Traumatic events commonly lead to a range of mental health consequences, from adjustment reactions to chronic PTSD. Various factors affect mental health outcomes following disasters, including demographics of the population studied, the lack or presence of emotional and social support, and disaster type. Regarding this last variable, with other characteristics being held constant, levels of impairment are most likely to occur when individuals experience mass violence, as opposed to technological disasters and natural disasters.1
Predisaster functioning predicts postdisaster outcomes. That is, those with prior mental health problems are at greater risk for new or renewed mental health symptoms compared with survivors without a history of psychopathology.
In one study, mass shootings were shown to lead to PTSD, with prevalence of 10% to 36% among survivors, responders, and bystanders.2 Rates of subthreshold PTSD were much greater, and very few persons were symptom-free. However, few studies focus on the mental health consequences of mass shootings on community members not directly exposed to the trauma, and there are no known studies on the impact of indirect exposure to mass shootings on those with preexisting PTSD.
PTSD as a specific form of preexisting psychopathology is the most dramatic manifestation of the impact of traumatic events on individuals. In persons with a history of PTSD, a reactivation of symptoms can occur following a subsequent stressor.3 This phenomenon is most striking when those previously traumatized are reexposed to combat.4 However, other types of stressors can also trigger a resurgence of symptoms.5
Population studies involving the impact of disasters on individuals fail to provide clinical nuances or an exploration of the connection between the current exposure and patients’ earlier traumatic experiences. Such studies do not attempt to explain why certain patients might be deeply affected while others are not. For this reason, case reports can be of value, both to explore associations, and to provide the impetus for further study.
The following case illustrates how PTSD can be reconceptualized for certain combat veterans by invoking the construct of moral injury.6 We will then explore how the experience of being exposed to a mass shooting can be used by patients with moral injuries in a therapeutic setting to assist healing. Exploration of the pain caused by such an exposure can be used as a therapeutic tool to foster posttraumatic growth.7
Robert, a 65-year-old Marine Corps veteran with service-connected PTSD, emergently called his VA psychologist 3 days after the widely publicized mass homicide at Sandy Hook Elementary School. He is a retired high school English teacher. He now volunteers at a local elementary school and helps kindergarten through second-grade students.
As a young man, Robert had been deployed to Vietnam for a 13-month tour of duty. He has been in treatment for PTSD for approximately 7 years. When initially seen at the VA, he reported experiencing depression, insomnia, intrusive thoughts of his combat experiences, avoidance of crowds, feelings of alienation, problems maintaining enduring female relationships, and guilt over not stopping atrocities he had witnessed in Vietnam. He had a history of occasional suicidal ideation. His past treatment included prolonged exposure therapy (PE). When he was last seen by his psychiatrist before the Sandy Hook shooting, he had been stable.
When asked about his traumatic experiences in Vietnam, he reported having been highly distressed at witnessing “the suffering of innocent people.” He said that his most traumatic experience occurred when 14 of his fellow Marines were killed and 86 were wounded during a 2-hour battle involving mortar fire—he often had flashbacks and intrusive memories of the battle. He was troubled by their deaths and the knowledge he was not able to help relieve the suffering of the wounded. He described feeling overwhelmed and “helpless.” He also reported distress when he witnessed American Marines being unnecessarily cruel to the Vietnamese people. He noted that “when we sell our souls to survive, we die inside.”
In the past, Robert had been upset over mass casualty incidents reported in the media, but the shooting at Sandy Hook had affected him more deeply than any other incidents. He cried for 3 days as he watched news of the tragedy. He described himself as “in crisis” during this time. He was alarmed by his feelings of helplessness and terror which he imagined the children must have experienced before their deaths.
The role of empathy in moral injury
It is noteworthy that the focus of Robert’s trauma in Vietnam was not based on personal fear. Rather, his anguish originated in witnessing the suffering of others, and residual feelings of helplessness and guilt for not acting when he saw things that violated his moral code. We conceptualize him as having suffered from moral injury, which has been defined as experiencing events that transgress deeply held moral and ethical expectations that are rooted in religious or spiritual beliefs.6 In war, moral injuries stem from participation in direct acts such as killing or harming others, or indirect acts, such as witnessing death or dying, failing to prevent the immoral actions of others, or participating in acts viewed as gross moral violations. Robert empathized with the victims of Sandy Hook. He consciously and/or unconsciously connected the Sandy Hook tragedy to his experiences in Vietnam. The moral aspects of his original traumatic exposure resonated within him and led to his distress after hearing about the Newtown massacre.
Moral injury is a relatively new construct, and empirical studies are in their infancy.6Moral injury is also viewed by some as a controversial theory.8 We hypothesize that combat veterans who have suffered a moral injury in the past may be predisposed to a recurrence of the painful memories associated with previous trauma after exposure to similar traumatic events with moral overtones.
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