Moral Anguish is Not a Mental Illness
by Paula J. Caplan, Ph.D.
Many years of listening to survivors of various kinds of trauma led me to choose the term “moral anguish” for one category of the effects of trauma. That term differs from “moral injury” in that “anguish” makes it clear that the upset is deeply emotional and often tears the sufferer apart. “Anguish” implies something less clear, clean, and streamlined, less surgical than does “injury.”
What often causes moral anguish is trauma that is perpetrated by people or entities whom the victim has trusted – whether those trusted are family members, close friends, senior people in one’s workplace or faith-based community or educational, civic, social, or political organization; this causes moral anguish because of the conflict between that trust and the betrayal of it. For some people who have served in combat and have injured or killed people identified as the enemy, moral anguish often results from the tormenting conflict between having been ordered to attack and kill in the name of the good and the right, as opposed to an enemy that is presented as less than human…and then suddenly seeing that one has injured or killed a human being. Moral anguish often ripples widely, so that the victim understandably doubts their own judgment in many situations and doubts whether other people or entities are to be trusted…or is terrified to trust or is determined never again to trust. The immediate environment and often the wider world no longer feel safe.
This is a terrible way to have to live, and it is made worse when this kind of torment is wrongly classified as “Posttraumatic Stress Disorder” (PTSD), which is classified as a mental illness. It is stunning that the huge number of criteria listed for PTSD includes not a single mention of moral anguish or moral injury, making it utterly perplexing that moral anguish is so often labeled “PTSD.” The emotions and behavior listed in PTSD criteria sometimes result from moral anguish, but effective ways to help someone with moral anguish or conflict are simply not those one would use in trying to change behavior or feelings if one did not know the moral matters that gave rise to them. In fact, once the PTSD label has been applied, it usually happens that everyone -- the labeled person, the professionals, and the person’s family members and friends -- leaps to the conclusion that the best thing to do is get that person into traditional psychotherapy and, increasingly, to have them take one or often more (often vastly more) than one psychiatric drug. This route often leads away from talking explicitly with the sufferer about the conflict and betrayal that created the moral anguish, and it certainly leads away from the many other nonpathologizing approaches that can also be helpful and that will be described later in this essay.
Why Moral Anguish is Misclassified as PTSD
This misguided approach is due to these factors: (1) utter lack of recognition at the most fundamental level that PTSD excludes all mention of matters in the moral realm; (2) the mistaken belief that psychiatric diagnosis is a science and clearly shows the way to what is helpful for people who suffer; (3) therapists’ and researchers’ often unfounded claims about what is helpful; and (4) therapists’ frequent failure to mention anything helpful other than professional therapists and drugs. Traumatized people regularly report that even those family members and friends who will listen to them for a few minutes are quick to say, “You need to see a psychiatrist, because I am not trained to deal with a mental illness.”
The National Institute of Mental Health’s Web site states baldly that PTSD is a disorder, meaning a psychiatric disorder, not that it is an understandable, deeply human response to trauma, and the Society for Women’s Health Research instructs that if you think a loved one has PTSD, “The first step is to talk to your doctor or mental health professional.” A reporter for American Medical News quoted Daniel Potenza, a Department of Veterans Affairs psychiatrist, telling an American Medical Association symposium that “Promising therapies for PTSD exist, including medications and psychological treatments.” And in a USA Today article, the chief of the traumatic stress program at the National Institute of Mental Health claims, “Treatment gives most people [with PTSD] relief from symptoms.” Authors of major medical journal articles write widely disseminated pieces about treatments for psychological problems in which the only treatments even studied are drugs and therapy.
Is getting some help for those who are suffering better than getting them no help? Of course.
Some forms of help carry dangers that others do not, and that is true of the labeling of all people experiencing moral anguish as mentally ill and putting them on drugs and in psychotherapy.
Although some may benefit from either or both of these approaches, we must not lose sight of the fact that they carry dangers for at least some people, whereas other approaches are available that do not involve making people feel they are “crazy” and do not involve the risks that extremely often accompany drug therapy and sometimes even accompany psychotherapy.
