What is Moral Injury?

In intensely stressful circumstances, people may witness traumatic events that contradict deeply held moral beliefs and expectations. For example, someone who sees a child harmed, but is unable to intervene to offer assistance, is at risk of moral injury since most belief systems place great emphasis on protecting children from harm.

Moral injury involves the distressing behavioral, social, psychological, and sometimes spiritual aftermath of these types of traumatic events. People can experience a moral injury when they are put in a situation where they must behave in a way or witness behaviors that transgresses their deeply held values and beliefs.

Moral injury is frequently misunderstood and it is difficult to tease apart from other mental health diagnoses and struggles. Service members returning from combat are often diagnosed with post-traumatic stress disorder (PTSD). Among physicians, moral injury is typically thought of as burnout. While there is overlap, it is inaccurate and a disservice to think that they are the same. 

Moral injury does not always present itself immediately. Some people will deeply question themselves and their beliefs days after a traumatic event. For others, these types of troubling questions and thoughts may not surface for years.

Examples of Moral Injury

Therapists, counselors, social workers, military veterans, and health care workers are often at the front lines of being susceptible to moral injury. However, the broader community can also experience moral injury. Examples of behaviors or situations that can create moral injury include:

• Using deadly force in combat and causing the harm or death of civilians
• Giving orders that result in the injury or death of fellow military personnel
• Making critical life and death decisions, such as the rationing of care to a limited number of patients
• Being forced to prioritize speed over quality health care
• Struggling to make ethical mental health or medical care decisions within the framework of contradictory legal requirements 
• Freezing or failing to perform one’s duty during a traumatic event

Moral Injury for Medical Professionals in the Time of COVID-19

In the healthcare system, distress among medical providers may evolve into moral injury due to the gravity and complexity of dilemmas resulting from the COVID-19 pandemic. Navigating a path among intensely stressful drivers, such as feeling helpless to treat patients with a novel disease or comforting patients when family members are not allowed to visit, can be exhausting, grief-filled, and traumatizing for health care providers.

Rapid decisions made with significant consequences and actions based on rationing care may force providers to make choices among only terrible options.  The types of decisions where deeply held beliefs about the sanctity of life create vulnerability to moral injury.

Moral Injury Compared to PTSD and Burnout

While the symptoms and concepts of moral injury and PTSD are similar, there are distinguishing features. PTSD is a formal diagnosis, while moral injury is not. In simplified form, according to the United States Department of Veterans Affairs, the underlying component of PTSD is fear, where moral injury involves a sense of being alienated from one’s deeply held views and beliefs.

Burnout as a concept, especially in the helping professions such as mental health or medicine, does not fully capture the experience of those who emotionally and psychologically struggle to perform their professional duties. The experience of those in the healing and helping professions might be better captured by moral injury as the idea of “…being unable to provide high-quality care and healing in the context of health care.” That is, they are pulled in incompatible directions – between patients, themselves, insurance companies, and their employer – and are forced to make decisions where someone always loses.  

The Emotional and Psychological Consequences of Moral Injury

The most common consequences of moral injury include:

• Guilt: After a moral injury, a person may experience remorse regarding the event. Because of the guilt associated with the event, some people may find it challenging to open up to friends, family members, or even therapists due to a fear of being judged and viewed as complicit in the harm done to others.

• Shame: People may believe that they are a terrible person because they behaved in a way that contradicted their moral compass (e.g., “I am a bad person because of what I did.”).

• Betrayal: A sense of betrayal can occur when someone observes trusted peers or legitimate authority figures act against values. Betrayal can lead to anger, resentment, and a reduced sense of confidence and trust.

• Depression: For some people, a moral injury can be debilitating, preventing them from living healthy lives. The effects of moral injury can destroy one’s ability to trust others, leading to mental health problems such as depression.

• Suicidal ideation: Struggling with moral injury can worsen the symptoms of a traumatic stress disorder, leading to a higher likelihood of suicidal intent and self-destructive behaviors, such as substance use. Moral injury can also exacerbate the symptoms of other mental health conditions, including anxiety disorder, bipolar disorder, or depression.

What should you do if you’re experiencing moral injury?

One of the most difficult parts of moral injury is that it may lead people to believe that they do not deserve to feel better, which means that they might delay or never seek help and treatment. Yet, there are many forms of treatment that can be of true help.

• Therapy: Working with a mental health specialist can help you manage your distress, develop coping strategies, and emotionally process the events and beliefs tied to moral injury. Common approaches to moral injury include acceptance and commitment therapy (ACT), psychodynamic psychotherapy, cognitive-behavioral therapy (CBT), and interpersonal psychotherapy.  

• Trauma-focused PTSD treatment: Researchers have suggested that trauma-focused PTSD treatment, such as prolonged exposure (PE) and cognitive processing therapy, can be an effective treatment for patients with moral injury. PE allows patients to process the injurious event and gather context, which can help them make sense of their trauma through exposure.

• Social support: Although it may seem intimidating, reaching out to a friend or family member can help you process what you’ve been through. They may not fully understand the complexities of your experience and the choices that you were forced to make, but you might find great relief and compassion in their willingness to listen. If you feel uncomfortable talking about your personal experience with a loved one, consider joining a support group where people with similar experiences share their stories and support one another.

• Meditation and mindfulness practices: Studies have shown that mindfulness practices can help alleviate the stress that may result from a moral injury. 

What should you look for in a therapist?

For some people struggling to cope with moral injury, opening up to a therapist may seem intimidating. They may wonder, “Am I being judged?” or “Is this too much for my therapist to handle?” It’s essential to find a therapist that you feel comfortable talking to about your personal experiences.

Your therapist should convey an accepting, nonjudgmental, and empathic stance toward your moral injury. If you’re experiencing a mental health crisis, consider reaching out to a licensed mental health professional through WithTherapy. WithTherapy’s unique service will provide you with matches so that you can feel more confident in your choice of a therapist, regardless of your personal preferences and requirements.

Find a Therapist to Navigate Moral Injury