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Moral Injury Poses Hidden Risks for Service Members

A still picture from a video shows a man talking
Dr. William Nash address the Mental Health Integration for Chaplain Services program. A video of his presentation is available.

About 30 years ago, two Navy ships were approached by refugees begging for rescue who had escaped Vietnam in underequipped boats. At the time, so-called “boat people” rescues had become so frequent that they were taking Navy ships from their missions. Officers were directed to rescue refugees only when their crafts were not seaworthy.

Capt. Corwin Bell, in command of the USS Morton, a 415-foot Navy destroyer, decided to pick up the refugees since a storm was approaching. He was later reprimanded.

Capt. Alexander Balian of the USS Dubuque, a 16,500-ton amphibious transport vessel, decided the refugees’ wooden junk was seaworthy, gave them ample food and water and sent them on their way. Crew members reported pushing the desperate refugees off the lines as they attempted to climb aboard the Dubuque, the only ship that had stopped to help during their weeks at sea. When the junk’s survivors finally reached the Philippines, newspapers there reported that some had resorted to cannibalism after again running out of food. Balian was court-martialed and resigned his commission.

Decisions like these have a lasting impact on everyone involved and can affect the brain in the same way as posttraumatic stress disorder (PTSD), causing physiological and psychological damage, a phenomenon known as moral injury, says Dr. William Nash, a retired Navy psychiatrist. Moral injury likely affected many of those aboard the Dubuque or the junk that day, he said.

“Think about all of the people who were scarred for life or lost their lives because of this moral choice,” Nash told some 300 military chaplains and psychological health providers during a meeting of the chaplains working group, hosted by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. “It’s tragic, but it’s not unique. I’m sure we all know of choices that seem small at the time but end up having huge moral consequences.”

The term moral injury was coined in the aftermath of the Vietnam War, when psychiatrist Jonathan Shay, then with the Department of Veterans Affairs, used it to describe the reactions of Vietnam veterans to atrocities committed or condoned by their superiors. Nash and others have since extended the term to describe what service members experience when they themselves commit an act that violates their own beliefs—for example, when a service member kills a child who is shooting at him. Working group attendees offered other examples: cutting off the ears of fallen enemy combatants as souvenirs; not stopping to give food or water to civilians who may be concealing an improvised explosive.

Moral injury is not clinically defined nor captured as a formal diagnosis, and no clinical practice guidelines are available for it. However, health care providers in the military often address moral injury when treating a psychiatric disorder. Chaplains, frequently the first resort for service members struggling with moral issues, also counsel service members who experience moral injury.

Nash offered tips for treating and counseling service members with moral injury. It’s important to understand that the emotion underlying the injury is not fear, but shame, guilt, or outrage, he said.

Psychiatry defines PTSD as a fear-based reaction that can occur after a life-threatening event such as battle or rape. Exposure therapy, in which patients repeatedly relive the event to lessen the fear reaction, has been clinically shown to be effective for PTSD.

But exposure therapy can actually worsen moral injury, Nash said. Moral injury patients need to experience not safety, but forgiveness. Chaplains and behavioral health counselors can assist by helping them understand how much blame to bear (patients may either deny all blame or exaggerate their responsibility for an event), learn to tolerate their intense negative emotions, and figure out how to become useful members of their communities or make some other form of restitution. Other techniques used in treating PTSD, such as improving physical health, group therapy, or religious practice, can also be helpful, he said.

Moral injury has become a loaded term, in part because some see it as a judgment on the person who experiences the injury. In fact, Nash said, patients who experience moral injury are likely to be highly moral.

“Psychopaths don’t experience moral injury,” he said. Service members, with their ideals of duty and honor, may be especially vulnerable to this kind of injury, Nash said.

To talk with someone about moral injury, contact your local chapel and ask for help. If you need help finding a chaplain, contact Military One Source to find a military chaplain in your area, or use the National Guard Family Program’s Local Community Resource Finder.

If you or a loved one is wrestling with moral injury, seek help now. Contact the DCoE Outreach Center to confidentially speak with trained health resource consultants 24/7 at 866-966-1020, via live chat, or by email.

Additional resources on moral injury are also listed below.