Traditionally, psychotherapy was not designed, and therapists were not trained, for grappling with matters of morality. And those who refer to the PTSD criteria are unlikely to focus on moral anguish as the root cause of emotional suffering and behavioral problems. Psychotherapy was designed to help with an individual’s inner conflicts or with conflicts between the individual’s needs and society’s demands and expectations. But moral anguish often results from: (1) dramatic disparities between what the sufferer has been told they can expect from the person or entity that caused them harm and what the person or entity has actually done (e.g., a father who has sexually abused his child, a university administration that protects the “rights” of a student who is a rapist over validation and justice for the rapist’s victim, a government or a commanding officer claiming justification for a military action that turns out to be false), (2) retribution when the sufferer speaks the truth about what happened, and (3) loved ones and/or those in authority “gaslighting” the sufferer by failing to state strongly that the disparity and hypocrisy that the sufferer has dared to describe is real.
In fact, one need not be a therapist in order to make validating and supportive statements, and even if a therapist does make them, it is essential for other people in the sufferer’s everyday environment – ideally, as many people as possible – to confirm the sufferer’s recognition of the reality. If only a therapist does that, it often happens that, in essence, in exchange for being believed and supported by the therapist, the sufferer is in the deeply confusing position of feeling, “My therapist believes me, but I am seeing a therapist because I am mentally ill as a result of what happened.” It is much healthier and certainly accurate for the person instead to know that the moral anguish is not a bizarre or otherwise abnormal reaction to the trauma but is deeply human and very common.
How to Decide What Is a Mental Illness — and the Harm the Labels Cause
At the foundation of everything that happens to everyone in the mental health system is the psychiatric diagnosis. In principle, no one may be treated for psychological suffering without receiving such a label, regardless of the nature of the treatment. And historically, the number of categories of alleged mental illnesses in the successive editions of the psychiatric diagnosis handbook, the Diagnostic and Statistical Manual of Mental Disorders, or DSM, has grown by leaps and bounds. Molly Hogan has written, “When I returned to psych nursing in 1989 [after being out of the field since 1972], I discovered that all the psych labels . . . that I was familiar with, which had never made much sense to begin with, had been replaced with new labels. I noted that it was now much easier to get a psych label.”
Unlike physical problems, such as broken bones or high cholesterol levels, there are no clear, reliable, and valid tests for almost anything that is called a mental illness. Clinicians and researchers—some of them smart, some of them caring, some both, some neither—see people who are suffering and try to divide the manifestations of that suffering into categories. This is an effort I have compared to looking at the night sky and deciding how to divide the stars into constellations. It is extremely rare that one finds two patients with identical symptoms, and in fact there are 12,870 different combinations of symptoms of PTSD that one can have and still meet the DSM-IV criteria for it, and still more combinations became possible with the increase in PTSD criteria in DSM-5. Because many thousands of symptom pictures can fit within the PTSD specifications, those who get the PTSD label can differ tremendously from each other. It is hard to find well-done studies that truly provide information about how to help an individual who sits before us. Human behavior is complex, and a person’s strengths and resources, as well as problems, help determine what will help them.
If the creation and use of labels led to more knowledge about how to help, this would be a different conversation. However, at this stage of the evolution of psychiatric categories, there is little or no evidence that choosing a label helps much in deciding on treatment or predicting eventual outcome. An enormous amount of ado about nothing fills the psychiatric and psychological journals, which bulge with well funded but largely uninformative studies about psychiatric labels and treatments.
The way we decide what a mental illness is and who has it is important, because getting a psychiatric label is far from risk-free. Even the mildest of diagnoses can carry the following dangers, and patients are almost never warned of these:
- the damage done to the labeled person, who therefore feels “I must be crazy” and “I should have been over this by now";
- the failure to be regarded by oneself and others (including one’s therapist) as consisting of more than one’s problems;
- difficulty obtaining or keeping a job (discrimination on the basis of mental disability is illegal, but in the real world there is an enormous burden of proof on people with psychiatric labels to prove that they were not hired or were mistreated at work or fired because of the diagnosis rather than, as management often claims, because the employees were not “team players” or were “hard to work with”);
- increased health insurance premiums or denial of long-term care insurance on the grounds that the individual has a preexisting condition;
- loss of the right to make decisions about one’s medical and legal affairs;
- loss of custody of one’s children; and
- the danger that overemphasis on mental illness will lead doctors to overlook traumatic brain injury (or other problems of physical origin) because of jumping to the conclusion that some of its symptoms, such as memory loss, irritability, and sleep problems, are signs of psychiatric disorder.
