When moral injury hits, it hits hard and can have a long lasting emotional and psychological impact.
What Is Moral Injury?
Moral injury is a disruption in an individual’s confidence and expectations about his/her own moral behaviour or others’ capacity to behave in a just or ethical manner. It “results from having to make difficult moral choices under extreme conditions, experiencing morally anguishing events or duties, witnessing immoral acts, or behaving in ways that profoundly challenge moral conscience and identity and the values that support them.
Moral injury is found in feelings of survivor guilt, grief, shame, remorse, anger, despair, mistrust, and betrayal by authorities. In its most severe forms, it can destroy moral identity and the will to live. The possibility for moral injury is not limited to those in active combat but can include any position where life and death decisions are made.
In military communities where it was first identified as ‘moral injury’ and was defined by Psychiatrist Jonathan Shay as the psychological, social and physiological results of a betrayal of “what’s right”.
Moral injury is a loss injury; a disruption in our trust that occurs within our moral values and beliefs. Any events, action or inaction transgressing our moral/ethical beliefs, expectations and standards can set the stage for moral injury.
Some examples leading to moral injury include:
· Unintentional errors leading to injury or death
· Witnessing and/or failing to prevent harm or death
· Transgression of peers, leaders or organizations that betrayed our moral/ethical beliefs or expectations
The injury is caused by the betrayal, but it’s in the beliefs and our response to them that it actually resides.
When we suffer a moral injury, our beliefs about ourselves, our world, or both are shattered in the wake of what we’ve witnessed or done.
Our moral beliefs are one of the ways we see the world and one of the ways we conceptualise ourselves. Everything flips when people no longer adhere to a ‘code’, good people are forced to do bad things for good reasons, or our different identities contradict one another.
Moral Injury - Raises OH&S Issues
Organisations should start paying attention to this risk for three reasons:
1. To take preventative steps to ensure their workers are not hurt with a moral injury (basically, as an OH&S issue).
2. Learn how to identify and manage moral injuries if they do occur.
3. To identify what support is required should it be determined moral injuries are an ‘occupational hazard’.
The OH&S analogy is very relevant in view of for example, the Royal Commission into Misconduct in the Banking, Superannuation and Financial Services Industry. Employees exposed to acute trauma as a result of misconduct are likely to have their own world views of honesty and ethical behaviour challenged. A sense of betrayal could be argued. We are yet to hear the result of the numbers of employees made ill as a consequence of the misconduct in this sector.
However as a movement begins to stir in the corporate world casting a much wider view on ethical and honest behaviour, moral safety of employees will become an issue discussed at leadership of many of these organisations. Keeping people safe morally will add another layer to a very complex reset, reform and cultural agenda.
Duty Of Care
Today, we expect organisations to think about their duty of care in a broad sense – taking an active interest in their employees’ wellbeing, seeking to reduce the risk of physical injuries, managing and minimising psychological stressors and mental illness, and providing support when physical or mental stressors are likely to have a negative effect on employee wellbeing.
So, naturally it follows that if some ethical issues can have an effect on wellbeing, they should be treated seriously by organisations claiming to care about their people.
Why Haven’t We Heard About Moral Injury Before?
Traumatic brain injury (TBI) and post-traumatic stress disorder (PTS or PTSD) became household terms over the last decade thanks to the maturation of attitudes about the costs of war; moral injury is now the object of growing focus by researchers and academics in the same manner.
Moral injury does not, by its nature, present itself immediately. Some will experience questions of moral injury days after an incident; for many others, difficulties will not surface for years. An experience with potential for moral injury is typically realized after a change in personal moral codes or belief systems.
What Are The Consequences Of Moral Injury
Moral injury can lead to serious distress, depression, and suicidality. Moral injury can take the life of those suffering from it, both metaphorically and literally. Moral injury debilitates people, preventing them from living full and healthy lives.
The effects of moral injury go beyond the individual and can destroy one’s capacity to trust others, impinging on the family system and the larger community. Moral injury must be brought forward into the community for a shared process of healing.
In the context of a soul, with respect to the diversity of beliefs and spiritual perspectives held by those involved with moral injury, consider this:
Moral injury is damage done to the soul of the individual. War is one (but not the only) thing that can cause this damage. Abuse, rape, and violence may cause similar types of damage. “Soul repair” and “soul wound” are terms already in use by researchers and institutions in the United States who are exploring moral injury and pathways to recovery.
