Care is often conceived in basic terms: to provide assistance, support, or solace to someone in distress. Yet when “care” is placed in the context of moral injury, we see how superficial treatments—especially those denying the significance of unconscious processes and the fluid nature of meaning—cannot address the potentially deep ruptures of moral injury. Moral injury as an aspect of trauma potentially undermines a person’s capacity to make sense of the world, whether it arises from ethical conflicts (e.g., participating in perceived wrongdoing) or from overwhelming trauma that shatters previous moral or existential frameworks. To tackle moral injury effectively, care must first acknowledge the truth of the unconscious and différance before it can delve beneath symptoms, engaging hidden dimensions of self, language, and cultural codes.
In this blog post, I draw from several key influences:
Heidegger’s notion of Mitsein, which underscores our ontological entanglement rather than just a meeting of conscious minds.
Lacan’s triadic structure (Imaginary, Symbolic, Real), revealing how moral and existential breakdowns unravel shared meaning.
Derrida’s trace and différance, highlighting the perpetual movement of signification and the impossibility of complete presence.
Levinas’s emphasis on responsibility to the Other, opening an ethical dimension that transcends technical solutions.
Alan Bass’s concept of disavowed difference, cautioning against flattening the Other’s complexity.
My variation on Heinz Kohut's notion of “healthy narcissism” rooted in a self-cohesion that does not disavow the unconscious and the fluid dynamism of meaning.
I will show that any therapy denying unconscious complexity and the perpetual flux of meaning traps both clinician and patient in a defensive, unhealthy fantasy of conscious agency grounded by stable meaning—an approach ill-equipped to address the patient's disruptions to healthy meaning-making and trust in the world. Ultimately, an ethics of care must embrace these realities to be both ethically sound and genuinely effective. If a therapist or treatment modality colludes in denying these truths, it becomes structurally unethical, precisely because it fails to promote true health.
Denials of Psychoanalysis and Deconstruction
The University’s Denial of the Unconscious
Jacques Lacan famously articulated four discourses—Master, University, Hysteric, and Analyst—each describing a particular set of social bonds and modes of producing knowledge. In the discourse of the University, the supposed pursuit of “objective” knowledge often masks an underlying refusal to confront the unsettling truths of the unconscious. For Lacan, the University discourse is characterized by a veneer of scholarship and rigor, which, while purporting to be neutral or purely intellectual, ultimately represses or sidelines the raw disruptions of desire, fantasy, and subjectivity that psychoanalysis highlights.
In contemporary American psychology departments, this denial is most apparent in the preference for empirical, quantifiable research that marginalizes or outright excludes psychoanalytic insights. Studies of cognition, behavior, and standardized assessment tools often strive for measurable outcomes, with little interest in the murky, unquantifiable realm of unconscious processes. Although valuable in addressing certain clinical or research questions, this stance—if made absolute—ultimately reinforces an intellectual climate that rejects the truth of the unconscious. It perpetuates a “discourse of the University” which drapes itself in academic authority yet fails to acknowledge that humans are not wholly rational and that much of our psychic life lies outside conscious awareness.
Derrida’s “Who’s Afraid of Philosophy?”: The Marginalization of Différance
Just as psychoanalysis faces marginalization in mainstream psychology, deconstruction encounters a parallel dismissal from philosophy proper, a phenomenon Jacques Derrida insightfully critiques in “Who’s Afraid of Philosophy?” Derrida laments that philosophy departments tend to exclude or trivialize deconstructive approaches, relegating them instead to literature or cultural studies programs. The core of his critique is that official academic philosophy is often invested in preserving its own metaphysical foundations, implicitly denying the concept of différance—the radical insight that meaning is never fully present, never fully graspable, and always in motion.
When philosophy refuses to engage différance, it clings to a fantasy of final truths, neat categories, and definitional clarity. The same impetus leading psychology to bar the unconscious from its purview drives philosophy to bar différance from the center of its discourse—both, in essence, reassert a fantasy of stable, transparent knowledge. This stance underscores the complicity of the university in denying the complexities of subjectivity and meaning: for psychology, the inconvenient truth is the unconscious; for philosophy, the unwelcome idea is the play of différance.
Complicity of the University and the Need for a Corrective
Put together, these systemic denials within academic disciplines exemplify Lacan’s discourse of the University writ large: the ideal of knowledge wrapped in elaborate theoretical frameworks that refuse to see how knowledge itself is shaped by desire, language, and illusions of mastery. Precisely because the university can wield institutional authority and intellectual prestige, its denial of the unconscious and différance does more than stifle innovative inquiry—it actively undermines the foundational tenets of an ethics of care that must, by definition, consider the depth of subjectivity and the ceaselessly deferred nature of meaning.
