Moral injury

This article is part 4 of a series on trauma written by the Fortem clinical team. To read part 3, click here.

What is moral injury? 

Moral injury is a psychological, social and spiritual wounding that can occur in high-stakes situations that deeply challenge the integrity of personal values, expectations, and social norms. 

Moral injury is not a formal diagnosis. While it shares some features with PTSD, there are important differences we will explore further below. However, the research indicates that moral injury is strongly associated with more severe PTSD, depression, and suicide among service personnel. 

What causes moral injury? 

Events that cause moral harm are generally thought to fall into two broad types.  

Moral betrayal is the experience of being let down when it counts. This can involve: 

• Feeling betrayed by superiors, colleagues, or even the public 
• Shortfalls in resources that compromise your ability to work to appropriate standards 
• Gross injustice or systemic failure 
• Witnessing or experiencing discrimination, persecution, or inappropriate blame 

Moral betrayal is a particularly powerful cause of moral injury for first responders and is most damaging when it occurs at a time when you are most vulnerable and in need of “backup.”  

Sometimes it is not the traumatic events themselves but the response to you or the incident that causes you hurt. When systems that are supposed to protect people fall short, this can feel like a violation of a social contract that doesn’t just damage but shakes the foundations of integrity and honour on which your life is built. 

Moral transgression refers to actions that breach your ethical code and sense of what is morally right. Moral transgressions can include: 

• Bearing witness to acts of extreme violence, cruelty, neglect or abuse 
• Failing to prevent tragic or criminal events 
• Failing to protect members of the public or colleagues 
• Accidentally causing harm 
• Impossible choices between saving civilians and protecting staff 

First responders are often placed in impossible situations. Moral injury can come as a result of having to make a split-second decision in a crisis or being forced into a situation where no morally acceptable action is available. 

You can feel morally compromised by your own or someone else’s choices and actions. Either way, it is often experienced as personal corruption caused by outcomes that directly conflict with your intentions. 

It is helpful to understand that there is a spectrum of distress associated with morally challenging events. 

Moral frustration  >  moral distress  >  moral injury. 

A key element for injury is the high-stakes context in which moral challenges can occur. The greater the chances of serious physical or psychological harm, the greater the risk and severity of moral injury when events breach important moral boundaries, whether intentionally or inadvertently. 

What does moral injury feel like? 

Where life threatening events involve intense feelings of fear, terror and helplessness, morally harmful events provoke deep feelings of horror, anger, injustice, betrayal, embitterment, shame, guilt, and loss.  

Moral injury from transgressions can be experienced as a sense “lost goodness”, of shattered integrity and honour. Feelings of moral corruption and subsequent guilt and shame can be just as strong when witnessing the transgressions of others, whether you had the power to prevent them or not. This can leave you feeling tainted long after the traumatic events have passed. 

Moral betrayal can feel like an assault on your own moral code. However, it can also come with a deep sense of abandonment and loss. Experiencing injustice or systemic failure can invoke feelings of outrage, anger, and embitterment. In the long term, this can result in a loss of faith in people and the systems around you, leaving you feeling “alone in the wilderness.” 

What does moral injury look like? 

The wounds of moral injury are often invisible to others. However, they can show up in the form of heightened frustration, embitterment and disillusionment with organisational structures. It is not uncommon for morally injured first responders to become preoccupied with justice and have more intense anger reactions to even small examples of injustice. 

Morally distressed first responders may also withdraw from those around them because of shame or a feeling that they carry something “toxic” that they don’t want to spill over onto loved ones. Importantly, people who have experienced moral injury are more likely to perceive a lack of social support around them, which in turn is linked to a greater risk for suicide. 

Recovering from moral injury 

Experiences of moral injury can be deeply wounding and change your world drastically. The healing process is very personal and unique for each individual. Recovery often involves a combination of self-reflection, support from others, and professional help when needed. 

Traditional treatments for PTSD may not hit the mark for these types of injuries. Finding experienced clinicians who have a broader understanding of traumatic injuries, especially in the line of duty, can help you on the right path to recovery. 

For a more in-depth look into moral injury, you can visit this website created by the author. 

Article written by Dominic Hilbrink, Senior Clinician at Fortem Australia.