In the early 2020s, moral injury emerged as one of the explanations for the wave of employee resignations across industries. Moral injury occurs when an individual experiences an event that deeply violates their moral beliefs and threatens their core values, leading to profound psychological, spiritual, and social distress. The concept of spiritual distress may not connect for non-religious persons, but it can be understood more broadly as a profound sense of disorientation and loss of meaning or purpose. This type of distress can manifest in feelings of betrayal, guilt, and a crisis of identity, affecting individuals regardless of their religious beliefs. As a result, many employees found themselves unable to reconcile their work environments with their personal values, prompting them to seek new opportunities that better aligned with their ethical standards.
Comparison to PTSD
Moral injury is a recognized and significant phenomenon, distinct from but related to conditions like PTSD. It affects millions of individuals, particularly those in high-stress professions such as healthcare, education, and law enforcement. Research indicates that moral injury results from acts of perceived moral transgression by oneself or others, leading to profound feelings of guilt, shame, moral disorientation, and societal alienation[1]. Unlike PTSD, which is often associated with fear-based trauma, moral injury is characterized by cognitive and emotional responses to events that violate one’s moral or ethical code[15].
Impact and Extent of Moral Injury
The impact of moral injury is extensive, leading to serious distress, depression, and impairment in functioning. It can destroy an individual’s capacity to trust others and significantly affect family systems and the larger community[13]. The effects of moral injury extend beyond the individual, making it a public health concern[13].
The extent of moral injury is subjective and personal, typically involving emotions such as guilt, shame, disgust, and anger. These emotions arise from the individual’s perception of their actions or inactions during morally injurious events[14]. A hallmark of one type of moral injury is an inability to self-forgive, which can lead to self-sabotaging behaviors[14].
As a Spiritual Phenomena
For those who identify as spiritual, moral injury can profoundly impact an individual’s spirituality. Those affected may struggle to reconcile their beliefs with the morally injurious event, leading to uncertainty about previously held spiritual beliefs[14]. This spiritual distress often necessitates the involvement of spiritual care providers for such persons, alongside mental health clinicians to address the full spectrum of moral injury’s effects[14].
Also A Non-Religious Phenomena
The strongest evidence for moral injury as a secular phenomenon is rooted in its rigorous scientific study and validation through objective measures. The Moral Injury Events Scale (MIES) is a prime example, developed and validated by researchers to quantify the experience of moral injury based on empirical data rather than religious beliefs. Studies utilizing the MIES have demonstrated its reliability and validity across diverse populations, including military personnel and healthcare workers, focusing on the psychological and emotional impacts of moral injury. These studies have shown that moral injury can lead to significant mental health issues such as depression, anxiety, and impaired social functioning, which are addressed through secular therapeutic approaches like cognitive behavioral therapy and acceptance and commitment therapy. The development and validation of the MIES, along with the consistent findings of its psychological impacts, provide robust evidence that moral injury is a legitimate and significant phenomenon recognized within secular frameworks, independent of the religious beliefs of the researchers or participants.
Examples Where Moral Injury May Occur
Some examples of moral injury include:
- Using deadly force in combat and causing the harm or death of civilians, knowingly but without alternatives, or accidentally
- Giving orders in combat that result in the injury or death of a fellow service member
- Failing to provide medical aid to an injured civilian or service member
- Returning home from deployment and hearing of the executions of cooperating local nationals
- Failing to report knowledge of a sexual assault or rape committed against oneself, a fellow service member, or civilians
- Failing to report knowledge of a conspiracy which results in deaths
- Participating in providing a state mandated treatment known in some cases to cause serious injury or death
- Becoming aware of protected corruption which is above the law with no viable means for reporting or correction
- Following orders that were illegal, immoral, and/or against the Rules of Engagement or Geneva Convention
- A change in belief about the necessity or justification for war, during or after one’s service
- Witnessing or being unable to prevent cruel behavior that goes against one’s moral code
- Being betrayed by someone in a position of authority or trust
- Healthcare workers having to make difficult triage decisions or postpone care.
The Moral Injury Events Scale (MIES)
The Moral Injury Events Scale (MIES) is a 9-item psychometric tool developed to measure exposure to potentially morally injurious events, primarily in military contexts. Created by Nash et al. in 2013, the scale assesses experiences of transgressions—both witnessed and perpetrated—as well as feelings of betrayal. Respondents rate their agreement with each item on a 6-point Likert scale, with higher scores indicating greater exposure to these morally injurious experiences.
