Effects on mental health and implications for treatment
Military personnel and first responders all have to make quick, difficult decisions on a daily basis, and can be involved in extraordinary traumatic events that they may have no power over. This kind of exposure can make each day a battle between the tough situations that one finds themselves in and their moral compass.
Knowing what the “right” thing to do isn’t always black and white, and regret or guilt after any of these traumatic events can cause its own moral injury. Moral injury can be a devastating, life-changing experience where a person questions themself and even their own identity.
Addressing moral injury is still a relatively new practice, and those suffering from moral injury may have gone unnoticed or untreated in this particular aspect after experiencing these difficult situations either in the field as a first responder or in a warzone. However, learning to identify moral injury in oneself or loved ones can help promote a necessary dialogue around the topic and help each person receive the proper, focused kind of care that may be necessary to begin an effective healing process. While tools like the moral injury events scale may be beneficial in helping identify potential events and exposures to morally injuring scenarios, it is also important to recognize moral injury symptoms as early as possible in both military and non-military personnel.
Moral Injury Definition
Moral injury can manifest in several different ways and has close ties to symptoms of trauma or post-traumatic stress disorder (PTSD.) Moral injury is where a person experiences or participates in an event that may directly clash with their moral compass, whether they are witnessing something that goes against their moral code and have no power to change the outcome, does have the agency to change the outcome but remains a bystander, or actively participates in a situation that stands in contrast to one’s own beliefs, even if they are participating because they were commanded.
Moral injury has many lasting emotional, behavioral, and even spiritual effects, and can cause a person to continue to question their own identity. It can often coincide with great feelings of guilt or shame and can change a person’s worldview as well as their self-image. While PTSD and moral injury often have an overlap in their symptoms and who suffers from their effects, they are still two distinct issues that need to be addressed in order to overcome.
Causes of Moral Injury
Moral injury can occur from fast-paced, difficult situations that a member of the military or a first responder may encounter each day. In war, the use of deadly force against non-military opposition may cause moral injury, as well as not using deadly force in a situation where it may have been necessary to secure the safety of a person or persons around them. The decision to use deadly force in high-stakes situations is also prevalent in law enforcement officers and can cause a great degree of moral injury if situations play out negatively.
Commanding officers are also at great risk for experiencing moral injury, as giving orders or leading colleagues into disastrous situations can take a large mental, emotional, and moral toll on a person. Receiving and acting on orders from higher commands may also cause a great deal of turmoil within a person, especially if the order they were given may be illegal or strongly go against one’s moral compass. Failing to provide medical aid to another, whether due to one’s own decision or if a person was completely out of control of the situation, can also cause this unique kind of injury. Even if a person may have suffered injuries too severe to treat on-site, feelings of shame and guilt can lead the way to developing a moral injury.
Withholding information can also cause moral injury to occur, especially if a person withheld information that then led to dangerous and uninformed decision-making. Whether a person knowingly withheld information, such as sexual assault, or chose not to bring up certain information because they did not think it was pertinent to the situation, withholding information can also cause damage to one’s moral code, and take an immense emotional and psychological toll.
Lastly, feelings of betrayal can be a major source of moral injury. Whether a person feels they betrayed another by failing to provide needed support, or a person feels betrayed by their colleagues after difficult actions in the field.
Moral Injury Symptoms
Moral injury and PTSD may both need to be treated simultaneously depending on the person, but there are additional aspects to address when it comes to moral injury. Moral injury may manifest as overwhelming guilt or shame and can cause a great deal of anxiety, depression, or feelings of isolation. A person may become more emotionally, or even physically, shut off from their own social lives or loved ones. Those who have experienced moral injury may become emotionally guarded as well, and avoid conversations even if others may be reaching to them to help.
Feelings of betrayal can cause a person to deteriorate their trust in others around them, even those who were not involved in the inciting event. This can further one’s disconnect with even the most supportive loved ones, and can make recovery difficult as a person may not trust others, or feel like anyone has their best interest in mind as a result of any kind of morally taxing event. Moral injury can also cause spiritual damage, as a person may lose their faith after their experiences, or see their situation as hopeless.
