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How Do Counselors Address 'Moral Injury'

How Do Counselors Address ‘Moral Injury’?

By Gray Otis, PhD, LCMHC, DCMHS-T

Drawn from part of the Counseling Tips on page 8 of the Fall 2019 issue of The Advocate Magazine
Graham was agitated and confused. After completing a recent Army deployment to Afghanistan as a public affairs officer, he was welcomed home by his partner, two children, family, and friends. But as he settled into the routine of his new job of training new military specialists, he began to have terrifying, recurring nightmares. Always, he saw himself holding the photograph of a dead young boy mangled by an American artillery explosive.

In Kabul, Afghanistan, Graham had given briefings almost daily to Afghan officials concerning recent events of the war. Like other veterans, he had to steel himself against the daily reports of warfare. Often, he was confronted with combat photographs and videos that conveyed the horrific impact that war always has on civilians. Although he had been in the Army for nearly six years and was considered highly competent in his specialization, nothing had prepared him for the shock of real warfare. Towards the end of his deployment, an IED exploded a few hundred yards from his office. A few weeks later, Graham was home and Afghanistan was behind him. Or so he thought.

Within a few weeks, the severity of his nightmares convinced him that he needed help. When he first met with Lara, a licensed Clinical Mental Health Counselor (licensed CMHC), he told her that he was afraid to go to sleep at night. Lara explained that he was probably experiencing the effects of post-traumatic stress disorder (PTSD), normalized the occurrence of his nightmares as not uncommon, and reassured Graham that this could be resolved.

Understanding “Moral Injury”

What was causing Grahams nightmares? He had not served in direct combat. Other than the IED explosion, he really had not been exposed to typical PTSD experiences. One of the possible explanations for his distress was “moral injury.”

Moral injury refers to psychological harm to an individual's moral conscience. It results from an act (or acts) of perceived transgression that conflicts with the individual’s sense of right and wrong, or conscience. It can produce an exceptional degree of emotional shame and moral disorientation.

Moral injury is traumatic. If not resolved, the trauma will change the person’s sense of self in a very disruptive way. Individuals who have been reasonably self-assured become anxious and worried about who they are. They can adversely question almost every aspect of their previous life’s experiences. Often, they feel an overwhelming sense of isolation and a loss of self.

Moral injury has occurred with soldiers in combat when innocent civilians are wounded or killed. It also occurs when, for example, a driver causes an accident that results in injuries or fatalities. Law enforcement officers who have harmed others may feel they have overstepped their own sense of right and wrong. It can occur when a parent’s momentary inattention results in their child becoming permanently disabled. In all of these examples, the person may experience trauma that also entails moral injury. It is as if the moral injury has turned their emotional sense of rightness upside down and inside out. The consequences seemingly give them no escape from their shame. They feel hopeless and believe that they are absolutely powerless.

Treating Those Who Suffer a Moral Injury

The treatment for these psychological injuries is similar to treatment for trauma. However, it is important for licensed CMHCs to pay particular attention to the individual’s ideals, standards, religious beliefs, and his or her moral compass. It can be re-traumatizing if any attempt is made to overlook or dismiss the person’s previously held principles or values. Rather, individuals should be gently guided to see how the traumatic experience has called into question prior beliefs that had been essential to their worldview and their self-identity. They can then start to assess how their beliefs are probably still effective and well-founded.

Self-identity is based on the individuals’ central beliefs about who they are. For instance, most people feel that they are trustworthy. They also believe that they are caring and conscientious, and that they act according to their values. Persons who have suffered moral injuries may question if they are worthy to be trusted, whether they are caring, or even if they have any reliable values.