The MIES has demonstrated strong psychometric properties, including good internal consistency and construct validity, correlating well with measures of psychological distress and social support. While it has been primarily used in military populations, a civilian version (MIES-C) has also been developed. Ongoing research is focused on refining the scale’s structure and exploring its applicability across various contexts, including both combat and non-combat personnel.
Treatment of Moral Injury
Addressing moral injury requires a multidisciplinary approach focused on ethical reflection, spiritual care, and systemic changes to support those affected.
Treatments aim to help individuals face moral conflicts directly rather than avoiding them. Healing from moral injury requires acknowledging it and its subjective nature[2]. Forgiveness, both of others and self, is crucial[4]. Addressing spiritual concerns and finding ways to reconcile moral beliefs with traumatic experiences is essential[4]. Therapeutic interventions like Acceptance and Commitment Therapy, Adaptive Disclosure, and Trauma-Informed Guilt Reduction Therapy have been developed to target moral injury[4].
Clarifiying Boundaries of Personal Responsibility
Recognizing the boundaries of personal responsibility is a powerful tool in mitigating moral injury. When we understand that we cannot control the actions of others, even if those actions are tangentially related to our own words or deeds, we free ourselves from undue guilt and emotional burden. This realization allows us to focus on our own choices and their direct consequences, rather than shouldering the weight of others’ decisions. By accepting that each individual is ultimately responsible for their own actions, we can maintain a clearer sense of our ethical boundaries and reduce the likelihood of experiencing moral injury. This perspective shift empowers us to navigate complex moral situations with a more balanced and psychologically healthy mindset, fostering a sense of inner peace and resilience.
Acceptance and Commitment Therapy
Acceptance and Commitment Therapy (ACT) is a powerful psychological approach that encourages individuals to embrace their thoughts and feelings rather than fighting or feeling guilty for them[18]. At its core, ACT aims to help people accept what is out of their control and commit to actions that enrich their lives[18]. This therapy is based on the premise that suffering is a natural part of the human experience, and our instinct to control our experiences doesn’t always serve us well[18]. Instead of trying to eliminate or suppress undesirable thoughts and emotions, ACT focuses on developing psychological flexibility[19]. This is achieved through six core processes: accepting difficult experiences, defusing from unhelpful thoughts, staying present, viewing the self in context, clarifying personal values, and committing to actions aligned with those values[19][20]. By learning to navigate life’s challenges with openness and mindfulness, individuals can pursue meaningful goals and live a rich, fulfilling life, even in the presence of pain and discomfort[18][19].
Adaptive Disclosure
Adaptive Disclosure is an innovative, emotion-focused psychotherapy specifically designed to treat combat-related PTSD and moral injury in military personnel and veterans[22][23][24]. This approach differs from traditional cognitive-behavioral therapies by focusing on three distinct categories of traumatic experiences: life-threatening situations, traumatic loss, and moral injury[23]. Developed to address the unique needs of service members, Adaptive Disclosure comprises eight 90-minute sessions aimed at “planting healing seeds” rather than providing a prescriptive cure[22]. The therapy emphasizes accepting difficult experiences, defusing from unhelpful thoughts, and committing to actions aligned with personal values. Research has shown that Adaptive Disclosure is no less effective than established first-line psychotherapies like Cognitive Processing Therapy for treating PTSD symptoms, depression, and improving overall functioning in military populations[24][26]. This treatment approach offers a promising alternative for clinicians working with service members and veterans struggling with the aftermath of war-zone experiences.
Trauma-Informed Guilt Reduction Therapy
Trauma-Informed Guilt Reduction (TrIGR) Therapy is a brief, transdiagnostic psychotherapy designed to address guilt, shame, and moral injury stemming from traumatic events. Developed to treat combat-related PTSD and moral injury in military personnel and veterans, TrIGR comprises six 90-minute sessions aimed at helping clients accurately appraise their trauma and re-engage with their values to lead more meaningful lives. The therapy focuses on reducing trauma-related guilt and shame, which are common features in many problems trauma survivors experience, including PTSD, depression, substance use, and suicidality. Research has shown that TrIGR is efficacious in reducing guilt associated with moral injury, as well as PTSD and depression symptoms among combat veterans. The treatment offers flexibility, as it can be delivered in both individual and group formats, and has demonstrated high attendance rates in clinical trials[27][29][30].
