Can Psychedelics Help Heal Moral Injury?

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By Amanda J. Khan, PhD

What is “moral injury” and how might psychedelics help?

Moral injury refers to the biopsychosocial-spiritual suffering stemming from participating, witnessing, or learning about events that transgress one’s deeply held moral beliefs (Litz et al., 2009; Shay, 2004). Moral injury is not a new construct, and the idea of a “soul wound” has long been evident in the writings of Homer and Plato. However, over the past 15 to 20 years, the term moral injury has resurged as a focus within the field of clinical psychology and psychiatry. At the same time, psychedelics are similarly experiencing a renaissance. Is this mere coincidence or an indication of a deeper underlying process at play? How might psychedelics hold promise for healing moral injury?

Moral injury is not a psychiatric diagnosis (Farnsworth et al., 2017; Jinkerson, 2016), but it can include feelings of guilt, shame, anger, disgust, and sadness, thoughts of personal regret and systemic failures, and avoidance and self-handicapping behaviors (Ang, 2017). Considered to be more “syndromal” than “normative” moral pain, moral injury is associated with significant impairment in relational, health, and occupational functioning as demonstrated by poorer trajectories in these areas (e.g., Maguen et al., 2020; Purcell et al., 2016). 

Although the two often co-exist, moral injury is distinct from post-traumatic stress disorder (PTSD). While PTSD is largely rooted in and characterized by fear-based conceptualizations (i.e., focus on life threat, victimization) and symptoms, moral injury is rooted in perpetration, complicity, and betrayal and characterized by moral emotions (guilt, shame, spiritual conflict). Largely studied in the context of military experiences (see Griffin et al., 2019 for review), researchers have bifurcated morally injurious events into transgressions (by others and self) and betrayal (Bryan et al., 2016; Nash et al. 2013). However, morally injurious events are not limited to certain people or contexts, but rather range widely (e.g., killing in combat, deciding which COVID-19 patient gets a ventilator in resource-poor settings, witnessing police violence against people of color, being ordered to break rules of engagement, institutional betrayal in sexual assault cases) (e.g., Badenes-Ribera et al., 2020; Smith & Freyd, 2013; Litam & Balkin, 2021).

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In my professional experience, those who experience moral injury stemming from transgression they themselves committed (either through action or inaction) can often carry deeply painful thoughts of “being a monster” and often engage in various forms of self-punishment and isolation in order to “protect others from themselves.” Most often, self-forgiveness feels like “letting oneself off the hook” for what was done, which is unacceptable. This deep sense of accountability, of course, reflects the actual inherent goodness and strong moral compass within the individual. Those who have experienced betrayal and transgression by others may find it especially difficult to trust people, carrying deep existential wounds about the goodness of humanity. However, most often, those struggling with moral injury have experienced all three of these types of wounds to various extents. 

Moral injury is in essence a social wound, predicated on the morals and values constructed and shaped by communities and society (Scheder, Mahapatra, and Miller, 1987; DePrince, & Gleaves, 2007; Litam & Balkin, 2021). But how does one heal a social wound? Evidence based treatments for post-traumatic stress disorder (PTSD), a related ailment, yield underwhelming efficacy especially in veterans, with up to 60% not experiencing meaningful improvement (Steenkamp, Litz, & Marmar, 2020). One reason for this may be that these approaches are not adequately addressing moral injuries within traumatic stress responses. Interestingly, the mental health field generally tries not to discuss morals, and yet it is clear that trauma and suffering are inextricable from morality. The false assumption of moral neutrality is deeply damaging and has allowed the mental health field to largely bypass the “moral” nature of trauma, war, and discrimination. 

Relatively antithetical to current PTSD treatments, individuals struggling with moral injury need the moral violations acknowledged and held, rather than cognitively restructured away. Even in our approaches to healing, the Western mental health field places high value on the role of the individual as both the source of the problem and the solution, rather than the collective or society. In other words, it’s an individual’s “problem” and it’s on them to do the work to “heal themselves.” Much of current research is an exemplar of this through attempts to pinpoint just what’s wrong in the person’s biology, thinking, or feeling that leads them to be this way rather than searching for and acknowledging the larger truth that often trauma is a form of societal abandonment.    