From this vantage, your form of health humanities constitutes a crucial corrective. It insists that genuine care cannot remain shallowly invested in “fixing symptoms” (as we see in certain empirical psychology models) or in defending final truths (as traditional philosophy often does). Instead, a health humanities approach rooted in psychoanalysis and deconstruction acknowledges precisely what these hegemonic academic frameworks deny: that humans are largely driven by unconscious forces, that meaning is unstable, and that both these insights are indispensable to an ethics genuinely oriented toward healing and health.
The Irony: Lacan’s Own Denial of Différance
There is an added complexity in that Lacan himself, despite championing the truth of the unconscious, has been accused by Derrida of denying différance. In “The Purveyor of Truth,” Derrida argues that Lacan’s reading of Poe—and broader aspects of Lacan’s style—betray an attempt to pin down an authoritative interpretation, effectively reinstating a master position even when critiquing it. Put differently, Lacan unveils the unconscious only to reinscribe meaning in a way that might ignore or suppress différance, much like the philosopher who undercuts deconstruction or the psychologist who dismisses Freud.
This paradox suggests that Lacan partakes in half of the typical denial you condemn: he undermines the academic denial of the unconscious but replicates the academic denial of différance. The result is a partial critique that still stops short of fully embracing the ethical consequences you find central to care. This half-denial is itself symptomatic of the broader University discourse—a desire to claim mastery over meaning (in Lacan’s case, by asserting his singular interpretation of the text, or of the unconscious) while refusing the radical notion that no single reading or closure is ever final.
Toward a More Comprehensive Ethics of Care
By recognizing both halves of the denial (the unconscious and différance), your ethics of care avoids the pitfall of situating itself in an institutional fantasy of final knowledge. Instead, it affirms that healing hinges on appreciating that human subjects are complex, partially unknown to themselves, and always in flux. When universities deny one or both of these truths—refusing the unconscious in psychology or rejecting différance in philosophy—they produce frameworks ill-suited for actual care, which must remain open to the destabilizing dimensions of desire and language. Confronting these institutional denials, my style of health humanities insists that care is not a tidy enterprise but a profoundly ethical act, one that depends on facing the real complexities underlying our psychic and linguistic lives.
Heidegger’s Notion of Mitsein: More Than “Relational”
Heidegger’s concept of Mitsein cuts deeper than the idea of two self-aware subjects choosing to engage one another. It asserts that our very being is fundamentally being-with, an ontological condition in which we are inseparably entwined with others—even before conscious interaction occurs. We inhabit communal horizons of language, history, and culture, much of which remains unconscious. This is not just “relational” in the usual sense of two clearly defined individuals facing off; it is a constant interweaving of influences, many of them unconscious or implicit.
In moral injury, this shared fabric can break down from two directions:
A direct ethical clash: The subject confronts actions or systemic practices that violate deeply held moral convictions.
A broader existential collapse via trauma: Overwhelming suffering shatters the subject’s capacity to interpret and endow events with meaning, independent of any explicit moral code.
Regardless of how it arises, moral injury reveals not simply a breach of specific values but the fragility of the entire field of Mitsein. This surpasses mere intersubjectivity—where two conscious minds meet on equal footing—and extends to the unspoken, ontological interplay between individuals in a shared world. Therapies that approach the patient as an isolated “case” miss the latent, pre-reflective structures that shape how we exist together. If they also deny the unconscious and the ceaseless deferral of meaning, they can only address symptoms superficially, neglecting the deeper wounds of moral injury.
Beyond Symptom Management: The Challenge of Moral Injury
In mainstream trauma work, interventions often focus on symptom alleviation—taming flashbacks, regulating anxiety, or restructuring cognitive distortions. While these strategies can be vital for short-term stabilization, moral injury poses a far more fundamental rupture. It does not merely concern how one feels but how one understands, belongs to, and orients oneself within the shared world. This breakdown of meaning can stem from:
Ethical contradictions: Witnessing or participating in behavior diametrically opposed to one’s cherished values.
Traumatic overload: Events so catastrophic that preexisting frameworks of meaning seem painfully inadequate.
The Forced Fantasy of Agency
Certain therapeutic models—especially those aligned with purely behavioral or cognitive approaches—often exhibit what we might call a “fundamental countertransference,” to borrow from Alan Bass’s perspective on disavowed difference. By denying unconscious motives and the ever-shifting nature of meaning, the clinician unconsciously imposes their own illusions about stability and total agency onto the patient. In doing so, they promote a rigid, “correct” reality that reinforces prevailing cultural or institutional norms rather than questioning the deeper structures that contributed to the patient’s moral injury in the first place. This countertransference arises when the therapist’s own need for coherence and control supersedes an openness to the patient’s complex ethical and existential crisis.