Community Support
Community-based support groups play a crucial role in helping individuals recover from moral injury. These groups provide a safe and supportive environment where individuals can share their experiences, emotions, and struggles with others who have faced similar moral dilemmas. Here are some ways community-based support groups help with moral injury:
1. Peer Support: Trained peers who have experienced moral injury themselves lead these groups. This peer support helps individuals feel understood and validated, as they are able to connect with others who have gone through similar struggles[5].
2. Sharing Experiences: Group members can share their stories of moral injury, which helps them process their emotions and gain a deeper understanding of their experiences. This sharing also fosters a sense of community and belonging, which is essential for recovery[7][11].
3. Validation and Affirmation: Group members validate each other’s experiences, providing emotional support and affirmation. This helps individuals feel heard and understood, which is critical in rebuilding their moral core and sense of personal worth[8][11].
4. Education and Coping Strategies: These groups often provide education about moral injury and coping strategies to manage the associated distress. This education empowers individuals to better understand their experiences and develop effective coping mechanisms[7][10].
5. Rebuilding Moral Integrity: Community-based support groups help individuals rebuild their moral integrity by providing a space to reflect on their values and beliefs. This reflection enables individuals to reclaim their moral core and restore their sense of personal worth[8][10].
6. Reducing Isolation: Moral injury can lead to feelings of isolation and disconnection. Community-based support groups combat this isolation by providing a supportive network of peers who understand the struggles associated with moral injury[11].
Community-based support groups offer a comprehensive approach to addressing moral injury. They provide a safe space for individuals to share their experiences, receive validation and support, and develop coping strategies to manage their distress. These groups are essential in helping individuals recover from moral injury and rebuild their moral integrity.
While moral injury cannot be completely avoided, steps can be taken to mitigate it[2]. Clearly defining one’s moral beliefs, ensuring accountability of leaders and those in positions of power, and establishing strong support systems can help[2].
Summary
In summary, moral injury is a real condition with real effects. Treatment involves not only psychological and emotional support but also community or spiritual interventions to facilitate healing and restore individuals’ moral and ethical integrity[1][2][3][4].
More Reading
[1] https://en.wikipedia.org/wiki/Moral_injury
[2] https://moralinjuryproject.syr.edu/about-moral-injury/
[3] https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp
[4] https://moralinjuryproject.syr.edu/resources/scholarly-references/
[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9328408/
[6] https://www.scientificamerican.com/article/moral-injury-is-an-invisible-epidemic-that-affects-millions/
[7] https://www.psychologytoday.com/us/blog/the-lost-art/202210/it-takes-village-repair-moral-injury
[8] https://recoveryreview.blog/2021/05/27/healing-moral-injury-in-our-sud-community-care-service-system/
[9] https://www.moralinjuryguide.ca
[10] https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp
[11] https://news.va.gov/109140/support-veterans-battling-moral-injury/
[12] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9887329/
[13] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8270769/
[14] https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366%2821%2900113-9/fulltext
[15] https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp
[16] https://www.scientificamerican.com/article/moral-injury-is-an-invisible-epidemic-that-affects-millions/
[17] https://www.racgp.org.au/afp/2012/september/acceptance-and-commitment-therapy
[18] https://positivepsychology.com/act-acceptance-and-commitment-therapy/
[19] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5509623/
[20] https://en.wikipedia.org/wiki/Acceptance_and_commitment_therapy
[21] https://www.healthline.com/health/mental-health/acceptance-and-commitment-therapy
[22] https://www.amazon.com/Adaptive-Disclosure-Treatment-Military-Trauma/dp/1462523293
[23] https://traumapsychnews.com/2018/07/review-of-adaptive-disclosure-a-new-treatment-for-military-trauma-loss-and-moral-injury/
[24] https://www.sciencedirect.com/science/article/abs/pii/S0165178121000585
[25] https://www.sciencedirect.com/science/article/am/pii/S0165178121000585
[26] https://pubmed.ncbi.nlm.nih.gov/33540206/
[27] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9068861/
[28] https://shop.elsevier.com/books/trauma-informed-guilt-reduction-therapy/norman/978-0-12-814780-1
[29] https://pubmed.ncbi.nlm.nih.gov/33326878/
[30] https://www.ptsd.va.gov/professional/articles/article-pdf/id1586433.pdf
[31] https://www.sciencedirect.com/book/9780128147801/trauma-informed-guilt-reduction-therapy