Thus, moral injury has been shied away from at least in part because it requires us to collectively acknowledge and take responsibility for the traumas that happen and their moral roots. Indeed, more often than not, those with transgression by self-related moral injury withhold these experiences from the therapist out of fear of moral judgment. People are often unsure if the person can confront and hold the truths of war and the dark side of humanity without restructuring it away. The same is often true for transgressions by others and betrayal related to racial trauma. However, to heal moral injury necessitates that we carry our share of the weight by confronting the social responsibility we have for each other. In other words, to move through moral injury, a society must actively incorporate and care for their individuals. 

Individuals struggling with moral injury need the moral violations acknowledged and held, rather than cognitively restructured away.

Indeed, a recent groundbreaking study in warriors from Turkana, a non-Western, small-scale society, showed the robust buffering effects of having explicitly moral-affirming cultural norms, social responsibility, and integration (Zefferman & Matthew, 2021). This is in line with recent efforts to incorporate community healing ceremonies into treatment for veterans. For example, Cenkner, Yeomans, Antal, and Scott (2020) found a ceremony in which veterans shared testimony on their moral injury with the general public significantly decreased depression, and improved self-compassion, spiritual struggles, personal growth, and psychological functioning. These findings provide preliminary evidence of the healing potential of communitas for moral injury, which is where psychedelics come in.

Psychedelics may create the opportunity for individuals to connect with the prosocial sense of communitas inherent in us all. Psychedelic compounds including empathogens (e.g., MDMA), classic psychedelics (e.g., psilocybin, LSD, ayahuasca), and dissociatives (e.g., ketamine) may provide both the context and content needed to treat moral injury. Psychedelics have the ability to “reopen” critical windows to feelings, thoughts, perceptions, and sensations previously blocked by the ego’s well-intended presence (Brouwer & Carhart-Harris, 2020). Psychedelics induce interactive neural and neuromodular effects across whole brain systems (Carhart-Harris & Friston, 2019), which translate to a context in which rigid patterns of thinking, relating, and feeling are relaxed, allowing for more psychological flexibility (Davis, Barrett, & Griffiths, 2020). 

Beyond providing the flexible ego-relaxed context, psychedelics may also “naturally” generate the content for treating moral injury and PTSD. Unlike evidence-based therapies, psychedelic-assisted therapies use non-directive approaches and although there is certainly preparation, there is no way to “enforce” what material is covered during dosing sessions. Despite this, evidence across numerous studies reveals psilocybin and other classic psychedelics consistently incline users toward confronting traumatic material and salient autobiographical memories, which relate self through past, present, and future (i.e., self-definition, expectations) (Camlin et al., 2018; Gasser et al., 2015; Malone et al., 2018; Watts et al., 2017). This is representative of the innate healing wisdom within each person. Much like how the body’s cells know what to do when a physical wound happens, the psyche on psychedelics appears to be naturally directed to the wound, toward confronting suppressed traumatic material, and limiting self-other concepts in need of healing.

There has been no empirical investigation to date into the use of empathogens (e.g., MDMA) or classic psychedelics as a treatment for moral injury. However, MDMA has been extensively studied as a treatment for PTSD, with very promising efficacy in reducing symptoms in combat veterans (Mithoefer et al., 2018). Announced this year, Drs. Amy Lehmer and Rachel Yehuda at the Bronx VA will be conducting a study using MDMA to treat moral injury in veterans (Lehmer & Yehuda, 2021). MDMA holds much promise for healing moral wounds in those who served, likely through its empathogenic qualities. Of particular relevance to military populations, MDMA may facilitate moral injury recovery through increases in self-other forgiveness and self-other compassion. It may help those suffering from moral injury disclose the experiences and get unblocked from beliefs about deserving to suffer and the unacceptability of forgiveness.

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To elucidate this point, I spoke with John*, a Special Operation Forces post-9/11 veteran who deployed to Iraq and Afghanistan. John has also used psychedelics to treat his moral injury and PTSD.

John shared, “MDMA has allowed me to pull back from how I view the actions I took during war. I now see what I did as reactions to my environment based on the limited insights I had in a moment. The military created me, created my wolf mindset. I see now that I was just operating from how they made me. It’s given me the ability to see myself from a distanced perspective, and I can more accurately see cause and effect without judging myself. I used to view these experiences with just endless pits of guilt and shame, and now I see myself and what I did with much more compassion and forgiveness instead.” 

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