Instead of helping the patient explore how illusions of moral certainty or cultural legitimacy may have unraveled under traumatic conditions, the therapist pushes for “re-internalizing” the very narratives that allowed these illusions to flourish. This stance glosses over the patient’s sense of betrayal and alienation, effectively dismissing their moral indignation or confusion as mere dysregulation. Bass underscores that such disavowal of difference not only negates the ethical depth of the patient’s suffering but also perpetuates illusions that are fundamentally defensive in nature. What looks like “helping” can thus become an unethical form of collusion, where the therapist’s unconsciously motivated assumptions about reality, health, and normalcy obstruct or even betray the patient’s need for the therapist's ethical care.
The Symbolic, the Imaginary, and the Real: Lacan’s Three Registers
Lacan identifies three pivotal spheres that shape the subject’s psychic life:
The Imaginary: The zone of images, identifications, and ego-structures.
The Symbolic: The network of language, laws, cultural codes, and moral systems.
The Real: That which resists or transcends symbolization, often experienced in moments of profound crisis.
When moral injury disrupts the Symbolic register—whether through ethical betrayal (discovering systemic wrongdoing) or existential overload (confronting unthinkable violence)—standard therapies that dismiss unconscious processes and différance try to “repair” the subject’s moral scaffolding with quick-fix scripts. These types of approaches avoid grappling with the potential dissolution of trust in the world moral injury can cause, never truly engaging the ethical question: How does a therapist care for a patient who struggles with basic engagement with others and a world without reliable meaning structures on which to base engagement?
From Alan Bass’s vantage, this avoidance by the "concrete" therapist (the therapist that disavows differance and the unconscious) can be seen as a fundamental countertransference, wherein the therapist’s unacknowledged need to uphold Symbolic ideals—despite their breakdown for the patient—drives them to impose a superficial normalcy on the patient via projection. The clinician unconsciously disavows the depth of moral despair, preferring to reassert societal or institutional norms that the patient can no longer accept at face value. This disavowal mirrors the basic disavowal of all concrete subjects: the disavowal of differance and the unconscious, meaning the therapist's investment in the very modality is actually symptomatic of the therapist's own concreteness.
While it may look like “helping,” this stance is unethical not because it colludes with the very illusions whose failure precipitated the patient’s injury, but because the patient suffering from moral injury cannot be helped by a countertransferential and unethical projection by the concrete therapist, in the concrete therapist's unconscious attempt to secure his or her own fragile Symbolic façade, rather than grappling with the collapse of the patient's probably similar but ultimately different facade. Such an approach not only fails to restore a healthy-enough "narcissism" (or necessarily illusory meaning-making system) but also risks further alienating the patient, who is probably desperately wanting connection with another but is struggling to engage without a functioning meaning-making foundation to their ego, or what Kohut called their "selfobject" functions, functions that can only function well if they are grounded in a healthy-enough narcissism, or a healthy-enough Imaginary.
Derrida’s Trace and Différance: Meaning as Perpetually Unstable
Derrida challenges the assumption that meaning can be fully present or mastered. Every sign carries traces of what came before and resonates with future contexts we cannot predict. Différance describes the ceaseless deferral and difference within language, suggesting that no concept—like “justice,” “duty,” or “honor”—stands stable and complete. For someone grappling with moral injury, discovering that cherished ideals may have been grounded in illusions compounds the trauma. It reveals the precariousness of meaning itself.
Why Denial Leads to Unethical Care
A purely behavioral or cognitive approach that disregards the unconscious and the flux of meaning typically aims to reassert a rigid, “correct” reality, rather than helping the individual grapple with existential disturbance and the true processes of meaning-making that persist even under non-traumatic circumstances. Such an approach is unethical not merely because it risks overlooking the patient’s suffering, but also because it discounts unconscious processes and the unending deferral of meaning. In ethical care, caregivers are compelled to acknowledge these truths, while patients deserve honesty and mutual recognition of complexity.
Crucially, patients also deserve care that genuinely works—that is, care that truly heals them and addresses the real dynamics of their suffering, arising from trauma and a compromised ability to make meaning in the world. This principle forms the foundation of my ethics of care: it is unethical to adopt treatment methods that do not heal, that do not work. The only path to ethical care is one that acknowledges the importance of the unconscious, the cultural unconscious, and the fact that meaning remains in flux even when we are not traumatized.