What Should We Do About Moral Injury?
Moral injury must be acknowledged in the same way that we acknowledge the physical and mental costs of traumas experienced in war and other place of danger. Moral injury is subjective and personal. Research on moral injury is younger than research on PTSD – the definitions, ideas, and practices that are being evaluated are both experimental and varied.
Trauma of a type and severity that cause PTSD are likely to cause moral injury, too. This does not mean treating PTSD will “treat” moral injury, nor vice versa. The current tenets for “treatment” of moral injury must be defined by the individual according to their beliefs and needs. Outlets for acknowledging and confronting moral injury include talk therapy, religious dialogue, art, writing, discussion & talking circles, spiritual gatherings, and more.
Therapists, counsellors, social workers, and clergy are often at the front lines of addressing moral injury; however, the larger community can also take part. Consider that moral injury affects, and is affected by the moral codes across a community. In the case of military veterans, moral injury stems in part from feelings of isolation from civilian society. Moral injury, then, is a burden carried by very few, until the “outsiders” become aware of, and interested in sharing it. Listening and witnessing to moral injury outside the confines of a clinical setting can be a way to break the silence that so often surrounds moral injury.
What is Happening At Present About Moral Injury
1. A core group of healthcare professionals and spiritual care practitioners are beginning to foster public dialogue about moral injury.
2. Opportunities are being developed for veterans to design and participate in programs that explore moral injury.
3. Academics are researching and educating on moral injury.
Brock, R. N., & Lettini, G. (2012). Soul repair: Recovering from moral injury after war. Boston, MA: Beacon Press.
Center for Constitutional Rights (2013). The Right to Heal: Holding the U.S. Accountable for the Human Costs of War (Fact Sheet).
Copland, L. (2013). Staff Perspective: On Moral Injury (blog post). Center for Deployment Psychology. Retrieved from http://www.deploymentpsych.org/blog/staff-perspective-moral-injury
Currier, J. M., Holland, J. M., Drescher, K., & Foy, D. (2013). Initial psychometric evaluation of the Moral Injury Questionnaire—Military Version. Clinical Psychology and Psychotherapy. doi:10.1002/cpp.1866.
Dao, J. (2011). After combat, the unexpected perils of coming home. New York Times (5/28/11). Retrieved from http://www.nytimes.com/2011/05/29/us/29soldiers.html?pagewanted=all
Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schutz, K. & Litz, B. (2011). An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology, 17 (1), 8-13. doi: 10.1177/1534765610395615.
Evans, W.R., Stanley, M.A., Barrera, T.L., Exline, J.J., Pargament, K.I., & Teng, E.J. (2018). Morally injurious events and psychological distress among veterans: Examining the mediating role of religious and spiritual struggles. Psychological Trauma: Theory, Research, Practice, and Policy, 10(3), 360-367. doi: 10.1037/tra0000347.
Farnsworth, J.K., Drescher, K.D., Evans, W., & Walser, R.D. (2017). A functional approach to understanding and treating military-related moral injury. Journal of Contextual Behavioral Science, 6, 391-397. doi: 10.1016/j.jcbs.2017.07.003.
Harris, J. I., Park, C. L., Currier, J. M., Usset, T. J., & Voecks, C. D. (2015). Moral injury and psycho-spiritual development: Considering the developmental context. Spirituality in Clinical Practice, 2(4), 256-266. doi:10.1037/scp0000045.
Hynes, H. P. (2013). The Iraq War and moral injury. Truthout.org (3/20/13). Retrieved from http://truth-out.org/news/item/15218-the-iraq-war-and-moral-injury
Jamail, D. (2009). The will to resist: Soldiers who refuse to fight in Iraq and Afghanistan. Chicago, IL: Haymarket Books.
Jones, A. (2013). They were soldiers: How the wounded return from America’s wars—the untold story. Chicago, IL: Haymarket Books/Dispatch Books.
Kinghorn, W. (2012). Combat trauma and moral fragmentation: A theological account of moral injury. Journal of the Society of Christian Ethics, 32 (2), 57-74. Retrieved from http://www.jstor.org/stable/23563037.
