Moral Injury
I recently read a terrific Psychotherapy.net article about moral injury entitled “Beyond Resilience: Addressing Moral Distress During the COVID-19 Pandemic,” and it resonated with me in a way few articles have lately. It was an interoceptive resonance that was simultaneously cognitive, emotional, visceral, kinesthetic and proprioceptive. Some of these words are quite new to my vocabulary, as I am a clinical psychologist trained in the depth psychology traditions of classic and modern psychoanalytic thought — Gestalt therapy and Jungian analysis. But more recently, I was trained in a 3-year program of trauma resolution developed by Peter Levine called Somatic Experiencing, and I began to develop some powerful new perspectives on the human condition that, in this piece, I would like to apply to the understanding of moral injury.
Moral injury is a term coined by Jonathan Shay¹ that describes a traumatic act of omission or commission that crosses a personal boundary of conscience. Shay, a psychiatrist, developed the concept of moral injury through his long and meaningful work with Vietnam veterans and other combat veterans at the Department of Veteran Affairs. The primary feelings of moral injury are shame, dishonor and ignominy. Frequently cited examples of how moral injury can occur include military personnel electing to follow an illegal or immoral order, law enforcement officers engaging in the use of deadly force, people participating in state-ordered executions, doctors and nurses involved in end-of-life decisions or with a decision to save one?s own life while another?s is lost.
Shay?s writings and perspectives are compelling and contribute immensely to broadening our understanding of trauma. His conceptions have developed almost exclusively from his work with adults, but the psychological literature on child development is replete with evidence that conscience and the “moral self” develop at a very early age, primarily from the internalization of parental values and the quality of the parent-child relationship. Studies have shown that infants as young as 3 months can show a preference for shapes that behave “prosocially” to ones that behave “antisocially.”
Two distinct dimensions of conscience have been identified: a) one relating to the emotional capacity to experience guilt and to be empathic to others and b) one relating to rule-oriented compliance to authority and authority figures. The child?s sense of themself as a moral being — with feelings of pride, guilt, shame, and embarrassment — is believed to be clearly developing by the age of 5. Findings like these from developmental psychology become especially important when considering the impact that incidents of childhood trauma can have on the delicately budding moral self. For example, research has shown that Adverse Childhood Experiences (ACEs) are predictive of moral injury in adulthood. Furthermore, survivors of childhood abuse may seek out positions in the military, law enforcement and other danger-filled professions in order to escape the perpetrators of their abuse, making them more likely to expose themselves to life-threatening situations and consequentially to exacerbation of their original trauma.
“The spiritual, emotional, or physical scarring of a child wounds their conscience as well and is deeply damaging”. Endemic to these woundings are important somatic sequelae that bind the guilt- and shame-filled experiences, making them long-lasting and difficult to undo later in life. It is my proposition that a somatic examination of these sequelae can enhance our understanding of moral injury, how to ameliorate it and how to help resolve it. After providing a brief overview of a somatic approach to healing trauma, I would like to discuss a case that I hope will bring to life the application of somatic psychotherapy in resolving the wounds of shame and injury to the moral self.
A Somatic Approach
For years, somatic practitioners like Peter Levine², Pat Ogden and Bessel van der Kolk³ have appreciated that the wounds of trauma do not linger simply in the form of cognition or within the limbic system, but are also stored in the body in muscular, skeletal and visceral forms and structures — stored in what is commonly known as “muscle-memories.” And while there has been a great deal of research supporting the perspective that trauma takes a cognitive-emotional form and can be resolved through a process of exposure and catharsis, the conceptualization of how human beings retain and reenact past trauma took an evolutionary leap forward with the development from neuroscience of Stephen Porges? polyvagal theory?.
