Michael W. Marks, PhD

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.

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.

 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.

 This phenomenon is most striking when those previously traumatized are reexposed to combat.

 However, other types of stressors can also trigger a resurgence of symptoms.

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.

 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 


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 

. 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.


It is noteworthy that the focus of Robert’s trauma in Vietnam was not based on personal fear. Rather, his anguish originated in 

, 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.

 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 

Moral injury is a relatively new construct, and empirical studies are in their infancy.

 is also viewed by some as a controversial theory.

 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.

Although there has been little written about empathy as a risk factor for PTSD, some research supports the connection between empathy and symptoms of traumatic stress.

 Empathy may lead to PTSD-related symptoms, including survivor guilt and feelings of helplessness in veterans who are prone to moral injury. These individuals are deeply affected by the sufferings of others. It may prove worthwhile to further explore empathy as a risk factor for PTSD symptoms in the subpopulation of veterans who are likely to have moral injury from their combat experiences.

While Robert’s reaction suggests a link to previous moral injury, it should be noted that other sequelae are also possible. A discussion with other counselors in our program indicated that some veterans with preexisting PTSD also reacted strongly to the Sandy Hook shootings; however, their PTSD pathologies emphasized issues of safety. Based on their experiences in combat, this group viewed the world more as an unsafe place in which they had to be constantly on guard for signs of danger. Perceiving the world as full of danger, they feared that the response of society would lead to gun restrictions, which would further curtail their ability to protect themselves.

 suggest that future research to examine the role of fear conditioning and fear extinction models might shed light on the development of symptoms among individuals indirectly exposed to mass trauma. While this might be a fruitful avenue of research for some veterans who respond to trauma in a more fearful manner, the above case suggests that those with a history of trauma related to moral injury might benefit from another approach.

Traditional PE treatments for PTSD may not be enough to heal the wounds of moral injury. Although PE therapy is considered the gold standard for PTSD treatment, not everyone benefits equally. There is a substantial dropout rate for existing PTSD treatments, including PE therapy, and it may be that a certain proportion of individuals who drop out do so because they believe they are not benefiting-or are even getting worse-from the therapy.

 Further, the National Center for PTSD argues that traditional therapies may not be sufficient to heal moral injuries of war, especially killing-based transgressions.

 are piloting a new approach that specifically addresses the moral injuries of combat. This approach, described as “moral repair,” has shown some success, but has not yet been adopted in general practice. For the time being, PTSD treatment (eg, PE therapy, cognitive processing therapy) can be tailored for patients who have suffered a moral injury. Strategies such as reparation and forgiveness, which are components of moral repair, along with attempts to foster resilience and posttraumatic growth can be incorporated into treatment.

While standard treatments utilizing psychological and psychiatric modalities are useful approaches to treating symptoms of PTSD, helping or encouraging patients to access their creativity may be another path to healing, and therapists can use positive reinforcement to support their patients with such an individualized approach. For example, writing about traumatic experiences can be an effective treatment for PTSD and can ease a variety of symptoms, including feelings of shame and guilt.


Several weeks after Robert called his therapist in distress, he indicated he was feeling better because immersed himself in writing poetry. He had written poems specifically about the Sandy Hook shooting. One of his poems, titled “The Pistol-packin’ Boogyman,” read in part, “My Lai comes to Connecticut . . . God invites them (the children) to sit in a reading circle . . . He touches the bullet holes in their heads . . . In their hearts . . . and their wounds fly away.” Robert said that through his poetry, he felt he “won back part of my soul because I chose to feel, I chose to be human.”

Although it may be unpleasant to revisit the original trauma in light of a new exposure, either directly or indirectly experienced, novel therapeutic approaches and creative reflections can help patients find meaning and strength in a more complex view of life and one’s place in it. Thus, re-experiencing a moral injury and working through the pain of a new traumatic exposure can lead to resilience, growth, and a healing outcome.

1. Norris FH, Friedman MJ, Watson PJ, et al. 60,000 Disaster victims speak. Part 1: An empirical review of the empirical literature, 1981-2001. 

 2002;65:207-239.
2. Norris FH. Impact of mass shootings on survivors, families, and communities. 

. 2007;18(3):1-8.
3. Port CL, Engdahl B, Frazier P. A longitudinal and retrospective study of PTSD among older prisoners of war. 

. 2001;158:1474-1479.
4. Solomon Z, Garb R, Bleich A, Grupper D. Reactivation of combat-related posttraumatic stress disorder. 

. 1987;144:51-55.
5. Macleod AD. The reactivation of post-traumatic stress disorder in later life. 

1994;28:625-634.
6. Maguen S, Litz B. Moral injury in veterans of war. 

. 2012;23(1):1-6.
7. Tedeschi RG, Calhoun L. Posttramatic growth: A new perspective on psychotraumatology. 

www.psychiatrictimes.com/ptsd/posttraumatic-growth-new-perspective-psychotraumatology

.
8. Dokoupil T. A new theory of PTSD and veterans: moral injury. 

http://www.thedailybeast.com/newsweek/2012/12/02/a-new-theory-of-ptsd-and-veterans-moral-injury.html

. Accessed May 8, 2013.
9. Regehr C, Goldberg G, Hughes J. Exposure to human tragedy, empathy, and trauma in ambulance paramedics. 

. 2002;72:505-13.
10. Neria Y, Sullivan GM. Understanding the mental health effects of indirect exposure to mass trauma through the media. 

. 2011;306:1374-1375.
11. Hembree EA, Foa EB, Dorfan NM, et al. Do patients drop out prematurely from exposure therapy for PTSD? 

. 2003;16:555-562.
12. Maguen S, Litz B. Moral injury in the context of war. National Center for PTSD. 

http://www.ptsd.va.gov/professional/pages/moral_injury_at_war.asp

. Accessed May 20, 2013.
13. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. 

. 2009;29:695-706.
14. Resick PA, Uhlmansiek MO, Clum GA, et al. A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. 

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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.

Michael W. Marks, PhD

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