Moral injury and operator syndrome

“You are killing me, Doc…”

If he said it once, he said it dozens of times in the hour we sat together, me at my desk on Zoom, him in a room with six other Special Operations Forces (SOF) guys somewhere in the Iowa wilderness. They had gathered for an “Operators Reset,” a health and wellness program run by 5by5 Performance Therapy, an organization that specializes in providing integrated therapies for special operations forces. It was the last day of the week-long program that introduced these elite fighters to, among other things, “operator syndrome.”

OS, as it is sometimes called, is a term coined by Chris Frueh and colleagues (2020) to describe the unique and natural constellation of health and performance effects experienced by SOFs, particularly an extraordinarily high allostatic load. Allostatic load is the strain placed on the body's biological systems by sustained chronic stress and physical demands associated with this occupation. Interrelated conditions include traumatic brain injury, hormonal dysregulation, sleep apnea, chronic pain, depression, anger, insomnia, and addiction. Operator syndrome also includes social systems of family, work, and cultural environments, as well as psychological factors such as posttraumatic stress disorder, anger, and depression, and existential issues such as a mindset that disregards the future, loss and grief, survivor guilt, the importance of killing, and fear of developing “invisible wounds,” including suicide.

Moral injury

I was on Zoom that day to introduce the guys to the concept moral injury. Moral injury occurs when a person's core moral principles are violated in situations where the stakes are high. This injury changes the way people view themselves, others, and the world, and can produce behavioral changes that indicate a loss of trust, connectedness, self-esteem, and meaning. Although Frueh's model does not directly include moral injury, my work and research—and many professionals who work with SFOs, like 5by5—have recognized that the “existential issues” that operators often grapple with naturally spill over into the moral and spiritual realm as well.

I opened the session as I always did, by asking, “How many of you have heard of moral injury before today?” And as operators often do, there was a pregnant pause; heads turned slowly to see the reactions of the others in the room; and then one (maybe two) hesitantly raised something like a hand. (In more than half the cases, no hand was raised at all.)

I have been working with veterans and soldiers for 20 years, first with couples and families, then over time with individual sessions. Like Jonathan Shay, who first coined the term moral injuryI, too, have seen the harmful effects of the victims of war on the human soul. For example, empty or wandering eyes that pull a person back to a place where bad things happened and everything became very “shitty” – when they or others became “monsters” that they never wanted to be, never thought they could be, never thought existed in the world. Or the flood of shame and the stream of guilt that crushes them, suffocates their spirit and drowns them on the “board” where conscience lies. And searing, red-hot anger, contempt and disgust for transgressive acts they committed under duress, or damnable situations they could not prevent, or betrayal by trusted people.

I got to the part of my presentation where we discuss the systemic manifestations of moral injury, particularly in the context of broken global meaning systems. “It can feel like the world no longer makes sense or is unsafe,” I said. “Or like you’ve lost your sense of humanity, goodness, or faith…that’s the definition of ‘innocence lost.’” I started talking about weakened spirituality and negative attributions to God or a higher power when “Charlie,” as I’ll call him, started pumping his fist in the air—or rather pointing his fist—and yelling, “You are killing me, Doc… you're killing me… That is It!”

Suddenly another SFO began to nod and point, and then another, and another. Soon the once dead silent room was transformed into a chaos of “aha moments” in which feelings, experiences and stories arose in rapid succession. Then Charlie said, “I had NO I had no idea what operator syndrome was when I came here and that blew me away with all the associated physiological symptoms I had. But now this moral injury… no one never told me about it, not even my therapist… That is the one who gave a name to what I have been dealing with for years… what almost cost me my life and my marriage and almost my relationship with my children.”

Extension of the operator syndrome model to include moral injuries and presentation of an overall picture

The model by Frueh and colleagues (2020) identified a unique and common pattern of interconnected medical, psychological, and quality of life impairments in SFOs, categorized by losses, biological dysfunctions, psychological factors, and (physical) injuries.

In fact, this model assumes that the operator syndrome affects the whole person – that is, the physical, biological, psychological, social and “existential” systems. The domains of himself serve as interrelated categories rather than symptoms, influences, or outcomes, allowing for a more centralized approach and model of integrated care (see schema in Frueh et al., 2020). The “existential” domain is expanded to include the moral and spiritual domains, which are simultaneously more distinct and more broadly understood and therefore may provide more targeted clinical service options. In addition, this schema specifically includes moral injuries, which research (Gielas, 2024; Koenig & Al Zaben, 2021) has shown to greatly affect military personnel and veterans, including operators and their families.

“Whatever the cost” and “Never give up” are mottos often associated with SFOs. Their bodies bear the burdens, their minds process the memories, their relationships bear the brunt, and their souls endure the ongoing toll of war (or deployment) to an extraordinary degree. All too often Posttraumatic stress disorder becomes a collective term, if not a diagnosis, for the diverse and physical problems of soldiers, which affect both their functional abilities and their quality of life and hinder their successful reintegration into civilian life.

Intensive outpatient programs that provide a multidisciplinary approach to treating operator syndrome have proven useful. These programs may prove even more useful if the model is expanded to include moral injury and related new therapies, thus providing the truly holistic health and wellness program needed for this important population to thrive.

If you or someone you love is having suicidal thoughts, seek help immediately. For 24/7 help, dial 988 for the 988 Suicide and Crisis Hotlineor contact the Crisis text line by SMS with the text TALK to 741741. To find a therapist in your area, visit the Psychology Today's Therapy Directory.