Up to this point, we had believed that the autonomic nervous system had two functions operating in two branches: the sympathetic (energizing) branch and the parasympathetic (calming) branch. Polyvagal theory states that there are actually two branches to the parasympathetic nervous system that are activated during the threat response that developed in evolutionary sequence. The most primitively formed of these parasympathetic branches defends the organism by simply shutting down, immobilizing and conserving its energy to survive — death feigning, “playing possum,” thanatosis, or “freezing.” Co-developing in early vertebrates and reptiles was the capacity for the fight/flight response — defensive responses activated by the sympathetic nervous system. Finally, the “social engagement system” developed, through which mammals became capable of identifying areas of danger and safety and communicating this information about what was safe and what was unsafe to others. This second branch of the parasympathetic system gave mammals an additional way of managing their threat response. What was revolutionary about Porges?s work was that it identified two distinct anatomical structures of the vagus nerve corresponding to each of these parasympathetic functions. What was previously thought of as a single parasympathetic system was actually two separate structures and functions — each of which plays their own essential role in the management of threat.
“Whenever we are threatened in any way, our body goes through a rapid sequence of automatic responses that are hard-wired into our nervous system”: a) movement stops, b) we orient ourselves to the environment and begin scanning it, c) we evaluate whether it?s safe or dangerous, d) we begin to initiate protective responses, if needed, like flight, fight, freeze, or reaching out to others for help, and e) when the danger has passed, the arousal dissipates and we naturally discharge our excessive energy and begin to settle. Based on millions of years of evolution, the human body knows how to do this automatically. This defense cascade — arousal, intentional motionlessness, flight, fight, tonic or collapsed immobility (freeze), and then rest — corresponds to unique neural patterns in the amygdala, hypothalamus, periaqueductal gray, ventral and dorsal medulla, and spinal cord.
When it comes to everyday experiences, we have long known that they are stored in two ways: in explicit memory and in implicit memory. Explicit memory stores the general knowledge of facts, ideas, and concepts (semantic memories), and it stores the memories of event locations, times, and sensory images that can be explicitly stated (episodic memories). Implicit memory stores things like how to ride a bike, use a hammer, walk, or button our shirt — what are called procedural memories. Explicit memories are available for conscious recollection; implicit memories are not, and it is in these implicit procedural memories where trauma is stored. With experiences that feel life threatening, we can become stuck somewhere in the defense cascade and procedurally fail to complete it. Implicit memory is where the memories associated with these incompletions are stored, and they are out of our conscious awareness. By attending to the somatic sequelae of a traumatic event, a client is able to gently release the somatic constriction and associated emotion-laden reminders of the experience by completing uncompleted defensive action sequences.
“While somatic trauma practitioners may vary in the particular categories, they all typically encourage their clients to notice their own bodily experience” — what?s called interoceptive awareness — they all try to attend to a derivative of the following somatic aspects of humanness:
a) sensations coming from inside the body (kinesthetic awareness of muscle tension, movement impulses, bracing, involuntary sensations like heart rate and respiration, and awareness of posture, balance and other proprioceptive processes)
b) inner images (memories, dreams, symbols, and input from the five primary senses)
c) behavioral movements (facial gestures, rocking, emotional expressions, postural shifts, yawning, tearing, swallowing, trembling, shifts in breathing pattern and stillness)
d) emotions (including those expressed and unexpressed by the client and those sensed by the therapist)
e) meaning-making (beliefs, judgments, thoughts, analyses, and interpretations)
To illustrate some examples of the interoceptive awareness integral to somatic trauma therapy, I would like to describe some of my somatic reactions while reading the essay “Beyond Resilience” mentioned at the outset of this essay. As I began reading, I quickly noticed a heaviness developing in my chest and a feeling that my face and shoulders were opening. An image of a butte or plateau came to mind, where I was imagining a new level of understanding, and the thought came to me, "What a fascinating line of thinking about something I have been familiar with for years but never really thought about in this very succinct way." I found myself leaning into the computer screen, my back arching backwards, and I noticed feelings of excitement emerging from within me, especially in my cheeks and jaw, where I felt a subtle tingling sensation. I began to feel grateful to the authors and to Psychotherapy.net for publishing their piece. I could also feel little micro-movements, movement impulses really, in my arms and hands, which were anticipatory responses later manifesting when I wrote Victor Yalom to tell him how much the article deepened my understanding of this very important aspect of trauma. As I noticed the richness of my own internal life, a memory came to mind. It was of Jessie.
