Incessant ethical distress and moral injury: Feminist perspective

Moral injury and what it means has been on my mind for a long time, and it has all come to a head in the last few years. I feel that I need to explore and make sense of it. I sense that it is a deeply brewing concept that is hard to easily understand and give it a sufficient meaning. But it is always there, in the deeper layer of our thoughts and, in particular, deeply disturbing, which can have ramifications on our identity, self-esteem and our relationship with the world around us.

What is moral injury?

Moral injury is described as "the deep emotional and psychological distress caused by perpetrating, failing to prevent, bearing witness to or learning about acts that transgress deeply held moral beliefs”. The feeling is often intensified by a sense of betrayal by someone in authority or someone we aspire to in the first place. 

Understanding of moral injury claimed to have evolved in the military context in the US and UK and perhaps in the West in general. Since the global pandemic, increased awareness of how the emotional responses unfolded and their relevance to healthcare staff who work on the human frontline brought the issue of morality to the forefront of our minds.

In a recent survey of doctors by the BMA, 78% said the terms moral injury or moral distress resonated with their experiences of not providing their best and being limited by inconsistent services. Moral injury is being increasingly recognised across multiple professions, including social work, academia and mental health professionals like counsellors and psychotherapists.

Anecdotal examples include not being able to provide care that feels good enough or the limitation of the use of individual resources, a sense of betrayal or abandonment by those in authority, through lack of accountability, staff shortages and lack of pay and pay freezes. The most hardworking section of the profession, as care workers, nurses and doctors, continuously fight for a proper and deserving wage, and yet they are the least well-paid professionals in a world where some individuals hold zillions for their own individual use. Is this a global issue? I am uncertain - without generalising and making it a global one - I feel that we need to stay with what is very obviously an issue for us in the UK and perhaps anywhere in the West with soaring right-wing rhetoric, the culture and its public services becoming much uncaring and underserved.

We, as members of our community, are expected to provide as much as possible, and we are expected to carry out the most painful task of caring for the ill, and we are at the same time constantly told that there is no money. We know that there is plenty of money in the hands of just a few like Elon Musk, Jeff Bezos, Mark Zuckerberg and Richard Branson, as well as the state reserves run by the uncaring patriarchal political parties, including Labour and Tories in the UK and neo-liberal democrats in the US. This proved to be true when the Tory government handed in many to the public as well as the business without any difficulty during the COVID-19 period.

How can moral injury/ethical distress affect mental health? 

In cases in which the effects of moral injury extend beyond psychological to emotional harm, clinicians who assess people exposed to potentially morally injurious events must ask about moral injuries sensitively because otherwise clients/patients might avoid talking about their experience or their altered beliefs for which they fear others might judge them.

As a therapist, when I am sitting in the counselling room with a female client who is battered and betrayed by their husband, father or brother, I am engaged with and facing up to deeply patriarchal oppression and its effect on women. They talk about violence in the street, they are afraid to be out in the dark. I am powerless in the sense of comforting them and helping them to help themselves. In the past, the cycle of the behaviour of ignoring the realities of pain and violence caused by male members of any family was deeply bothersome but politically dispiriting, affecting one's sense of self and not being able to do anything about it. This can easily leave one in emotional pain and gradually the accumulative effect of the pain can naturally leave a scar on one's sense of self like a wound in the skin. People with moral injury often feel guilt, shame, disgust and/or anger. Another common reaction to moral injury is not being able to forgive oneself or feeling a need to punish oneself.

Someone with moral injury may end a relationship because they do not believe they are worthy of love, or they may not show up for therapy appointments because they do not believe they deserve to feel better or are too ashamed.

Let's look at this deeply hurtful but skillfully hidden from the awareness of the masses yet hugely meaningful issue from another angle, as the practice of moral injury is much more common than we might think. When you are a proponent of a political party which claims to work for the weak and vulnerable and aims to dismantle the injustices and inequalities in the culture when they are elected to govern. We as individuals aspire to use our democratic rights to choose someone who we are politically allied with as we help others or contribute to the culture to make a difference or change life for the better. We expect them to do the right thing and they don't. This is hurtful and leaves us in despair and deeply hurt.