Comments (20)

  • Bradford Hutchingson 11 Mar

    One thing seems blatantly clear from reading the above article. The Military has far too many psychiatrists, and far too few Chaplains. And, the Chaplains the DoD does have, are stretched too thin, and not given robust enough mission orders. A Chaplain shouldn't just sit in an office, and wait for a hurting troop to show up. No, they need to be much more involved with the day-to-day lives of the Troops. And, despite the assertions of the Army shrink, so-called "PTSD" is not very well treated by "exposure therapy". EMDR, Vipassana, or mindfullness meditation, and CBT are all much better treatments. And, yes, advances in self-care have been recently made. Again, for a hurting Troop to reach out to another hurting Troop should be a regular occurrence, because that practice most helps BOTH Troops. But at least the Military no longer uses "Phrenologists"....
  • Don Stallings 11 Mar

    Excellent presentation. I have a question. Can we get CEU credits for this presentation? Thanks
  • Lan T. Dalat 11 Mar

    More than 30 years ago, the historic aircraft carrier USS Ranger CV-61 — “Top Gun of the Pacific” — saved my life from the deadly South China Sea.

    Under the cover of darkness on March 8, 1981, my mother, my three siblings and I crept along the edge of the Saigon River in Ho Chi Minh City. In tense silence, we waited on the bank of the river, then we slipped unnoticed into a fisherman’s small wooden boat. We became “boat people,” joining thousands fleeing Communist Vietnam. Outcome and destination unknown, we hoped to land on a peaceful shore.

    Day and night, the waves relentlessly lifted our unseaworthy boat and crashed it down again. The engine sputtered, and the boat shuddered with each wave. The sea seemed determined to end our journey, yet we endured.

    After five days of pounding waves, the engine protested one last time and stopped, leaving us adrift on the open sea. For the next week, our boat carrying 138 people floated without food or water. Hope for survival dwindled.

    But just as the sea threatened to end our exodus, help appeared. On March 20, a deafening noise from two jets roused us from our sleep. That afternoon, excitement rushed through me when I saw a fleet of ships on the horizon. “I can see ships!” I screamed.

    The floating metal cities grew closer, and two helicopters approached our boat. A Ranger crew member was lowered down and handed a canteen of water to a little girl.

    That canteen changed everything. It restored hope and offered freedom.

    We all were rescued and taken aboard the USS Ranger, where we were examined, clothed and fed. Our first meal on the Ranger was unforgettable: My family of five sat on the floor, sharing a single chicken breast, not realizing the meal was meant for just one person. For dessert, I experienced the most wonderful taste when a sailor gave me colorful candies stamped with an “m.”

    Before reaching the U.S., we spent six months in a refugee camp in the Philippines. In September 1981, my family arrived at our first home in the U.S. — Lacey, Thurston County, where my uncle and his church had sponsored us.

    After high-school graduation, I joined the Army Reserve to serve my adopted nation. I often wondered if Ranger’s crew would be happy to know what had happened to us, so before my college graduation, I sought out the skipper responsible for the rescue to thank him. Capt. Dan A. Pedersen and I reunited and shared many stories.

    As a newly commissioned officer in the U.S. Army in 1997, I traveled to Bremerton to pay tribute to Ranger. Sixteen years later, having completed two combat tours in Afghanistan, I visited Ranger again, this time with my wife and children. I wanted to show them the ship that gave life, liberty and the opportunity to pursue the American dream to so many refugees. I shared stories about the crew — how they welcomed us generously and treated us with dignity and respect.

    Today, I am a Lt. Col. serving in the United States Army

    Lan T. Dalat

  • Robert Schwehr 12 Mar

    Chaplains are essential in these cases, whatever the belief or denomination, the military expertise is there.
  • ron gellis 12 Mar

    As a former Navy psychologist, moral injury is today, what PTSD was after the Vietnam war, a diagnosis whose time has come, to come out of the closet and get the recognition it deserves.
  • elizabeth ocskay 12 Mar

    I would like more intervention suggestions for survivors of trauma/PTSD as we treat substance abuse here and most of our clients have a trauma history.WJ7O
  • DCoE Public Affairs 12 Mar