Jessie
Jessie was 38 and had been raised by a family in the Ku Klux Klan. He was the oldest of three children and had been conscripted to parent his younger siblings in his parents? frequent absence. He also was a survivor of severe childhood physical abuse, which he had been indoctrinated to believe was his fault. Somehow he survived and, in his teens, managed to escape the family clutches, learning a specialized trade in healthcare and, remarkably, developing and maintaining, by the time he came to me, a healthy marital relationship of some 18 years.
When Jessie first came to my office, you could feel the frozenness in his gait. As he told his story, there was a stiffness in his posture and there were very few facial movements, but I could see, almost imperceptibly, the muscles in his lower legs flexing and tightening with a kind of rhythmic regularity. His authenticity about the life he had lived was both touching and tragic. As I took comfort in developing my bond with this man, I could feel my own visceral reaction to his story, which elicited my empathic responses while simultaneously interfering with my ability to do so. My own humanness was on full display.
Despite all that he had been through, Jessie was remarkably adept at learning how to reflect on his own somatic experience. While a client?s narrative themes are essential to track, a greater emphasis in somatic trauma work is placed on the story that the body tells. Two fundamental principles guided my somatic work with him: a) to focus first on what traumatic material was most available and accessible and b) to titrate and process only small changes in arousal level before proceeding to deeper levels of emotion. This is one of the biggest distinctions between somatic approaches to trauma work and exposure therapy. Somatic psychotherapy pays meticulous attention to taking small but manageable steps in order to avoid excessive cathartic releases that, while seemingly helpful, can themselves be retraumatizing. The goal of somatic trauma work is to assist the client in learning how to reregulate their own nervous system in the context of their traumatic memories.
Like all other psychotherapeutic approaches, somatic psychotherapy does not progress linearly, and there were ups and downs in my work with Jessie. At one point, though, we began to deal directly with more of the core of his moral injury, which for Jessie was two-layered: a) the stubborn belief that because he did not fight back against his father?s physical abuse, he was a living betrayal of what it meant to be a man and b) his belief that he had betrayed his younger siblings by failing to protect them from their abusers. As a society, as a culture, and even cross-culturally, we tend to shame others who don?t fight back, who cry for help, or who run away. We are expected to fight our perpetrators (or at least flee from them) but never cower, collapse, or freeze. This is consistent with Porges? notion that survivors are shamed and blamed because they didn?t mobilize, when in actuality, their bodies were involuntarily incapable of movement.
When we have transgressed, episodic shame is a healthy response. Awareness of our shame motivates us to apologize, to acknowledge our wrongdoing and to repair the injury we may have inflicted on another. Likewise, when we witness someone doing something harmful to another, we call it out. We inform them of their wrongdoing. Their momentary shame is healthy because it encourages peaceful cooperation and fosters a sense of social fairness. But when we call out someone?s wrongdoing, it is imperative that we also exercise our responsibility to repair their momentary shame by honoring and reinforcing their human dignity—to communicate to them that they are much more than the identified transgression. For example, when we interrupt a child from intentionally hurting their sibling, we are guiding them about what is acceptable in a family and in a society. But we must also commit ourselves to repair their shame by letting them know we continue to love and respect them. It?s chronic shame — the kind of shame we stay stuck in and can?t shake — that?s not healthy. Chronic shame demeans, degrades and obliterates human dignity — it kills the spirit. “Many clients who have been chronically shamed carry these wounds with them…and this was true for Jessie”.
My therapy with Jessie progressed, and in a particularly important session I noticed he began it with his eyes looking downward, his head lowered, his back curved forward and his breathing shallow. This kind of kinesthetic and postural presentation is typical of the shame-based, collapsed immobility (freeze) characteristic of moral injury. I asked Jessie if he noticed that his gaze was averted, which he acknowledged, so I asked him if he could become curious about it and see what might happen next. At first, he was out of touch with what he was introceptively trying to observe, until he said, “It?s kinda comfortable to look down … and not be judged for it.”