The Labour Party since Tony Blair took the office of Westminister with a euphoric win in 1997, supported by many like-minded people, was betrayed most dreadfully by aligning himself with the right-wing George Bush to invade Iraq and causing thousands of deaths and destruction. What could be much more morally damaging and politically dispiriting? And most importantly, the emotional hurt of being lied to and betrayed which can lead to hopelessness and even disengagement from social interaction with others and loneliness as a result. This political or cultural behaviour still continues today and we are helplessly watching the death and destruction unfold. Moral injury involves upsetting emotions, changes in behaviour, and difficulties relating to others. However, many people may experience distress after a potentially morally injurious event – this can last a lifetime if undealt with but most feel better over time with the help of therapy. 

How can talking therapy help one to heal?

Working with clients whose mental health problems are caused by moral injuries can be challenging for us as clinicians. As stated in some literature, moral injury might be an important public health concern. Yet, not many discussions or treatments about that currently exist in mental health care and educational institutions. Approaches that focus on self-forgiveness, acceptance, self-compassion, and identity might be more promising to deal with deeply hurt but not much understood emotional trauma.

The question is, what do we do with morally hurt feelings and when we are in ethical distress, are we able to heal when we are deeply hurt and injured? How do we hold our politicians to account or bring them to the basics of morality and ethics of caring? Can we heal from these incessant problems of inconsistencies and failings? Would becoming politically active citizens or forming a group that can do the job properly help? These are all the questions we can begin to ask ourselves and people in power for consideration at least because they are accountable to us, and as members of our community, we have a responsibility to challenge our representatives and use or take advantage of our democratic rights to ask questions. 

Working with a therapist who focuses on self-forgiveness, acceptance, and self-compassion might hold much more weight and promise to move towards healing. My approach is unique in the sense of practising techniques to help you in a particular way. Techniques will involve using humanist/feminist therapy in which we discuss your interconnected identity and the ways they show on the inside of the therapeutic space, which can help you to understand how you react when you are in similar circumstances outside therapy. The key techniques utilised in feminist therapy are self-disclosure and psychoeducation, as well as reframing, power analysis as well as social action. 

When you meet your therapist for the first time, it is essential that they provide a safe space for you in a collaborative way to identify how your moral injury manifests itself in your body and your mind. As moral injury becomes increasingly recognised in other spheres, more effective ways and appropriate techniques can be utilised to better understand the extent of the problem across life episodes in which you might be exposed to potentially morally injurious events. 

This therapy is a politically informed model that observes human experience within the framework of societal and cultural realities and through the dynamics of power informing those realities of race, gender, and identity, and most importantly, as a feminist therapist, the marginalised viewpoint is attempted to be made central, and modern-day therapy and theory which often addresses the concerns of people of colour, people with special needs, lesbians, gay, immigrants, refugees, and more. Those who have experienced oppression may be able to find a treatment that can inspire social transformation in addition to addressing mental health concerns. 

When you are in therapy and working through your hurt and pain, understanding moral injury is of great importance in the beginning stage of healing and recovery from ethical distress. Moral injury provides an ideal opportunity for multidisciplinary approaches that include attention to emotional, societal and psychological components. While many therapists and researchers would claim that attention to guilt and shame symptoms are already present in trauma-based treatments, I offer the radical notion that silenced voices of marginalised people are potentially the sources of the greatest wisdom. When made central to analysis and practice, this perspective is potentially transformative of everything about therapy, as the research suggests that feelings of betrayal and anger toward someone in power are to be broached by the therapist rather than morally questionable acts perpetrated by the sufferer. 

The primary objective of this therapy is to examine the differences in power dynamics between individuals, particularly between the perpetrators and the sufferers, and to make sense of how they may contribute to the individual’s problems. This is founded on the notion that gender affects everything around our outlook on life and our identity and well-being in general.

The main purposes of therapy for ethical distress are:

• assisting individuals in becoming more assertive
• reclaiming personal power
• enhancing self-esteem and dealing with distressful emotions
• helping to develop more effective interpersonal and relationship abilities 
• rebuilding helpful and thriving relationships
• re-enacting the silenced voices of marginalised people is the source of the greatest wisdom for change. 

This concept could prove relevant to understanding the high levels of burnout in medical staff and, indeed, those with carers faced with high levels of exposure to morally problematic scenarios, such as nurses and care workers.