    Thank you to all for sharing your thoughts and experiences with us! We appreciate hearing feedback from our readers.
  • DCoE Public Affairs 12 Mar

    Education credits are not available for chaplain working group meetings. To learn more about VA Chaplaincy Training, visit If you would like to learn about the DCoE Webinar series that does offer continuing education credits, visit:
  • Rodger 17 Mar

    It is too sad to see now that Chaplains are being restricted even more in serving the troops. Many are no longer allowed to even mention God. How can they present a moral discussion with someone who is religious without bringing up their beliefs and morals?
  • Richard Field 18 Mar

    A salute to Lt Col Dalat. His story, like those of all successful Vietnamese-American "boat people", serves as something of a redemption for us Vietnam War vets who still carry a sense of sorrow about the people of the Republic of Vietnam we left behind in 1973. With grit and determination, they sought freedom against all odds. They are today some of our finest fellow citizens.
  • Alan S. D. 18 Mar

    After reading this I realize that part of my problems for the last 63 years is a result of Moral Injury. In the spring of 1951 in Korea my hand grenade took out a NK sniper as well as a young lady and a baby. I watched the baby die, Mom was already gone when I cleared the building.

    I carried a huge pile of guilt for years. I self medicated with alcohol and sober 33 years ago. My PTSD was finally diagnosed in 2005. I am currently attending a PTSD support group at the local VA Vet Center. I am the sole Korea Vet in attendance.

    Open sharing at AA groups and discussions with my Parish Pastor finally allowed me to face the guilt and realize that I did not murder anyone. It was accidental. My PTSD group is helping with a lot of other issues.

    I retired from the Army with the rank of 1sg Sgt. after 4 years active duty and 30 years with the Army National Guard.

  • DCoE Public Affairs 20 Mar

    Thank you Richard for sharing

  • DCoE Public Affairs 20 Mar

    Alan, thank you for sharing your personal experience. We applaud your courage on your journey of recovery. If you need additional resources, please call our Outreach Center at 866-966-1020.

  • Joe San MIGUEL 22 Mar

    Never thought moral injury would be recognized! My ptsd comes from seeing own men being killed by their officer's bad decisions and being unable to say anything. During Desert Storm was even ordered to load our dead soldier's bodies which were in unlined body bags onto the front of our 5ton truck like a deer carcus. I refused and was given a bad NCOER. I had made my CPT look bad in front of our COL. Saw other things never reported of their incompetence but as a SGT had no say. Our Cmdr was so afraid of being fragged he also took our ammo away even when we were making runs for rations, water or other supplies while we were in Iraq!
  • DCoE Public Affairs 23 Mar

    Miguel, thank you for sharing your experience with us. It takes great courage to share what you went through in Iraq. Many people find sharing too difficult, but we know that it helps. If you're still struggling and need resources, please call the DCoE Outreach Center at 866-966-1020.
  • Mark Mitchell 30 Mar

    Good comments and a good article. Love Nash' stuff.:) I am working with Loyola Marymount University here in Los Angeles to launch a program of training for dealing with MI if anyone is interested. It will begin in the Fall of 2015.
  • DCoE Public Affairs 02 Apr

    Response from Dr. Jeff Rhodes, DCoE spiritual fitness subject matter expert: Rodger, military chaplains are representatives of their own faith group, but they are called to facilitate care for all and this includes those who are not of their faith tradition.  Chaplains are free to speak about God with service members, but they are also sensitive to those who don't hold to a practice that believes in God. Chaplains are well known by those they are called to serve (on a ship; with a ground infantry unit; in a foreign setting) and serve side by side helping to support the mission of their command. 
  • DCoE Public Affairs 02 Apr

    Elizabeth, the Department of Veterans Affairs National Center for PTSD released an interesting article on early intervention of trauma that you may find useful at We also discuss treatment options on our website at You can also call our 24/7 Outreach Center to discuss resources at 866-966-1020.
  • Justin 28 Apr

    Hello, the videos above are private. I would like to share them with my peers, as I really enjoyed Dr. Nash presentation in Phx recently. Can you please help? Thank you
  • DCoE Public Affairs 07 May

    Justin, we're looking into the videos. They used to be accessible by the public. We'll let you know what we find. Thanks for the heads up!

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