In light of these risks, it is essential to know that few people, even therapists, are aware that the psychiatrists who literally write the book of psychiatric diagnosis have acknowledged that they have failed to reach a consensus about a good definition of mental disorder. And when the DSM authors conducted their own studies to see whether two therapists would agree about which psychiatric label a person should receive, they obtained poor results. Perhaps most important is that psychiatric labels impoverish our understanding of the fullness of a suffering person’s humanity. As Athar Yawar writes,
A patient’s story is a symphony of suffering, longing, meaning, understanding, hope, fear, loss, wit, and wisdom. Not to accompany the person afflicted on his journey is inhumane ... Experiences are matched to labels of descriptive poverty. “Depression” implies a low level of something, presumably mood, rather than the rich and complex turmoil felt by the patient. 
Every time a traumatized person gets a diagnosis, some professional has decided that the person’s feelings have crossed the line from a normal response to a “diseased” one. Yet even contributors to the VA’s Iraq War Clinician Guide note that “the boundary line between ‘normal’ and ‘pathological’ response to the extreme demands of battle is fuzzy at best.” These authors say, for instance, that when soldiers are about to be deployed, “It is often difficult ... to determine the difference between reasonable anxiety and an excessive reaction or the development or recurrence of psychiatric illness, [and during deployment] the novelty of the situation may contribute to symptoms of dissociation.” Elsewhere in the same guide, one finds the warning that:
To avoid legitimate concerns about possible pathologization of common traumatic stress reactions, clinicians may wish to consider avoiding, where possible, the assignment of diagnostic labels such as ASD [Acute Stress Disorder] or PTSD.
And when so many military veterans I have interviewed have said that just having someone—especially a nonprofessional—listen to them without judging and with compassion has reduced or resolved their sleep or other problems, it makes no sense to say those problems or the moral anguish of nonveterans are signs of mental illnesses.
Problems with “PTSD” in Particular
There is remarkably little reason to think that suffering because of having been traumatized is proof that one is “mentally ill with PTSD.” As Meadow Linder describes in her illuminating history of the label and its problems, some military veterans whose suffering had been ignored came together with some caring mental health professionals and proposed that a new category be added to what was then the upcoming edition of the DSM. The category was ultimately called Posttraumatic Stress Disorder, and the intention was to persuade professionals and others to take the vets’ suffering seriously.
PTSD was initially defined (in DSM–III) as a normal reaction to abnormal situations, a response to something so terrible that it would “evoke significant symptoms of distress in almost everyone.” But from its first appearance in the DSM, PTSD carried the mixed message, “You are normal. You are mentally disordered.” The DSM is periodically revised, and as a result of serving for awhile on two committees for the fourth edition (DSM-IV), I was stunned and troubled to discover that decisions about how to define “mental disorder,” what categories to put in the DSM, how to title each category, and what symptoms to list for each category are vastly more likely to be marked by misuses of science and by poor-quality science than by responsible, straightforward use of well-done research. As new editions of the DSM were produced, the DSM authors decided to specify that, in order to receive the PTSD label,the person must have “experienced, witnessed, or been confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others,” and to have responded to the event with intense fear, helplessness, or horror. By that definition, couldn’t we say that virtually everyone who has been at war or who was raped would have what gets called PTSD? And if that is the case, what benefit is there—other than getting insurance coverage for therapy (not an unimportant benefit)—from giving so many people this label? If it helped therapists predict what kind of treatment would be most likely to work,that would be different, but that is not the case.