Licensed CMHCs who understand the basis of moral injuries can help individuals restore their sense of worthiness. Cognitive Behavioral Therapy (CBT) can be used to demonstrate that their values are still valid. In addition, skilled trauma specialists can help clients resolve their inexplicable traumatic experiences.
Graham was exhausted from an overwhelming sense of distress and depression. Lara let him talk about his wartime experiences by primarily focusing on his emotions. Because he did not know how to describe his emotions, she gave him a simple-to-use vocabulary to express how he felt. Using one or more of the following five “feeling descriptions,” Graham could better understand the feelings that were underlying his mad, sad, and anxious emotions. He said:

  1. 1. Accused: I felt accused when I accused myself of being callous and numb.
  2. 2. Guilty: I felt guilty when I felt I should have done something different.
  3. 3. Rejected: I felt rejected when I sidestepped what I thought I should do instead of what I did.
  4. 4. Unlovable: I felt unworthy to love or be loved when I betrayed the person I thought I was.
  5. 5. Powerless: I felt helpless and powerless because I couldn’t change the past. I was trapped and knew there was nothing I could do.

Two or more of these feelings commonly occur together. Describing the five feelings that underly the emotional states in the limbic system helps individuals gain greater self-understanding in a relatively safe context.

By expressing the feelings that were the basis of his anxiety, depression, and anger, Graham began to see himself more positively. From his prior adolescent experiences, he recognized that these often-subconscious feelings had always preceded any emotional distress. He began to normalize how these feelings were present even when he had been giving briefs about horrific wartime events. The feelings and the resulting emotions may have been repressed, but they still existed.

Once he had an emotional vocabulary, he was able to begin reprocessing his exposure to combat. In one session, Graham started to discuss his recurring nightmares. Lara asked him to stop the replay of the nightmare but to take a mental photographic image of any part of the dream that was distressing. She asked Graham to briefly describe his accused, guilty, rejected, unlovable, and/or powerless feelings associated with this mental image. When she asked him what he believed about himself, Graham immediately said, “I am so weak.”

Lara’s next question asked, “What is the self-belief that you want to have that would replace the belief, ‘I am weak’?” Graham struggled with coming up with a desired belief that was true about himself. Lara encouraged him but did not offer any suggestions. Finally, he said, “I want to believe that I am courageous.”

Lara helped him to understand that courage is the ability to face our fears. Then, she asked Graham whether he had ever been afraid and had dealt with it positively. He told her of a time when he stood up to a classmate who was making fun of his friend. This became the bridge that Graham used to resolve his moral injury. Lara encouraged him to daily look for ways to act courageously by offering to help others, saying hello to strangers, giving a hug to his children, etc. Courageous? Yes. For individuals with moral injuries, the simplest acts can be challenging, but doing them repeatedly reaffirms constructively who they are.

During the next session, Graham reported that somehow his nightmares had become less frightening. In one dream, he looked at the picture of the dead child and began to cry. In another week, he reported that the nightmares were gone. He had begun to practice mindfulness and was engaging in both prayer and meditation. Graham said, “It is like discovering myself all over again, but it is a new and better sense of who I am.”

In their last session, Lara asked him if he had gained any meaning from all of these experiences. His response, “You know, I had always thought of myself as patriotic. Now my sense of personal patriotism has a much deeper meaning for me. I am not sure how I am going to use this, but I am convinced that the rest of my life will be lived with real purpose.” From this point on, Graham had a more vibrant sense of what his life meant to him.

“Key Core Beliefs: Unlocking the HEART of Happiness & Health” is available from Gray Otis is a licensed clinical mental health counselor and an AMHCA Diplomate & Clinical Mental Health Specialist in Trauma. A past president of AMHCA, he has a private practice in Cedar Hills, Utah. He is also the primary author of the 2018 book, “Key Core Beliefs: Unlocking the HEART of Happiness & Health,” which was written for both mental health professionals and members of the public. Learn more at, and email him at

How Do Counselors Assess Integrated Behavioral Health?