Kopacz, M.S., Connery, A.L., Bishop, T.M., Bryan, C.J., Drescher, K.D., Currier, J.M., & Pigeon, W.R. (2016). Moral injury: A new challenge for complementary and alternative medicine. Complementary Therapies in Medicine, 24, 29-33. doi:10.1016/j.ctim.2015.11.003.
Litz, B.T. (2014). Resilience in the aftermath of war trauma: A critical review and commentary. Interface Focus, 4 (5). doi: 10.1098/rsfs.2014.0008.
Litz, B.T., Lebowitz, L., Gray, M.J., & Nash, W.P. (2016). Adaptive disclosure: A new treatment for military trauma, loss, and moral injury. New York, NY: Guilford Press.
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695-706. doi: 10.1016/j.cpr.2009.07.003.
Maguen, S. & Litz, B. (2012). Moral injury in veterans of war. PTSD Research Quarterly, 23 (1), 1-6. Retrieved from https://www.wisconsinchaplains.org/wp-content/uploads/2017/04/ptsd.va_.gov_.pdf
Maguen, S., Metzler, T. J., Litz, B. T., Seal, K.H., Knight, S. J., & Marmar, C. R. (2009). The impact of killing in war on mental health symptoms and related functioning. Journal of Traumatic Stress, 22, 435-443. doi: 101002/jts.20451.
Maguen, S., Vogt, D. S., King, L. A., King, D. W., Litz, B.T., Knight, S.J., et al. (2011). The impact of killing on mental health symptoms in Gulf War veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 3, 21-26. doi: 10.1037/a0019897.
Nash, W. P., Marino Carper, T. L., Mills, M. A., Au, T., Goldsmith, A., & Litz, B. T. (2013). Psychometric evaluation of the Moral Injury Events Scale. Military Medicine, 178 (6), 646-652.
Powers, K. (2012). The yellow birds. New York, NY: Little, Brown, and Company.
Purcell, N., Koenig, C.J., Bosch, J., & Maguen, S. (2016). Veterans’ perspectives on the psychosocial impact of killing in war. The Counseling Psychologist, 44 (7), 1062-1099.
Russell, M. C. (2008). War-related medically unexplained symptoms, prevalence, and treatment: Utilizing EMDR within the armed services. Journal of EMDR Practice and Research, 2 (3), 212-225. doi: 10.1891/1933-322.214.171.124
Shay, J. (1994). Achilles in Vietnam: Combat trauma and the undoing of character. New York, NY: Atheneum.
Shay, J. (2002). Odysseus in America: Combat trauma and the trials of homecoming. New York, NY: Scribner.
Silver, D. (2011). Beyond PTSD: Soldiers have injured souls. Truthout.org (9/3/11). Retrieved from http://www.truth-out.org/news/item/beyond-ptsd-soldiers-have-injured-souls
Tick, E. (2014). The moral trauma of “21st century warriors.” Truthout.org (11/22/14). Retrieved from http://truth-out.org/opinion/item/27419-the-moral-trauma-of-21st-century-warriors
Van Buren, P. (2014). What they died for. Truthout.org (6/29/14). Retrieved from http://www.truth-out.org/news/item/24583-what-they-died-for
Vargas, A. F., Hanson, T., Kraus, D., Drescher, K., & Foy, D. (2013). Moral injury themes in combat veterans’ narrative responses from the national Vietnam Veterans’ Readjustment Study. Traumatology, 19 (3), 243-250. doi: 10.1177/1534765613476099.
Whitman-Bradley, B., Lazare, S., & Whitman-Bradley, C. (Eds.) (2011). About face: Military resisters turn against war. Oakland, CA: PM Press.
Wisco, B.E., Marx, B.P., May, C.L., et al. (2017). Moral injury in U.S. combat veterans: Results from the National Health and Resilience in Veterans study. Depression and Anxiety, 34, 340–347. doi.org/10.1002/da.22614.
Wood, D. (2014). The grunts: Damned if they kill, damned if they don’t. The Huffington Post (3/18/14). Retrieved from http://projects.huffingtonpost.com/moral-injury/the-grunts
Wood, D. (2014). The recruits: When right and wrong are hard to tell apart. The Huffington Post (3/19/14). Retrieved from http://projects.huffingtonpost.com/moral-injury/the-recruits
Wood, D. (2014). Healing: Can we treat moral wounds? The Huffington Post (3/20/14). Retrieved from http://projects.huffingtonpost.com/moral-injury/healing