Some people say that it is a relief to be told they have PTSD, because getting a label made them feel that their suffering was taken seriously. However, it is easy enough to let people know that we take their suffering seriously without making it a condition that they allow themselves to be labeled mentally ill. Furthermore, there are the major risks of psychiatric labeling described earlier. The good news is that instead of saying “You have PTSD,” we can say “We believe that you are suffering. You are not making this up,” and leave out the part about mental illness. This has the added benefit of opening us all up to considering a wider array of ways to try to alleviate the suffering. More than two dozen of these are presented at http://www.youtube.com/playlist?list=PL51E99E866B9D735E from a conference about veterans, but they are helpful to a great many others suffering from moral anguish, because they are focused on connection, creation, or both, and these dimensions take people into realms not fraught with hypocrisy and denial of reality. They include but are not limited to meditation and mindfulness; involvement in the arts, volunteer work, or political action; legal action; having a service animal; and having someone simply listen without asking questions or making comments but with their whole heart and 100% of their attention.
Details of the PTSD listing change every time a new edition of the DSM manual is published. Each time, the therapist is told that a certain number of symptoms in each category (categories such as “intrusion” with symptoms like distressing feelings or dreams, or “avoidance” or thoughts, feelings, or external reminders of the trauma, or symptoms of “negative alterations in cognitions and mood” or “alterations in arousal and reactivity”) must be present in order for the diagnosis to be assigned. This sounds impressively scientific, but it is not. How, after all, might one choose the numbers of symptoms the person needs to have? For PTSD, as for most categories in the DSM, there has been no scientific basis for choosing, and the choices have often depended on political considerations, including which person on what DSM committee has how much power. One might wonder, then, why these categories of problems are listed at all. The only clear answer is that it increases the aura of scientific precision surrounding the enterprise of psychiatric diagnosis.
The PTSD Label Masks Real Problems and Introduces New Ones
The very choice of words in the title, Posttraumatic Stress Disorder, should raise concern. “Posttraumatic” is nonspecific, failing to indicate the source of the traumatizing moral anguish – war, domestic violence, rape, etc. – and thus de-emphasizes and even covers up that source. When one is told that a person “has PTSD,” one has only the information that something bad happened, and the vagueness makes it harder to understand and empathize with that person. The vagueness also diminishes the visibility and thus the culpability of the perpetrator, where there is one.
With regard to “Stress,” If you ask five people what comes to mind when they think of the word “stress,” you get answers like “distracted” and “worried,” with examples of stress-causing situations such as “losing my credit card” or “being stuck in a traffic jam.” Words matter, and to use the word “stress” in this label seriously misrepresents the intensity of the suffering of traumatized people, whose feelings are often more accurately described by words like “terrified” and “despondent.”
Finally, the word “Disorder” identifies it as a mental illness. But even the well-intended move to remove the “D” and refer instead to “PTS” is woefully inadequate. It will be years, if not generations, before most people – upon hearing “PTS” – will stop thinking “D” for Disorder. And even removing the final letter leaves the problems described for the other two words.
A different and helpful perspective on the concept of PTSD comes from a look at other cultures. In a New York Times Magazine article, journalist Ethan Watters noted that “PTSD, many Americans assume, describes the way that all humans react to trauma,” but he reports that this is not the case. For instance, “the deepest psychological wounds” for Sri Lankans exposed to a tsunami were not on the symptom checklist for PTSD but rather were “the loss of or the disturbance of one’s role in the group.” Derek Summerfield dismisses PTSD as a useful concept, writing that, “The notion that war collapses down in the head of an individual survivor to a discrete mental entity, the ‘trauma’ that can be meaningfully addressed by Western counseling or other talk therapy is absurdly simplistic.” He also notes that despite the absence of objective evidence that “psychological debriefing,” talking with a professional about the horrific events, is helpful, Western professionals and organizations put tremendous effort into using this approach. According to Summerfield, this happens even when people in different cultures make it clear that the central problem is the need to fix the social world that war has broken rather than to provide counseling.
Even in the United States, individuals grow up in different cultural contexts, in families with varying ways of expressing (or not expressing) feelings and of coping with problems, so it should not be surprising that Americans’ reactions to trauma vary. It can interfere with our efforts to help people experiencing moral anguish if we try to force their reactions into the symptom clusters that happen to have been constructed for the DSM.