I asked Jessie how it might be for him if we were to just sit with and notice the comfort together. As we did, his breathing became fuller, which we both acknowledged. When addressing such potentially powerful traumatic states — which are being expressed somatically and almost certainly out of the awareness of the client — it?s so important to help them first establish a strong-enough connection with their own inner resources — what one of my Somatic Experiencing teachers described as “islands of safety.” Pausing on these soft places to rest and to moderate and titrate traumatic pain is essential to anchor and center a client and to stay off, for the moment, the rush of feeling overwhelmed that is almost certainly waiting in the wings.
I then asked Jessie if he noticed his downturned posture and invited him to take his mind?s eye and go into his curved back and see what he noticed. After a time, he said, “It feels dark … I know this feeling, but I can?t name it … I don?t like it.” Because traumatic emotions are stored in implicit memory and not readily accessible to awareness, they often cannot be identified with semantic labels like anger, sadness or shame. As I mentioned earlier, emotions are only one of the critical memory elements of trauma. Equally important to somatic trauma work is accessing the procedural memories themselves — those kinesthetic, proprioceptive and neuroceptive containers of trauma. I sensed Jessie was adequately tolerating his discomfort, but I asked him anyway to be sure, which he confirmed. I then suggested a little experiment to see what might happen if he were to curve his back downward a little further, but only just a very small amount. As he did so, a memory emerged of himself kneeling, pleading with his father not to beat him as his father yelled, “You?re a pussy! Quit your cowering! Take it like a man!”
As he recalled his humiliation, Jessie became aware of greater tension in his back. I asked him, “If your back could move in any way it wanted, what might it want to do right now?” When he said he didn?t know, I invited him to become curious about what it might be like if he were to very slightly lower his head even further. As he did so, his hand became tremulous as he said, “He hurt me so badly!” I wondered if I might have been pushing him past his window of tolerance, so in order to lower his activation level, I then empathized with his pain. This is a good example of an important choice-point in psychotherapy, and in somatic work in particular — that is, I made the decision to go a little deeper into what Peter Levine calls the “trauma vortex.” This is reliably going to raise the client?s level of arousal and can be quite helpful, but a) only when it?s done slowly and in small steps and b) only when the client is ready and able to contain the added arousal. To gauge the appropriateness of this kind of intervention, the clinician must rely on their observations of their client?s somatic markers and the clinician?s own felt sense.
I asked Jessie to consider what it might be like to raise up his head and back a bit. Doing this calmed his tremble, more color returned to his face, and his breath became more regular as he stated clearly and with some conviction, “I wish I would have stood up to him.” “I asked him what it felt like to raise his head and back, and he said that it felt “freeing” and that he “felt taller.”” We took the time for his nervous system to reregulate to what he had just experienced, and we just sat with his calm sense of freedom and taller-ness for the rest of the session. This was a big part of Jessie?s moral injury — the notion that he had abandoned being true to himself by not confronting his father and not fighting the abuse he was forced to endure. For years, he had worn his valueless humiliation as a scarlet letter of his own worthlessness, until he returned to an essential element of his trauma that was yet to be completed — physically embodying the posture of standing up for himself.
As my sessions with Jessie proceeded, he became better able to honor and stand up for his own moral beliefs of fairness and respect. He also became more comfortable with articulating his belief that what his father had perpetrated against him and his siblings was wrong, while moderating his nervous system activation and later feeling the calm and peaceful presence of embodying his budding moral convictions.
* * *
Everything in the universe oscillates — the tides come in and they go out, day turns into night and into day again, the seasons change, the breath goes in and the breath goes out. This is the natural way of things. With trauma though, that pendulation — the natural flow between physiological polarities — gets shunted and needs to be repaired. With Jessie, there was much work that followed, but a key to his recovery was embedded in his newly acquired ability to regulate his arousal and return to a safe-enough place so he could repair and repair again what he had been forced to internalize.
References
Shay, J. (2011). Casualties. Daedalus, 140, 179-188.
Shay, J. (2014). Moral responsibility. Psychoanalytic Psychology, 31, 182–191.
(2) Levine, P. (2015 June 10). Peter A Levine, PhD on Shame – Interview by Caryn Scotto D?Luzia [Video]. YouTube.
(3) Van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New York: Viking.
(4) Porges, S. W. (2001). The polyvagal theory: phylogenetic substrates of a social nervous system. International Journal of Psychophysiology, 42, 123-146
