What is a moral injury? As you might guess from the name, it’s an injury or wound not to your physical body, but to your conscience or sense of personal ethics. A veteran’s organization defines it this way: “Moral injury is when one feels they have violated their conscience or moral compass when they take part in, witness or fail to prevent an act that disobeys their own moral values or personal principles.”
The experiences that are most likely to cause moral injury to happen in high-stakes situations or involve choices that aren’t clearly right or wrong. You can be morally injured not just from inflicting or witnessing harm, but also from hearing about it or even surviving it yourself. If you’ve been harmed, you may feel moral injury from trusting someone in authority who failed to do what was right. Or maybe you decided not to report someone who injured you, and you wonder if they’ll do the same thing to someone else.
Getting to the Root
It isn’t an event itself that causes moral injury but your response to it. Two people both participating in the same event can interpret it in very different ways. If you’ve experienced moral injury, you’ll feel damaged and wounded, maybe not immediately, but at some point, when the initial emotions of the event have died down, and you’ve had time to assess it more calmly. An article on moral injury and moral repair notes that the wounds can be emotional, psychological, behavioral, spiritual and social.
The American Psychological Society explains that there are two types of moral injury based on the “who” rather than “what” of the event. The betrayal of your conscience has either been initiated through someone else or your own personal actions, and the symptoms you experience are likely to be related to who you believe is most at fault. If you feel individually responsible, you may have more inward-focused emotions like guilt, but events you believe were caused by others may lead to externally-directed feelings like anger.
If you’ve had a moral injury, you might experience symptoms like these:
Feelings of guilt, shame and remorse
These feelings can be pervasive and sometimes overwhelming. They can color your view of yourself and affect how you interact with others. Because you judge yourself, you may expect others to judge you, too.
If you don’t like who you are, you can feel you don’t deserve success or happiness. You may consciously or unconsciously make life more difficult for yourself.
Depending on the situation, you may grieve for many different people and things. You’re likely to grieve for other people who were harmed and maybe for the loss of parts of yourself. You can feel like you’ve lost the person you thought you were and your positive self-identity. Grief can easily turn into depression.
Persistent memories of the event
Maybe you dream about the event at night or find yourself frequently thinking about it during your waking hours. Because you don’t want your memories to be triggered, you might avoid situations that remind you of them in some way.
Lack of trust
After a moral injury, trust can become harder to give, either to people in authority or to yourself. It’s easy to feel like you can’t trust your own judgment anymore, so you begin to second-guess all your decisions.
Anger and outrage
Anger related to moral injury can be fueled by the energy you wish you could have used during the event to change the outcome. It’s often directed outward, but you can also direct it toward yourself.
The idea of finding yourself in a similar situation again can trigger fears and anxious thoughts. You may lose your sense of safety or your sense of surety about how the world works.
Spiritual and existential questioning
After a moral injury, it’s common to spend time questioning social and personal definitions of morality. There may be a re-assessing of former beliefs.
Social and relational problems
Negative emotional states can easily lead to relationship challenges. You may find yourself wanting to isolate yourself or being irritable or aggressive around others.
Drug or alcohol abuse
It’s easy to turn to drugs or alcohol in an attempt to escape or manage emotional distress. Unfortunately, it can easily get out of hand and cause significant problems of its own.
Moral Injury and PTSD
Moral injury can correlate with mental health conditions like anxiety and depression. There’s also significant overlap between moral injury and post-traumatic stress disorder (PTSD). A study of moral injury and PTSD found that 25-34% of events that contributed to combat-related PTSD also resulted in moral injury.
Although there are many similarities between PTSD and moral injury, including similar initiating events and many common symptoms, there are also significant differences. PTSD, for example, is a fear-based condition and moral injury is conscience-based. PTSD generally involves hypervigilance, but it’s not a core part of moral injury.
The timing of symptoms also differs. The emotions related to PTSD are often present immediately, but those related to moral injury may rise to the surface over time. Sometimes they come after a re-assessment of your personal moral code or a shift in what’s socially acceptable.
People who did something that violated their values re-experience the event more than people who experienced a life-threatening trauma, according to an article addressing PTSD and moral injury by the U.S. Department of Veteran’s Affairs. They also have greater suicidal ideation.
Who Experiences Moral Injury?
Anyone can experience moral injury. The risk is more obvious for people who regularly find themselves in life and death situations, like military personnel, healthcare providers, and police, but no one is exempt.
A publication entitled Frequently Asked Questions about Moral Injury says this: “Under duress, people can violate their moral code in many situations. For example, a doctor misdiagnoses a patient with fatal consequences; a mother living with addiction loses custody of 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 married parishioner; or a train conductor fails to see a warning light and crashes his train.”
Treating Moral Injury
Knowledge of moral injury is still evolving, including knowing the best ways to address it. According to Syracuse University, the best therapy for moral injury “must be defined by the individual according to their beliefs and needs.”
The first challenge of treating a moral injury is that people often don’t want to talk about the event that caused it, especially if it was something that led to self-recrimination and feelings of guilt. Because of this, a safe, empathetic and nonjudgmental therapeutic environment is critical.
Although moral injury isn’t a mental illness, it’s associated with problematic feelings and beliefs as well as counterproductive coping mechanisms, which a mental health rehab can help you address. Individual circumstances dictate which approach is best for a particular person, but these are some of the approaches currently being used for moral injury. Therapists may combine elements of several programs depending on your personal circumstances and preferences.
Cognitive Processing Therapy (CPT)
CPT helps people evaluate and work through the beliefs that often underlie feelings of shame, guilt, and betrayal. Beliefs to be addressed may include things like “I should have done something different” and “I’m unforgivable.”
Adaptive disclosure involves imaginary dialogue with a compassionate moral authority, making amends when appropriate and growth in self-compassion.
Trauma-Informed Guilt Reduction Therapy
This approach helps people identify and evaluate the beliefs that contribute to guilt and shame. These involve things like hindsight bias and ideas about responsibility. People also evaluate the values that were violated and make a plan to live by them in the future.
Building Spiritual Strength
This is a spiritually based group program that includes a focus on forgiveness and a relationship with a Higher Power.
Sometimes beliefs about the situation and what could have been done differently are inaccurate, and counselors can help patients see the event through different eyes. In other instances, the beliefs are correct, and treatment needs to focus on forgiveness, clarifying values, determining what went wrong and making a plan to address future potentially problematic situations.
Incorporating some sort of restorative justice and restitution is also very healing for many people.
Anything that helps improve physical and mental health is likely to help the symptoms of moral injury to some degree. This includes things like exercising, eating well and avoiding environmental toxins. Relaxation exercises, like progressive muscle relaxation and breathing exercises, can also be beneficial. Mindfulness meditation can help you relax. It also helps you learn to focus more on the present and less on the past or future. Journaling can help you better understand the thoughts and feelings that aren’t in your full consciousness.
Sometimes techniques that help you separate yourself from the event that caused the moral injury are helpful. So that you can better externalize it and see that it’s only part of your story. This can involve creative outlets like making a piece of art that symbolizes the event or writing a song, poem or story about it. Turning the event and your reaction to it into something tangible and manageable can help give you a sense of control.
Get the Help You Need Now
Moral injury can affect your whole life. Devoting the time and attention necessary to heal it is wise. Receiving care from a residential mental health treatment program can help you focus on your goal in a peaceful, supportive, understanding environment. Your therapists can get to know you on a deep level. And help you sort out and make sense of your tangled feelings and experiences. If you’re ready to take that step, or just learn more, give us a call at 1.844.675.1022. We’re here to help.