Moral Injury Can Cause PTSD

Most people who are familiar with PTSD (Post Traumatic Stress Disorder) tend to associate it with war veterans. However, war veterans are not the only ones with this disorder. PTSD is a mental health condition that’s triggered by a terrifying event. This event can be either experiencing it or witnessing it such as sexual assault, traffic collisions, or other threats on a person’s life. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in how a person thinks and feels, and an increase in the fight-or-flight response.

Another term you may not be familiar with is “moral injury.” This occurs when one perpetuates, inflicts, or fails to prevent violence on others, or witness acts that transgress one’s deeply held moral beliefs. These may be either acts of omission and/or commission that lead to internal conflicts, shame, guilt and failure to forgive oneself.

Let me give you an example from a woman that I will call Kit. Kit’s roommate and best friend, Jane, developed cancer. Kit was an outgoing and highly social woman who enjoyed her job in the restaurant field as a server and bartender. She was a single mom, had many friends, and was a kind and giving person. When Jane became ill, Kit made the choice to be her primary caretaker in their home. She thought she could handle the responsibilities, with assistance from the hospice, and make Jane comfortable until the time came for her to die. It was her intention to provide quality, compassionate care for Jane. Her goal was for Jane to live as long as possible, and as well as possible.

Toward the end of Jane’s life she became restless and agitated. Kit administered a ‘comfort pack’ that hospice had provided to make Jane more comfortable. The comfort pack consists of medications to be used only when needed to relieve symptoms that arise in terminally ill patients. Jane was given two of these packs and her morphine drip was increased. Whereas Jane had been alert prior to the administration of the comfort packs, she became over sedated and could no longer speak. She died shortly afterward. Kit believed that she had mishandled these medications and caused her friend to die. She thought “It was not my role to administer the packs. We should’ve waited for more assistance. I didn’t understand what I was getting in to. I wish I had more education on what to expect.” Kit thought she had prevented Jane from communicating all that she may have wanted to say before she died. Instead of assisting Jane to live as long as possible, and as well as possible, she thought she had prevented Jane from her last words and had hastened her death. This was a moral injury.

Although she was a willing caretaker, she was unprepared for the reality of the dying process and she was not prepared for the emotional consequences to herself. Kit developed PTSD symptoms including depression and anxiety. She withdrew socially and rarely left the house. She was unable to work in situations that required social contact. She had intrusive memories of the process and could no longer tolerate the sight or description of blood; could not tolerate the sounds of labored breathing or slurping noises. She developed an aversion to certain smells and tastes.

I would like to say that Kit is now healthy and happy, but in spite of gains, remnants of this trauma persist. She still struggles with shame, guilt and failure to forgive herself as well as other PTSD symptoms. It is important to Kit that people understand that PTSD is not confined to war veterans. It can happen to anyone. If you are suffering from similar symptoms, get help from a mental health professional.


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