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Confronting Moral Injury

What is Moral Injury?

Moral injury is the suffering people experience when we are in high stakes situations, things go wrong, and harm results that challenges our deepest moral codes and ability to trust in others or ourselves. The harm may be something we did, something we witnessed, or something that was done to us. It results in moral emotions such as shame, guilt, self-condemnation, outrage, and sorrow.

Moral injury is a relatively recent term used to describe a crisis that soldiers have faced for centuries, the internal suffering that results from doing something against your moral code. In essence it is a wound to the conscience. However, it is not just military members that can experience this. And what is this? It is soul anguish, a broken spirit, a shredded soul.

Anyone who works with marginalized, at-risk populations has probably seen that empty stare that can be moral injury. People in poverty. People struggling with addiction. People whose daily lives and their choices erode their feeling of being a good and decent person, worthy of respect. People who carry unprocessed grief and guilt in ordinary life. Because of things we do, witness, are ordered to do, or fail to do in high stakes situations, we can lose our moral foundations and our sense of being a good person.

In war, it’s often the job of military personnel to do those things that violate everything they were ever taught is wrong. However, moral injury can also afflict anyone when no good choice is possible in situations and people must use the power they have to act, knowing they will cause harm, or violate their own core moral values. In those situations we actually don’t lose our moral conscience, but in judging ourselves, we become both betrayer and betrayed. A soul divided against itself.

Moral injury is a broken spirit – not a disorder or a psychiatric condition, though it profoundly effects our mental health. Moral injury is the feeling that one is no longer possible to be good anymore. It is the loss of the capacity for trust and empathy, of a sense of meaning, and even of faith in God.

Six common questions that are often asked about moral injury

  1. What causes moral injury? There is no predictable set of causes, but the main factors involve high stakes situations, such as life and death, a high risk for failure, no clear right and wrong choices, and harm done. A person can feel afflicted by conscience not only from directly inflicting harm, but also from witnessing it happening, hearing about it, or surviving being harmed. Victims of harm can also experience moral injury—they may feel ashamed of being contaminated by evil, believe they caused the harm, or do things to survive that violate their conscience.
  2. What are the symptoms? Rita Brock, Volunteers of America’s Senior Vice President, Moral Injury Programs, notes that people will often feel grief, as well as negative moral emotions such as guilt, remorse, shame, outrage, and despair. They lose trust in themselves and their moral foundations, which disrupts or destroys their relationships because they cannot trust others not to judge them. They may self-medicate their inner pain with alcohol or drugs. They can become alienated from societal norms and lash out in anger at the slightest provocation.
  3. How is it different from PTSD? Post-traumatic stress disorder is fear-based. Moral injury is not. They can share some symptoms, like anger, addiction, or depression, but moral injury has no diagnosis or treatment protocols. PTSD protocols can involve reliving the traumatic incident in a safe environment to defuse the fear. Dr. William Nash, a psychiatrist and expert on moral injury, points out that the very same therapy can sometimes aggravate moral injury, repeatedly “bringing it emotional immediacy” that makes it harder to address.
  4. What is the best treatment? With something as complicated as moral injury, there is no single best agreed-upon treatment, but this complexity means that it can be processed in a number of ways. When people have trouble accessing what is wrong, having them create an image, go through a guided meditation, or write a poem or story can help them access a fuller memory. Prayer, chanting, and various forms of meditation offer collective ritual processes for calming inner turmoil and restoring capacities to reflect on and make sense of inner pain. A conversation with a benevolent moral authority, such as a chaplain or religious leader can help, but this will not be helpful if they impose their religious views. Helping people think is important; telling them what to think can delay or derail recovery. At some point, the precipitating incident(s) must be shared, talked about, and looked at reflectively. This sharing requires people prepared to listen deeply, with an open heart and without judgment. But how such sharing and listening are structured can vary by culture and spiritual tradition. Affinity groups can provide an effective point of entry for building trust so that sharing is easier, for example, veterans who share military culture, refugees from a particular region, or survivors who share a common experience. As Brock says, “Recovery is a lifelong process because it requires the restoration of love and empathy.”
  5. Does it apply only to soldiers? Not at all. Under duress, people can violate their moral code in many situations. For example, a doctor addicted to drugs steals them from his office; a mother living in poverty abandons her children; an office worker fabricates documents for fear of losing a job; an expectant mother has to abort a problem pregnancy; a minister has an affair with a parishioner; or a train conductor fails to see a warning light and crashes his train.
  6. How can you help a loved one who suffers from moral injury? Attending to the behavior of someone you love is important. If they seem distant, reluctant to share, preoccupied, controlling, cold, drinking too much, overworked, or otherwise not able to be present, that may mean they have shut down because of inner emotional pain. They may be unaware of why they feel terrible, or they may be reluctant to share what bothers them if they believe you will think less of them or will be disturbed by what they hear. Ask them if they’ve heard of moral injury. Brock has noticed that when people are introduced to the term, their eyes light up in recognition. “They know it for themselves,” she says, “or they know someone who has it.” Ways to introduce it include films, books, blogs, essays, stories, and conversations with someone who has experienced it. Just remember that you may not be the person they want to talk to, but make sure they have someone to talk to.

Moral Injury Resources

For additional information on moral injury and PTSD, we have summarized some websites, books, movies and journal articles that cover the topic.*

Websites

PTSD-RELATED

MORAL INJURY-RELATED

Books

Movies

The following list offers a small selection of films that depict PTSD, moral injury, or both. Considering PTSD and moral injury through film can help people better understand how symptoms manifest while providing examples that may help people talk about what they are experiencing.

Articles