Moral Injury: have you been hurt?

To describe moral injury, I’ll share an experience of it, which led the person concerned to become a psychotherapist. 

Many years ago,  Amy embarked on training as a mental health nurse. She wanted to support the healing of people who suffered because of their mental health. The training was split between classrooms and placements in different mental health settings. In lectures, Amy learnt about diagnoses, medication, and the importance of a therapeutic relationship, and she felt enthusiastic to ‘do the work’. Away from the classroom, although Amy achieved top grades on each placement, she finished each placement full of shame, alienation, and feeling worthless. Despite the ‘A grades’, Amy felt regularly ‘told off’ for ‘talking to patients’.

The turning point came after a night shift. Admitted for psychosis, a terrified patient calmed when talking about her childhood, so Amy listened. As she finished the shift, her supervisor remarked that spending all this time with a patient was ‘weird’ and that Amy had made colleagues who spent time in the nursing office rather than on the ward look bad in comparison. With hindsight, Amy understood that the team was understaffed, tired, and perhaps burnt out, focused on completing essential tasks and recording notes before the next shift arrived. As a student, Amy had fewer responsibilities and more time for patients. Harassing and observing a student able to fulfil the ‘nice’, or therapeutic, part of the role may have felt annoying to colleagues, particularly on only 30 minutes of sleep.

However, Amy felt bereft at the time. She had acted according to her values but now felt alienated and full of shame. If Amy couldn’t talk to patients, what was the value of her training? Her thinking took her to catastrophic future scenarios. Amy fretted about potentially constantly feeling like an outsider in the profession if she nursed the right way. Amy's feelings can be understood as moral injury, which we can look at more closely.

What is moral injury?

The term "moral injury" was first introduced in the context of military veterans by Vietnam War veteran Jonathan Shay, a psychiatrist and author, in his book "Achilles in Vietnam: Combat Trauma and the Undoing of Character" published in 1994. Shay used the term to describe the psychological and spiritual impact of war on soldiers, particularly about experiences that violated their moral beliefs and values. 

Since then, moral injury has gained recognition and has been studied in various fields, including psychology, psychiatry, and ethics, to understand better and address the psychological wounds that can result from moral conflicts. Moral injury may occur in relationships, the workplace, or situations containing power imbalances, such as fear of losing your job if you ‘rock the boat’ and call out bad practices in the workplace. 

The impact of moral injury

Moral injury can have a significant impact on mental health, as it can lead to a range of emotional and psychological symptoms that can be distressing and debilitating. Some ways in which moral injury can impact mental health include:

1. Increased risk of mental health disorders:

Individuals who experience moral injury may be at higher risk for developing mental health conditions such as depression, anxiety, post-traumatic stress disorder (PTSD), substance abuse, and suicidal ideation.

2. Emotional distress:

Feelings of guilt, shame, anger, and betrayal associated with moral injury can be intense and persistent, leading to emotional turmoil and inner conflict.

3. Loss of meaning and purpose:

Moral injury can shake an individual's sense of identity, values, and beliefs, leading to confusion, doubt, and a loss of purpose in life.

4. Relationship difficulties:

Moral injury can strain relationships with others, as individuals may struggle to trust, connect, or communicate effectively with loved ones due to shame, guilt, and alienation.

5. Isolation and loneliness:

The emotional burden of moral injury can lead to social withdrawal, isolation, and a sense of being disconnected from others, exacerbating feelings of loneliness and despair.

6. Physical health issues:

Chronic stress and emotional distress associated with moral injury can contribute to physical health problems such as insomnia, fatigue, headaches, and digestive issues.

Can a positive outcome occur from moral injury? 

Working through a moral injury may lead you to a more profound knowledge of yourself, including your values, ethics, and boundaries when relating to others. In Amy’s case, after thinking over her response and feelings with her therapist, she considered how to take what she loved about mental health nursing and do more of it. It led to psychotherapy training, and Amy is now grateful to be constantly ‘talking to patients’. She spends her working days thinking with clients, exploring how and why they feel as they do, and what they'd like to change.

For Amy, moral injury was the catalyst for change. She now understands herself at a deeper level.  Strengthening her resilience and self-esteem, working through her experiences in therapy sessions, led to a different relationship with herself and others and enabled Amy to make different life choices. 

It is important for individuals experiencing moral injury to seek help if they experience suffering from mental health professionals, therapists, or support groups,  to address these mental health challenges and work towards healing and recovery. Treatment may involve therapy, counselling, medication, and other interventions tailored to the individual's needs and circumstances.

Moral injury may feel overwhelming and complex to recover from alone, impacting how you experience yourself and others and perceive life.  Suppose this resonates or feels familiar to you. In that case, it may be time to consider finding a space to think with a trained professional rather than struggling alone to recover from a complex experience.