One problem with the list of PTSD criteria is that these symptoms do not always go together in real life: Not every trauma survivor and certainly not everyone experiencing moral anguish has nightmares or flashbacks and numbing and hypervigilance. What do we do with that information? We can decide that, because they do not meet the PTSD criteria, we will not take their suffering seriously and offer them help, whether professional or otherwise, or we can acknowledge that individuals suffer differently from each other and that their failure to fit an unscientific but predetermined matrix should not exclude them from our compassion. Surely it is better to recognize the uniquely individual aspects of suffering and to offer respect, compassion, and help to those who need it. How sad to waste resources trying to find just the right label for someone when our attention should be on the whole person, the nature of that person’s suffering, and the imperative to provide help. The diagnostic criteria pale in comparison to the rich but devastating details of individuals’ experiences, illuminating how much understanding we sacrifice when we retreat behind psychiatric labels.
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Paula J. Caplan, Ph.D., is a clinical and research psychologist, advocate/activist for veterans and their families, and author of 10 books, including When Johnny and Jane Come Marching Home: How All of Us Can Help Veterans (2016, Open Road), which won three top national awards for nonfiction. Her documentary film, “Is Anybody Listening?” about the chasms between veterans and nonveterans and the wrongful pathologizing of war trauma and military rape trauma, has won numerous festival awards, and copies may be ordered and screenings arranged through isanybodylisteningmovie.org. Her “Listen to a Veteran!” series of Public Service Announcements won a prestigious Telly Award. She is Founder and Director of the Listen to a Veteran! Project, information about which is at listentoaveteran.org. She is Associate at the DuBois Institute, Hutchins Center for African and African-American Research, Harvard University.
 Portions of this article are excerpted and adapted from When Johnny and Jane Come Marching Home: How All of Us Can Help Veterans by Paula J. Caplan (Open Road, 2016). Contact through paulajcaplan.net or listentoaveteran.org.
 Keitt, S. (2009). Post-traumatic stress disorder and the female soldier, press release. Society for Women’s Health Research, February 19.
 Landers, S.J. (2008). Suicide hotline lets veterans — and families — dial for help, American Medical News, August 25.
 Elias, M. Post-traumatic stress is a war within the body, for the military and for civilians, USA Today. October 27.
 For instance, see Z. Imel, M. Malterer, K. McKay, & B. Wampold. (2008). A meta-analysis of psychotherapy and medication in unipolar depression and dysthymia, Journal of Affective Disorders 110(3), 197-206.
 Caplan, Paula J. (1995). They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal. (Perseus Books)
 Hogan, M. (2009-2010). Speaking out for her family: Molly Hogan interview. MindFreedom Journal. Winter issue, p. 9.
 Caplan (1995), op. cit.
 Caplan (1995), op. cit.
 See discussion in Caplan (1995), op.cit.
 Caplan (1995), op. cit.
 Yawar, A. (2009). The fool on the hill, Lancet 373, 621-2.
 Cozza, S.J.; Benedek, D.M.; Bradley, J.C.; Grieger, T.A.; Nam, T.S.; & Waldrep, DA. (2004). Topics specific to the psychiatric treatment of military personnel. In The Iraq War Clinician Guide, 2nd ed., edited by R.G. Lande, B.A. Martin, J.I. Ruzek, et al. (Washington, D.C. : National Center for PTSD and the Department of Veterans Affairs), pp. 4-20, quotation at p.22.
 Cozza et al. (2004), op.cit., p. 11.
 Linder, M. (2004). Constructing Post-traumatic Stress Disorder: A case study of the history, sociology, and politics of psychiatric classification. In Bias in Psychiatric Diagnosis, editors Paula J. Caplan & L. Cosgrove (Lanham, MD: Rowman and Littlefield), pp. 25-40.
 American Psychiatric Association. (1980). Diagnostic and Statistical Manual of Mental Disorders-III. (Washington, D.C.: APA).
 Caplan (1995), op.cit.
 Caplan (1995), op.cit., and Caplan and Cosgrove (Eds.), Bias in Psychiatric Diagnosis (2004).
 Caplan (1995), op.cit., and Caplan (2016), op.cit.
 Watters, E. (2007).The way we live now: Idea lab: Suffering differently, New York Times Magazine, August 12.
 Summerfield, D. (1999). A critique of seven assumptions behind psychological trauma programmes in war-affected areas, Social Science & Medicine 48, 1449-62.