Have I suffered a moral injury?

Some time ago, I had the honour to work with a client who was ex-military, and a veteran of a number of high-intensity conflicts.

Each one had left a mark on them. In one of our sessions, they said something that left a lasting impression on me:

I feel disgusted at myself for not being able to help those civilians. I feel ashamed of not being able to save more lives. I feel totally used by my country.

As an ex-army reservist, this shocked and saddened me. The military isn't just a job, you join it to serve your country, to protect people, to be part of something special. The events that this person had taken part in had totally disillusioned them and made them feel disgusted and ashamed. This clearly troubled their personal morality and the ethical code that they followed. They had suffered a moral injury.  

What is moral injury?

The term moral injury dates back to the Vietnam War from 1955 to 1975 and the experiences faced by US service personnel. Although it is not a formally recognised condition, it is a lesser-known cousin of traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD).  

Like both TBI and PTSD, moral injury can affect mood, cause anxiety, depression, and frustration, and provoke flashbacks and nightmares. It makes people feel shame and guilt at their inability to prevent the events that trigger it, and anger because quite often there is an added dimension where the person feels let down by authority. In extreme cases, it can bring people to self-harm or consider taking their own lives. It is possible to have TBI, PTSD and moral injury at the same time – being injured in combat can cause brain injury and PTSD; moral injury comes from the feeling that all of the suffering was avoidable, either because the person involved made a terrible mistake or omission,  or because they feel somehow betrayed by their military or political leaders.  

However, it isn’t just the military that can suffer a moral injury. There is more evidence emerging post-Covid 19 that health professionals suffered something similar because their duty of care to save the lives of patients was violated by having inadequate resources to treat overwhelming numbers, and a perceived failure of leadership at local and national level. This has led to low morale in the case of many medical professionals, and feelings of depression and burnout, with many reporting relationship issues and that they now want to leave medicine. Police officers and journalists working on the terrorist attack by Anders Breivik in Norway in 2011, and law enforcement officers in the US also report similar instances of moral injury in their line of work, where they feel that they should have done more or were prevented from doing so by lack of staff, unwarranted bureaucracy, or mismanagement within their organisations.  

How do I heal my moral injury?

The main way to treat a moral injury is to talk to someone and learn to forgive yourself and others. This is best done through seeking counselling or therapy, understanding and accepting your feelings in a non-judgemental and empathic environment. By being able to reflect on the causes of the moral injury, and confronting the feelings of shame and powerlessness, you begin to accept what happened and put it into context. Both acceptance and commitment therapy and compassion-focused therapy can be effective. Joining a support group can also be helpful.  

If you feel you have suffered a moral injury, please don’t suffer in silence. You can reach out to me via my profile or contact other qualified counsellors on the Counselling Directory.  

References:  

Sonya B. Norman, PhD and Shira Maguen, PhD; Moral Injury https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp

Brett T. Litz, Nathan Stein, Eileen Delaney, et al, Moral injury and moral repair in war veterans: A preliminary model and intervention strategy, Clinical Psychology Review, Volume 29, Issue 8, 2009, Pages 695-706, ISSN 0272-7358, https://doi.org/10.1016/j.cpr.2009.07.003.

Jones, E. (2020). Moral injury in the context of trauma. The British Journal of Psychiatry, 216(3), 127-128. https://doi.org/10.1192/bjp.2020.46

Williamson, V. Murphy, D. Phelps, A. Forbes, D. Greenberg, N. Moral injury: the effect on mental health and implications for treatment, The Lancet Psychiatry, Volume 8, Issue 6, P453-455, June 2021, https://doi.org/10.1016/S2215-0366(21)00113-9

The British Medical Journal (2021), Moral distress in the NHS and other organisations https://www.bma.org.uk/media/4209/bma-moral-distress-injury-survey-report-june-2021.pdf

Hegarty, S., Lamb, D., Stevelink, S. A. M., et al. (2022). 'It hurts your heart': frontline healthcare worker experiences of moral injury during the COVID-19 pandemic. European journal of psychotraumatology, 13(2), 2128028. https://doi.org/10.1080/20008066.2022.2128028

Papazoglou, Konstantinos & Bonanno, George & Blumberg, Daniel & Keesee, Tracie. (2019). Moral Injury in Police Work. https://www.researchgate.net/publication/335842788_Moral_Injury_in_Police_Work