Those suffering from moral injury may acknowledge that they have changed and are in pain, however, these feelings may be accompanied by the notion that a person doesn’t feel like they “deserve” to feel better after any situation that damaged their moral compass, or isn’t “worthy” of emotional, psychological, or spiritual healing due to perceived transgressions.
Moral injury treatment can be extraordinarily complicated, especially when paired with traumatic elements or post-traumatic stress disorder. Identifying these symptoms and addressing the existence and importance of moral injury is crucial in creating a scenario that is supportive of healing in all dimensions in which it is required, not just addressing the symptoms of trauma. Moral injury may not surface right away and can develop as a person begins to look back on their experiences and replay the situation in their head.
How Moral Injury Changes One’s Identity
One of the most drastic effects that moral injury can have on a person is that it can cause a person to question their own identity and moral compass as a whole. A person’s perceptions of the event may change over time as a person tries to rationalize what had happened, and this can manifest in an overall drastically changed worldview. From days to years later, it is possible that the event may continue to take a moral toll on a person as they try to contextualize what had happened, what role they played in the event that caused this moral injury, as well as what that means for their very own identity as a result. It can compromise one’s confidence in themself and their abilities, or may change the expectations that a person sets for themselves and others. These changes may be an effort to try to find and maintain a clear-cut “just” moral compass.
Identifying Moral Injury With Moral Injury Events Scale
A moral injury events scale, or moral injury questionnaire, can be used to help a person identify the existence of moral injury beyond trauma or PTSD, as well as to measure a person’s exposure to events that may have caused a moral injury. It is a tool that can be used to help a person realize and measure feelings of betrayal or the degree to which a person may blame themselves or others for damage to their moral compass. Identifying and acknowledging moral injury can create a more focused plan for healing while addressing the unique ways in which a person’s world view may have changed, or how someone may see themselves after participating in something that went against their moral code.
Overcoming Moral Injury
Overcoming moral injury is a long process as it may have to address a person’s shifted world view as well as the effects of trauma that these events may have caused. However, healing only begins after starting a dialogue. While exploring moral injury is still relatively new compared to the treatment of trauma or PTSD, it still has many similar hurdles to address, especially since those who most often experience moral injury are military personnel and first responders. Much stigma still surrounds these communities that can make it very difficult for a person to reach out and express their vulnerabilities or emotions, even when it may be necessary for their mental health. Beginning a dialogue, either with a loved one who may be suffering from moral injury, or in general in an attempt to normalize conversations around it, can help encourage those whom it affects most to begin reaching out and breaking down their barriers to seek the professional help that may be necessary for an effective path to healing.
Many therapeutic approaches can be especially beneficial, from individual therapy to the use of art therapy or journaling, in order to provide a person with multiple outlets in which to explore the event and express feelings of guilt or betrayal in a meaningful way. Having a safe outlet in which to allow oneself to explore these complicated and difficult emotions is essential in learning to overcome these feelings that may plague a person daily.
Finding new communities can also create a situation where a person can meet new people and explore new outlets without feelings of judgment or guilt attached to them. Having a fresh slate to explore who a person wants to be and how they want to go forward can be invaluable in finding a new, positive outlook on one’s life. Even if meeting up physically is difficult for these groups, online communities and discussion boards surrounding certain hobbies can provide a person with a new social outlet to explore. This can also extend to finding new spiritual or religious communities in order to explore forgiveness, both in oneself and in others. While moral injury can be thought of as “damage to the soul,” it is possible to find a spiritual path to healing, as well.
Moral injury is complicated to overcome, and often may go overlooked. However, addressing moral injury and the fundamental way in which it can affect a person is necessary to allow for healing on all fronts following exceptionally difficult events. Whether a person acted against their moral code or was powerless to stop something that goes against their moral compass, exploring the deep-seated effects that moral injury has on each person is essential in creating an atmosphere that can truly move towards healing, and help a person reclaim their sense of identity and a positive world view as a result.