Thoughts on PTS and “Moral Injuries”  


Over the past five years, a good percentage of this blog has been focused on the effects of war on health. Some of these topics have included:

  • Other effects of war, such as forced displacement, food shortages, and destroyed infrastructure (here, here, here, here, here, & here)


I’ve largely stayed away from one of the most recognized effects of war: psychological impacts such as post-traumatic stress (PTS), perhaps with one notable exception: “Reconciliation, Biology, and the Second Indochina War.” This remains one of my favorite posts on this site. However, it dealt not with PTS per se, but with guilt and the desire for forgiveness and reconciliation, with many examples stemming from war.

I bring this up now because a few months ago I first encountered the idea of the long-term effects of ‘moral injury.’ According to Litz et al. (2009), a moral injury stems from “events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long-term, emotionally, psychologically, behaviorally, spiritually, and socially.”

In other words, while both have long-term psychological effects, moral injury may be distinct from PTS. As Thomas Gibbons-Neff wrote “unlike post-traumatic stress, which is a result of a fear-conditioned response, moral injury is a feeling of existential disorientation that manifests as intense guilt.” Neither idea is new, though both may have been unintentionally intertwined in psychology (at least in my non-expert understanding of this).

The terminology has been fickle, and PTS has been called many different names over the past several decades including shell shock, soldier’s heart, or combat fatigue. More recently, there have been efforts to drop the word ‘disorder’ from PTSD to simply PTS, in an effort to minimize stigma as well as to shift how those suffering from stress see themselves. Vocabulary really matters, and re-framing the terminology helps everyone see people with PTS simply as fellow human beings undergoing a very difficult period, rather than as permanently damaged.   

According to one study, references to post traumatic stress may extend as far back to the Assyrians in Mesopotamia between 1300BC and 609BC. Some ancient soldiers reportedly described “hearing and seeing ghosts talking to them, who would be the ghosts of people they’d killed in battle.” However, to me, this seems more like moral injury and manifestations of guilt, rather than fear, so perhaps these would be better categorized as moral injuries. Though it is almost impossible to do this retrospectively.

Some, like the primatologist Frans deWaal (2012), have suggested that the frequency of PTS among soldiers indicates that committing acts of violence does not come easily to humans, and that war is not a deep part of human nature:

“If there were truly a genetic basis to our participation in lethal combat, we should willingly engage in it. Yet soldiers report a deep revulsion to killing and shoot at the enemy only under pressure. After these experiences, they often end up with substantial psychological damage. Far from being a recent phenomenon, haunting memories of combat were already known to the ancient Greeks, such as Sophocles, who described Ajax’s “divine madness,” now known as posttraumatic stress disorder (PTSD).”

I’m not so sure. There is evidence that some people are drawn to violence and enjoy participating in it. A recent powerful essay by Tage Rai argued that the key to understanding human violence is that people are most apt to engage in it when they believe they are morally justified:

“Across practices, across cultures, and throughout historical periods, when people support and engage in violence, their primary motivations are moral. By ‘moral’, I mean that people are violent because they feel they must be; because they feel that their violence is obligatory. They know that they are harming fully human beings. Nonetheless, they believe they should. Violence does not stem from a psychopathic lack of morality. Quite the reverse: it comes from the exercise of perceived moral rights and obligations.”

If there is any good news, perhaps it’s that individuals who suffer a moral injury must, almost by definition, have some deep reservations about certain acts of violence. After all, one’s sense of morality cannot be injured if it didn’t exist in the first place. Secondly, the concept of ‘injury’ implies that healing is possible. Marek Kopacz (2014) wrote that after trauma, military personnel often seek out “support in an effort to realign their existential beliefs and reaffirm the meaning and purpose of life.” My guess is that — evolutionarily speaking — because humans have such a long history as social primates, it is likely that a person’s moral sense is integral to their meaning of life. Therefore, it is also likely that attempts at moral healing/ re-alignment could go a long way in terms of psychological health and overall well-being.



De Waal F. 2012. The antiquity of empathy. Science 336: 874-6. Link

Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, & Maguen S. 2009. Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review 29: 695–706. Link

Kopacz MS. 2014. Moral injury – A war trauma affecting current and former military personnel.  International Journal of Social Psychiatry  60: 722-3. Link