What Is Moral Injury And How To Heal From It

The concept of moral injury is not new, yet it is believed that while working with Vietnam veterans, psychiatrist Jonathon Shay developed the concept. The idea defines individuals’ ethical and moral struggles because of conflicts with one’s moral code. Simply put, when a person fails to perform in accordance with moral beliefs, ethical codes, or values, they suffer moral injury, and when this happens, the person feels potentially morally and mentally hurt.

Unlike post-traumatic stress disorder, which is a result of threat-based trauma, moral injury events do not necessarily involve a threat to life. Rather, they harm or threaten one’s beliefs and trust, causing the feeling of shame and guilt and altering cognition beliefs, making one fall for negative perceptions about themselves like I am a failure,

No one likes me, etc. Also, the individual might fall for substance abuse, self-destructive acts, or social withdrawal. It is because of these outcomes a person struggles with mental health problems linked with post-traumatic stress disorder, depression, and suicidal tendencies.

Moral injury is a specific trauma people face when their conscience and moral values are deeply violated or shaken. It can occur in different ways, and the most common ones involve: 

• Act of commission
• Act of omission
• Betrayal

In this post, we will discuss moral injury and how to deal with it in detail. 

 What is Moral Injury?

“Changes in biological, psychological, social, or spiritual functioning resulting from witnessing or perpetrating acts or failures to act that transgress deeply held, communally shared moral beliefs and expectations” is moral injury. This includes accidentally killing or witnessing the killing of innocent people, etc.

When someone is the victim of moral injury, they undergo psychological distress, causing guilt, depression, self-harm, loss of spirituality, a sense of rejection, etc. Due to this, it is often misinterpreted and confused with PTSD. But after closely looking at both terms, it has been found that they are different. 

What is the difference between moral injury and PTSD?

Unlike PTSD, moral injury is not anticipated because of life-threatening events. Rather, it is predicated on thoughts and feelings, and the person’s response depends on how they process them based on their morals. To some extent, this shows some similarities between PTSD and moral injury and how individuals use cognitive and behavioral avoidance strategies to cope.

But this doesn’t mean they are the same. In contrast to moral injuries, PTSD traumas are emotionally associated, and they develop after the event has occurred. However, suppressing emotions is a way to cope with feelings of moral injuries. 

In moral injuries, experiencing trauma itself is not necessary. However, how people interpret the event tells how unhappy they are with their moral values, worldview, and actions. If this inharmony exists, it can negatively affect how a person feels about themselves, leading to self-criticism.  

Examples of Moral Injury

• Accidentally killing civilians in combat as collateral damage or knowingly as there is no alternative.
• Following or giving orders that might harm others or cause death. 
• Unable to help the needy due to lack of resources and see them dying. 
• Failing to provide medical aid to an injured civilian or service member.
• Unable to report sexual harassment against oneself, a team member, or a stranger. 
• Following illegal or immoral orders. 
• Change in belief to fit in. 

 Symptoms of Moral Injury

As moral injury does not fit into a medically diagnosable and treatable model. It is not considered to be a mental health condition. However, if the person exhibits the following symptoms for too long and feels like their moral compass is gone off the track, they might struggle with depression, anxiety, and aggression and might have suicidal tendencies. 

• Moral injury can cause complex feelings of guilt, shame, remorse, and anger. 
• It can also lead to continuous self-criticism.
• The individual feels unworthy, cannot forgive themselves, and feels that they are damaged and cannot be healed. 
• Unable to sleep well, and there are behavioral changes. 
• The person usually likes to be left alone, and their sense of empathy and compassion is weakened. 

Consequences of Moral Injury

When felt for a longer duration, moral injury can lead to the following consequences: 

1. Lead to serious distress, depression, and suicidal thoughts. 
2. Both metaphorically and literally it can prevent the person from living a normal and healthy life. 
3. It can destroy a person’s capability to trust others, impacting personal, interpersonal, and external relationships. 
4. The healing process takes time, as shared healing has no scope. 
5. It can damage an individual’s soul. 

Who is at Risk for Moral Wounds?

Whether therapists, first responders, human rights advocates, or political violence victims, anyone confronting a life-or-death scenario or anything severe can undergo moral injury.

When struggling with burnout, these people face difficulty maintaining their morale, beliefs, and values. Due to this, often, they have been seen taking extreme measures and are found struggling with agony and pain. Moreover, the inability to keep up with the commitment makes them feel worthless, leading to suicide, self-harm, and other negative effects.

This affects millions of people globally because some professions, like medicine and the military sometimes have to compromise with moral values and do as the time demands. This affects their mental well-being and has devastating effects.

How to Recover from Moral Wounds?

Different treatments are being developed to help people heal from moral damage, and they include cognitive behavioral therapy (CBT), which emphasizes forgiveness and self-compassion. When people follow this recommendation, the symptoms of anxiety and depression are significantly reduced. 

The same approach is used for people struggling with post-traumatic stress disorder(PTSD). In addition to these methods, techniques like mindfulness, exercise, healthy eating, and meditation are also suggested to help the person understand what’s happening.

However, one must remember that these approaches are not practical for dealing with moral injuries as they are not structured.  But they can surely help find some relief. 

How do You Protect Yourself from Moral Injury?

Generally, those who work in the healthcare industry are at higher risk of moral injury because they keep others’ well-being above their own. Therefore, self-care should be promoted for frontline workers as it will help them deal with moral injury.

In addition to this to stay protected against moral injury, one should pay attention to how they talk to themselves. How one talks to themselves tells a lot about a person’s mental state and also shows if they have a healthy outlook towards themselves or are self-critical and are struggling with low self-worth. 

Furthermore, when individuals find themselves going against their moral values and better judgment, instead of thinking negatively about themselves, they should accept what has happened, and try not to judge themselves.

They can also think about how they can deal with the situation better the next time they confront it, what they have learned from this incident, etc. Reflecting on self will help them gain a different perspective and be positive in situations that look negative. When they do so, they can look at things differently, help more people, and develop compassion and better understanding.

Moral Injury – What Can be Done about it?

A good way to move past moral hurt is to speak freely about the experiences. This can be done with friends, family, and people who can be trusted and are not critical of the morally hurt person.

When this is done, individuals feel supported and can develop a forgiving outlook. Therefore, when dealing with a person who is morally hurt or if you think you are morally wounded, pay attention to the traumas and feelings that come with it. 

Moral injury varies from person to person. It is subjective and personal. If you are not sure about what moral injury is, seek help. Remember, traumas cause PTSD and can even cause moral injury. Therefore, if you think treating PTSD will help with healing moral injury and vice versa, you are wrong. Both conditions need to be paid separate attention and treated differently.

People carry moral injury for a long time as they don’t know much about it. If you think that a certain act you performed has hurt your morals, ethics, or values, pay attention to it. Do not overlook it, as it will harm you in the long run. Seek help from friends and family. If you think talking is not helping, seek the assistance of a counselor.