The Enduring Moral Injury of September 11

Much of the research and advocacy in the burgeoning field of moral injury has focused on veterans who served in 9/11’s subsequent wars in the Middle East. Of the 2.7 million service people who served in Afghanistan and Iraq, reports show that roughly the same number who were diagnosed with PTSD (11 to 20 percent) were also coping with moral injury.

And yet for many people on the home front, the events of that horrific day also caused a laceration of conscience. Decades later, some still bear the invisible “soul scars” that uniquely define moral injury.

One story shared with me was a first responder who described “playing God,” having to determine which of the injured victims were a “black tag” (a triage term for a person who is dead or highly likely to die) and those who were a “yellow tag” (i.e., critical), and therefore had a modicum of hope — and having to make these life-changing, life-ending decisions in plumes of ash and smoke, without proper visibility. “It was impossible to make those decisions,” he said, “but doing so in those conditions … I know that I’m responsible for people’s deaths, only I was the one who was supposed to save lives.”

A good friend, whose in-laws lost a family member on one of the fated flights, said the family member’s spouse was inconsolable for months after the attack, and years later was still engaging in self-harming behaviors because he and his wife had had a fight the previous night and he purposely ignored her final call. A firefighter also told the story of ferociously hammering away at the wreckage in an effort to dislodge a person buried under the Towers' vast heaps of metal and screaming for help. He said he knew the equipment they had at that point could never do the job. All these years later, he still goes numb when things are "too quiet.”

Vaughn Allex, the man working at the airline ticketing counter who checked in two of the five hijackers who crashed the flight into the Pentagon, recently told StoryCorps that he didn’t know what he’d done until the next day when someone handed him the flight manifest. He recounted that people at work would neither look him in the eye nor talk to him. He blamed himself for the events of 9/11; sometimes just the mention of the day would activate a tsunami of guilt. Once, when a customer mentioned she’d lost her husband on that day, he heard it as, “You killed my husband on Sept. 11.”

Sharing the Story and Seeking Help

Like many people with moral injury, Allex said he had difficulty telling the story of his moral injury and getting help. “How do I sit in a room with people that are mourning and crying and they’re like, ‘What’s your role in this whole thing?’... Well, I made sure [the hijackers] got on the flight.” Being aware that many around him were struggling with the greater grief of a lost loved one also made attending support groups difficult. Such feelings were, no doubt, exacerbated by the initial shunning from his colleagues.

And herein lies one of the challenges with moral injury. Stories of moral injury can be excruciating or disturbing to hear. Many with moral injury don't share their experiences with others out of concern that they may contaminate them with their own terrible memories. They may fear they will be judged and rejected. They may also worry their anger or contempt will overtake them. Many people will not even tell a therapist about their moral injury frightened of being diagnosed, evaluated, or condemned. Any sign of repulsion or judgment risks derailing the healing process.

As I wrote in a previous article, reconciling difficult truths, honoring pain, transforming ways of thinking and being, and restoring moral integrity require, in part, trustworthy people who can listen to moral suffering empathetically even when words may be lacking, and hearts are crushed. Trustworthy listeners enable the telling and retelling of moral injury experiences. This continuous sharing helps moral injury to be processed and integrated into life stories that put moral injury into larger narratives of relationships.

The "Safe" Telling of Moral Injury Stories

For many people finding words to put to their morally injurious experience is simply too hard. Some in the throes of moral injury even find the act of speaking to be activating. Moral injury causes intense emotions, such as guilt, shame, disgust, anger, and contempt, among others. Like any difficult emotion strongly felt, sometimes that experience can cause one's nervous system to go “offline” and interrupt normal bodily functioning.

Decades of research has shown that narrative disclosure, that is recalling and renegotiating a traumatic story, is an important part of the healing process; likewise, that inhibiting negative emotions can lead to nervous system dysregulation and poorer health. It is also well documented that expressing one’s deeper thoughts and feelings through writing can result in significant physical and psychological health benefits in the short and long term.

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Accordingly, writing has emerged as a helpful tool for healing from moral injury as it provides a “safe” alternative into and processing the story. The Moral Injury Project at Syracuse University, The War Horse, the Moral Injury Institute, among others offer writing seminars for those trying to heal from moral injury.

Healing From Moral Injury — Both Individually and Collectively

More than two decades after our country experienced its, arguably, greatest loss of innocence, many are still struggling to process the experience. Certainly, individuals are, as is evidenced by more stories emerging, such as Allex’s, about the impact of that day on their conscience and moral identity. Collectively, we have also experienced moral injury: the existential crisis of having an attack upon our soil; controversial and interminable wars that have cost many lives and torn families apart; entrenched political polarizations that have put our own democracy at risk; and the fall of Afghanistan after our evacuation, to name a few.

Many believe healing from moral injury requires simply reordering a person’s fractured belief systems. While beliefs are a part of the picture, real healing requires re-establishing bonds of self-worth and life-sustaining relationships — whether that is with our own intimate circle of connections or our broader socio-cultural and political one.

As moral injury is processed through the telling and retelling of experience, it can be integrated into more meaningful life stories that put moral injury into larger narratives of relationships. As the stories are told and evolve, sharing them becomes easier without retraumatizing suffers or traumatizing listeners. The sharing can then deepen bonds of connection and love and open possibilities for a future worth living into together. This integrative relational process provides resources of resilience for everyone who has been burned by moral injury so they can move forward in life strengthened and renewed and better equipped for the challenges of life that are inevitable.

About

Dr. DeMarco is an award-winning writer, and a therapist, clinical ethicist, and trauma researcher specializing in moral injury and moral distress. She is the author of the Psychology Today blog “Soul Console: Healing from Moral Injury” and one of Medium’s Top Writers for Mental Health and Health, respectively. Her writing has appeared in national and international publications, including the New York Times, POLITICO, The Boston Globe, Psychology Today, and The War Horse, among others. She’s also been featured as a trauma, health, and spirituality expert for MindBodyGreen, Integrative Practitioner, Lifehacker, Bloomberg/WNBP Radio, Partners HealthCare, and the American Heart Association. Her new book Holding Onto Air: the Art and Science of Building a Resilient Spirit is now available.