral injury can be the result of racism and other isms related to differences between people and their color, gender, culture and so on. So I've named some of the effects of moral injury effects of moral injury. Others included physical sickness and inability to sleep. Some women lost their interest in sex completely. Others became promiscuous, having multiple partners on a regular basis. So you know, there are no like, not necessarily a lot of predictability in in how moral injury might affect someone, because people are unique and depends on factors and circumstances and there's a whole lot of different ways that people often react to things that happen to them like that. There's other research out there that associates moral injury and similar kind of things even if they don't necessarily call it moral injury, but traumas and how they affect not just the emotional and mental side of things but also affect you physically and relationally. So these other studies show that it can affect sleep, it can cause sleep problems, it can cause chronic pain, it can lead to depression, self-medication with alcohol and drugs, isolation and social withdrawal. We talked about that already and that isolation and social withdrawal can include family members, suicidal ideation associated with social isolation.

Speaker 1: 34:12

Now I'm only going to go into some healing or recovery. Just touch on that lightly, because I'm going to do a whole episode on it later and I really want to take the time in that episode to really dig deep into it. But I will say this that there are a number of healing modalities out there that involve both group and individual sessions, retreat-type sessions. There are a lot of different therapies they're finding that can be useful for moral injury, including your standard-type therapies like EMDR and those kind of things, cognitive behavioral therapies, and I mentioned retreats. There are some modalities specifically designed for moral injury. But all of these recovery methods are multi-week, sometimes multi-month approaches, because when you're talking about moral injury, you're talking about being violated in a very, very deep, deep way, like in a extremely being violated at the core of who you are, and that is something that is not easily recovered from and you're not going to be able to just talk someone out of moral injury. So talk therapies have their usefulness.

Speaker 1: 35:49

We need to get for moral injury. We need to get at or use modalities that really get at the heart, the emotions, the deep spiritual, the soul part of someone and help them find forgiveness, reconnection to a joyful state, to a joyful state, be able to reinterpret life from the lens of what happened to them and be able to find a new way of looking at life, a new way of looking at their religion or spirituality or God faith, all those kind of things. So we'll talk in depth about modalities in another episode. But a person who has been morally injured can reach out to Moral Injury Support Network because we are partnered up with a bunch of different organizations across the U? S, even um in Canada that can help people recover, and not just with, uh, mental and emotional support, but also with um obtaining more, you know, essential things for their life, like if they need to help get food or finances to pay for gas or to help finding a job, so on and so forth. Those things are the effects or having those challenges can be the effects of moral injury. So we're here not just to help women with the emotional and spiritual effects of moral injury, but also, you know, to look at their life holistically and see how we can help them with virtually anything that they need at the time, that they need at the time. So we can also help get them into healing programs or help whether it's a retreat or whether it's counseling, those kind of things.

Speaker 1: 38:05

We can be a place where service women can contact us. You don't have to be in the US. Us or Canadian Servicewomen can contact us. Even if you're outside those two countries, you can reach out to us and we will help. Primarily, we have been working in the US and Canada to this point, but we're certainly expanding and growing and we will help anyone that reaches out to us that needs some help.

Speaker 1: 38:39

So if this podcast has been meaningful to you and you're thinking I might have been morally injured, I might need to get some help, reach out to us 910-701-0306. You can find us on the web at misnsorg. You can email me at droberts at misnsorg and we will begin immediately to help you out. Or, if you'd like to set up some training for your chaplains or your group of psychologists, social workers, whatever it is. We've done that many times too.

Speaker 1: 39:25

We've trained people in both the US. We've trained literally thousands of providers, people in both the US. We've trained literally thousands of providers both in the US and in Canada on moral injury and how it affects, where it comes from, what they can do about it, and we've also provided training on how to help care providers care for themselves, because when you're working with people that are morally injured, it can take quite a toll on you too. So we're able to help with that and all these topics that I covered or alluded to, whether it's healing modalities or care for the care provider, peer support all these kind of things will be covered in depth in future episodes, but I'm happy to talk to you one-on-one also if you reach out to us.

Speaker 1: 40:26

And finally, moral Injury Support Network for Service Women Incorporated is a nonprofit organization based in North Carolina, and so we rely heavily on donations to keep us going. So if this moral injury is a meaningful concept to you or you want to help people who have been morally injured, then please go to MISNSorg donation and you can find our donation page. And for those who donate monthly, we provide our annual book, which covers moral injury research, discussions and support methods. But even if you just want to give a one-time donation, any amount is meaningful and we're very grateful for any support we get. And thank you for listening and I hope you have a wonderful day.