Many people are aware of Post Traumatic Stress Disorder (PTSD) but are generally less familiar with the term Moral Injury. Unlike PTSD, Moral Injury is not an official mental health diagnosis but is, nonetheless, gaining increasing attention due to the light it shines on some people's difficulty in recovery with traditional treatments for PTSD. Much of the research at present has focused on veterans but, like PTSD, it is can be experienced by anyone, not least healthcare staff during the pandemic.
Moral Injury often co-occurs with PTSD following a traumatic incident but they are increasingly seen as separate conditions. Whereas PTSD is considered a fear/threat based reaction, Moral Injury occurs following incidents that do not have to primarily evoke fear/threat but which lead to feelings of shame, guilt, anger and/or betrayal. These experiences can cause people to lose trust in themselves, others, their organisations, or wider society. Relationships with others can be significantly impacted as a result of the fear of judgement associated with feelings of shame or betrayal.
Distress from morally injurious events can result from a belief that an act, or acts, have occurred that transgress your own moral beliefs, values, or ethical codes of conduct. These types of experiences can be separated between events where distress is based on perception of individual moral responsibility (e.g., perpetration of an act or failing to prevent harm) or the perception of others’ moral responsibility (e.g., witnessing disproportionate violence or betrayal by trusted others).
EXAMPLES OF MORAL INJURY IN WAR:
Causing harm or death of civilians, knowingly, even if without alternatives, or accidentally
Giving orders that result in the injury or death of a fellow service person or civilian.
Hearing of the abuse of civilians by members of your own service.
Failing to report knowledge of abuse, unlawful killing or sexual assault committed against oneself, a fellow service member, or civilians
Following orders that were illegal or immoral
Changing beliefs about the justification for war
Moral Injury is not a new term. Thinking around it began with Vietnam era veterans, and focused on perceptions of leaders’ moral failures, where there has been a betrayal of 'what’s right', by someone who holds authority, in a high stakes situation (1). It has since expanded to include perceptions of individual moral failings, with Afghanistan and Iraq era veterans, where there is the belief that the individual has perpetrated, failed to prevent, borne witness to, or learned about acts that transgress deeply held moral beliefs and expectations, and the moral/ethical violation resulted in “lasting psychological, biological, spiritual, behavioral, and social impact” (2). The lasting impact is key as, like PTSD, exposure to a potential traumatic event does not on it’s own inevitably lead to Moral Injury but instead it is the sense the individual makes of the event, and the degree of dissonance they experience, which determines the likelihood of developing Moral Injury.
Perhaps unsurprisingly, events involving individual responsibility are more likely to lead to negative thoughts and feelings directed at the individual themselves (e.g., guilt, shame, lack of self-forgiveness), whereas events involving others responsibility are more likely to lead to negative thoughts and feelings directed towards those perceived to have responsibility (e.g., anger, trust issues, lack of other-forgiveness). These are not mutually exclusive, it is very possible to experience both, especially for individuals exposed to multiple traumatic events.
Many people experiencing Moral Injury have been diagnosed and treated for PTSD. And for some, they may experience improvement in their moral injury even though it is not the principle focus because, as their PTSD symptoms are reduced, they are more able to look at and consider new ways of understanding the events they have experienced and their personal responsibility for them. However, for many others, they remain ‘stuck’ with feelings like shame or guilt, or anger and betrayal, which persist and can even block their ability to address co-existing PTSD.
We know that how we respond following Potentially Morally Injurious Events, both as individuals, teams, organisations, and communities, can have a significant impact on people's outcomes. Reducing stress, having strong social support and seeking help early can make a real difference.
Addressing Moral Injury directly is important in helping people reduce their distress, move on from their experiences and build meaningful lives. Therapies such as (but no limited to) Compassion Focused Therapy (CFT) or modern forms of CBT, like Acceptance and Commitment Therapy, work to help people address distressing thoughts and feelings, such as shame and betrayal, to overcome the trauma they have experienced. The work is not about dismissing the past or giving up appropriate responsibility but about helping people heal from their trauma by learning new ways to relate to their experiences, others and themselves. The changes it can produce can be life changing even for people who have carried their Moral Injury for many years. Helping them to rebuild trust, self-forgiveness and move forward to regain lives of meaning and purpose.
The hope is that awareness of Moral Injury grows among clinicians, and the general public, so that we can reach more people and help them overcome their suffering and get back to living fulfilling lives.
If you are a Veteran of The British Armed Forces and feel you need help with your own mental health, you can speak with your GP who can refer you to appropriate help. You can either can either opt to work with someone like myself privately, or seek help via the NHS. If your difficulties relate to service you can self refer to the NHS OP Courage Mental Health Service. You can find the contact details here.
2: Litz BT, Stein N, Delaney E, et al.: Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev 2009; 29:695–706 Crossref, Medline, Google Scholar
Christian Hughes is a Psychotherapist, and former uniformed military mental health clinician, specialising in Acceptance and Commitment Therapy, Compassion Focused Therapy & CBT, with expertise in trauma & PTSD and a special interest in Moral Injury.