Levinasian Responsibility: The Other Beyond Our Frameworks
Levinas points to an ethical responsibility that arises in the face of the Other—a demand that precedes theoretical categories or personal preferences. However, Levinas does not explicitly address how unconscious drives or the flux of meaning intersect with this ethical call. In moral injury, the subject’s distress can be viewed as an Other calling for recognition of systemic failings or personal betrayals. Therapies that deny the unconscious and différance fail to honor that call, reducing the patient to a set of symptoms rather than a being whose fundamental horizons of sense-making have been shattered.
Expanding Levinas
To meet Levinas’s ethical imperative fully, we must acknowledge that neither the caregiver nor the patient is transparent to themselves. Each is subject to hidden motivations, and language never fully coincides with meaning. When moral injury surfaces, both parties face an ethical demand that surpasses normal frameworks. A caretaker insisting on stable truths or purely rational solutions effectively mutes or marginalizes this deeper ethical dimension.
Alan Bass on Disavowed Difference: When Treatment Becomes a Cover-Up
Alan Bass’s exploration of how difference is disavowed underlines how easily we sidestep complex truths for the sake of a stable self-image or cultural consensus. In therapeutic contexts, this may look like:
Pathologizing Moral Conflict: Reducing the patient’s moral crisis to “distorted cognitions.”
Ignoring Institutional Complicity: Refusing to examine how cultural or organizational narratives contributed to the injury.
Such an approach is unethical, not merely as a failure of empathy but as a denial of the authentic complexities—unconscious, cultural, and symbolic—that constitute moral injury. Ethical care, in Bass’s sense, would keep difference on the table, acknowledging that the patient’s critique may reveal deeper ideological or institutional failures.
Healthy Narcissism: Embracing Unconscious Dynamics and Flux
Heinz Kohut’s concept of “healthy narcissism” suggests that certain illusions or identifications can maintain self-cohesion in a constructive way. However, if either therapist or patient clings to the fantasy of total agency—denying the unconscious or ignoring différance—narcissism becomes destructive. Such rigid narcissism tries to stamp out ambiguity and fix meaning in place, thereby blocking authentic healing.
Measuring Health by Openness
A patient suffering moral injury may have lost faith in their identity and their moral universe. A truly healing stance helps them rediscover or rebuild frameworks of meaning, but without insisting on absolute certainties. Likewise, the therapist’s healthy narcissism demands humility: an openness to the unseen forces at play and to the fluidity of meaning that cannot be fully tamed. By letting go of the false promise of total agency, both parties carve out space for genuine care.
The Necessity of Acknowledging Unconscious Depth and Permanent Flux
Ultimately, moral injury ruptures a person’s capacity to make meaning within a world that suddenly appears untrustworthy. Whether prompted by direct ethical contradictions or by a traumatic collapse that overwhelms interpretive abilities, this disturbance cannot be addressed by therapies that disclaim unconscious complexity and the perpetual motion of meaning. Such therapies fail ethically because they deny the deeper truths revealed by moral injury—namely, that we are not fully in charge of ourselves or the sense-making apparatus, and that illusions of stability can just as easily be illusions of complicity or denial.
Clinical Implications: Toward an Ethics of Care that Actually Heals
Confront the Existential Breakdown: Therapists must engage the subject’s moral and existential collapse, not push them into a normalized “correctness.”
Maintain Awareness of Mitsein: Recognize that care is not a simple intersubjective dialogue but an ontological entanglement shaped by hidden drives and social signifiers.
Respect the Flux of Meaning: Embrace Derrida’s différance to avoid reimposing illusions of stable truth, which the patient’s trauma may already have shown to be precarious.
Rehabilitate, Not Obliterate, Fantasies: Some illusions underpin healthy selfhood, but illusions denying unconscious or cultural complexities remain damaging.
Preserve Ethical Depth: The therapist’s task is not to fix moral “errors” but to accompany the subject in re-examining the structures of meaning that have failed.
Conclusion: An Ethics of Care for a World of Fragile Meaning
Moral injury reveals that we are always enmeshed in a shared world—Mitsein—whose codes, norms, and values can fail us in devastating ways. Ethical care demands we acknowledge the unconscious dimension, the ceaseless play of meaning, and the potential illusions in our moral frameworks. Denying these truths to enforce a rigid “reality” is not merely insufficient; it is unethical. It preserves a fantasy of total agency that might have played a role in the very conditions leading to moral injury.
By contrast, an approach rooted in the recognition of unconscious interplay, cultural contingency, and différance offers the humility and openness needed to genuinely heal. This is where a carefully modulated “healthy narcissism” comes into play—enough self-cohesion to function, but not so rigid as to pretend we can fully master our psyches or the flux of meaning. Only by embracing this radical honesty can we respond adequately to moral injury, guiding both patient and caregiver toward a reweaving of trust, a more nuanced sense of ethical possibility, and a deeper appreciation of the manifold complexities that define our common world.
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