How Do Counselors Assess Integrated Behavioral Health?
By Gray Otis, PhD, LCMHC, DCMHS-T

Drawn from part of the Counseling Tips on page 14 of the Summer 2019 issue of The Advocate Magazine
When Lisa first met Eli, a licensed clinical mental health counselor (LCMHC), she said, “I don’t know what’s wrong with me. I am either anxious or sad all of the time.” After exploring how she experienced her symptoms, Eli asked her to tell him about herself. This open-ended question led Lisa to recount being raised by somewhat demanding parents, her divorce two years previously, and her concern about feeling nauseous much of the time.
Because Eli was trained in integrated behavioral health, he conducted a wide-ranging evaluation of Lisa’s overall wellness and psychological well-being. LCMHCs understand the importance of whole-health assessment as well as the growing requirement to collaborate with primary care providers (PCP) and other medical professionals.
One of the ways we LCMHCs can accomplish an inclusive health appraisal is to follow the step-by-step approach of the HEART Assessment. This approach includes a review of five essentials of total health. The first letter of each of these five essentials forms the acronym HEART*:

  • Health—physical wellness based on the principles of healthy living
  • Emotions—emotional balance through affect regulation and self-understanding
  • Awareness—cognitive engagement through the conscious use of mental abilities
  • Relationships—interpersonal effectiveness through satisfying connections with others
  • Transcendence—enrichment through inspiring and uplifting influences

(*The "HEART" model is part of the book “Key Core Beliefs: Unlocking the HEART of Happiness & Health,”

All five of the essentials interact with each other in mutually supportive or mutually disruptive ways. When these essentials are predominately detrimental, we are more likely to face problematic concerns that increase negative beliefs about who we are. When these essentials are primarily constructive, we become more resilient, develop richer relationships, and reinforce positive beliefs about ourselves.
Additionally, if one of these health components deteriorates, the other four areas will often be adversely affected. For example, over time, inadequate sleep will significantly impact physical health, and it also negatively affects emotional regulation, cognitive functioning, and our ability to feel connected with others. As Eli worked with Lisa, he went deeper into the HEART essentials, reviewing with Lisa her:
  • Health—nutrition, hydration, sleep, exercise, medications, substance use, etc.
  • Emotions—emotional lability, affect regulation, distress levels, ACE, past trauma, etc.
  • Awareness—mental status examination, cognitive engagement, learning, hobbies, etc.
  • Relationships—connections with family and friends, interpersonal effectiveness, etc.
  • Transcendence—mindfulness, meditation, faith, enriching or uplifting experiences, etc.

After reviewing these areas with Lisa, Eli was concerned about an automobile accident in which Lisa’s car had been totaled, but she had walked away with just dizziness and a severe headache. Because she had no external injuries, she had not sought a medical evaluation. Although the headache subsided, she often felt like she was in a mental fog. She also reported that prior to the accident, she had been in an emotionally problematic relationship. Her spouse’s almost constant criticism of her ultimately led to separation and divorce, which devastated Lisa. She came to believe that she could not never trust a committed relationship.
Lisa told Eli that she felt relieved just to tell someone how confused and upset she had become. Eli suggested that she see her PCP for an evaluation. He was concerned that the car accident might have caused an undiagnosed concussion or other neurological condition. His concerns were well-founded. After a blood clot in her brain had been located and surgically removed, nearly all of Lisa’s anxiety and depression symptoms were alleviated. With her consent, Eli coordinated with her doctor to ensure adequate psychological and medical follow-up.
Lisa also continued to see Eli to work through her anxiety about trusting in committed relationships. Her key self-belief that she could not confide deeply in anyone was transformed into a renewed self-belief: “Because I am perceptive, I am confident that I will know when I can trust someone.”
Had Eli had not referred Lisa to her primary care provider, the blood clot might have resulted in a far more injurious outcome. Today, LCMHCs like Eli are becoming recognized as integrated behavioral health care specialists. In addition to the skilled therapeutic work LCMHCs do, all mental health professionals can undertake additional education and training to become more adept at assessment, referral to medical providers, and coordination of care.
