Understanding Moral Injury

Moral injury, also known as a soul wound, is an invisible wound inflicted on your conscience through experiences that challenge your core values. This could include doing or not doing, failing to prevent, being subject to, or witnessing something that goes against your deeply held moral beliefs, spiritual values, or expectations, and violates your sense of right and wrong. It is characterized by deep psychological distress that leaves you feeling emotionally broken.

Although not a formal diagnosis, moral injury has recently been acknowledged by the American Psychiatric Association (APA) as a factor relevant to a person’s mental health, even though not labeled as a mental health disorder itself.

To recognize its clinical significance, the APA listed it under “other conditions” in a new, expanded diagnostic category entitled “Moral, Religious, or Spiritual Problem” that was added to their latest (September 2005) text revision of the DSM-5-TR, the Diagnostic and Statistical Manual of Mental Disorders, which is the official handbook used by U.S. mental health care providers to classify and diagnose mental health conditions.

While initially identified in combat veterans and most commonly associated with members of the military, moral injury has become increasingly recognized. It is seen in healthcare workers, first responders, and others in high-stress roles or faced with making challenging decisions in difficult circumstances. This goes beyond professionals to include civilians as well.

Moral Injury Versus Post-Traumatic Stress Disorder

Moral injury and Post-Traumatic Stress Disorder (PTSD) both stem from high-stress experiences. They have certain symptoms in common, such as intense emotional distress, nightmares, and withdrawal. They often co-exist, but they are very different types of trauma.

PTSD is officially classified as a psychiatric disorder that is caused by fear of death or danger, and is a nervous system survival-based fight or flight reaction. It stems from witnessing or experiencing a deeply traumatic, often life-threatening, war zone trauma, the ongoing intrusive memories of which cause intense terror.

Moral injury, on the other hand, is an internal, ethical conflict rather than a clinical diagnosis. It is a shame-based emotional wound caused by guilt over actions that violate your conscience and core moral beliefs. Unlike PTSD’s largely fear-focused symptoms, it is more commonly associated with feelings of grief, shame, anger, and disgust.

Origins of the Term Moral Injury

The term moral injury was first coined in the 1990’s by clinical psychiatrist Jonathan Shay. He used the term to describe a phenomenon he identified while treating Vietnam combat veterans suffering from deep psychological, emotional, and spiritual distress that seemed to fall outside the scope of PTSD.

Distinct from physical injury or the fear-based memories of traumatic experiences at the roots of PTSD, moral injury is characterized by mental anguish and damage to the soul. It happens when a veteran violates his conscience by participating in, failing to prevent, or witnessing actions in high-stakes situations that go against his personal ethics. These choices unmake his character in a way that negatively impacts his view of himself.

Examples of Events that Can Cause Moral Injury

• Having to make morally difficult decisions that affect the survival of others.
• Making an unintentional error that leads to the loss of a life.
• Having to stay silent in the face of injustice.
• Feeling betrayed by a trusted leader or authority figure in a way that shakes your understanding of goodness and justice.
• Having your expectations betrayed by superiors in unconscionable ways. One example is a soldier being sent to war believing the purpose was to eradicate weapons of mass destruction, but then finding out this was not the case.
• Witnessing an upsetting situation and not being able to help or intervene.
• A combat veteran participating in an act of violence that leads to the deaths of innocent civilians.
• A nurse being unable to challenge a decision made by a senior physician.
• Healthcare workers who are unable to give patients the care they need due to limited resources, legal banning of a necessary treatment, or hospital or insurance restrictions.
• A first responder not being able to save everyone who needed help, or feeling responsible for someone’s death in a situation where an impossible choice has to be made about the distribution of life-sustaining equipment.

Symptoms of Moral Injury and Ways It Can Affect Your Life

Moral injury begins with a violation of conscience that creates moral dissonance by separating your core values from your life practices. This inconsistency can change the way you see yourself and your life’s meaning, and lead to intense psychological distress, depression, self-destructive behavior, or even suicidality.

Some people exhibit symptoms of moral injury right away, whereas other people’s symptoms may take years to surface.

Common reactions, especially among combat veterans, include grief, anger, guilt, shame, disgust, bitterness, self-hatred, and an inability to forgive themselves. It also includes a belief that what they did or didn’t do makes them a bad person who does not deserve to be happy or have good things in life, even if they didn’t have a choice or were acting on orders.

Fear of judgment or misunderstanding can lead to isolation and withdrawal from friends, family, or church community. Moral injury may also cause you to question your spiritual beliefs, have a hard time reconciling what you’ve experienced with the tenets of your faith, and find it difficult to feel God’s presence or trust in His goodness.

Dealing with Moral Injury

Acknowledge the pain The first step to healing is to acknowledge your pain and bring it out into the open so it can be dealt with. Talk about it with trusted friends or family members.

Identify the core violation Identify the moral value that was violated that led to your moral injury, as well as the resulting negative beliefs and emotions the moral injury created.

Journal about it Journaling can help you process your feelings, gain new perspectives, and create a new narrative.

Forgive yourself Think of the why behind what you did or did not do, the pressure you were operating under, and the scenarios you were in where all options may have been bad and out of your control. Be compassionate and willing to forgive yourself as you reconcile with the past and move on.

Bring it to God in prayer Bring your pain to God in prayer and trust Him to heal your deepest wounds.

Join a peer support group A peer support group provides a safe, non-judgmental space where you can share your experiences with others who have faced similar ethical dilemmas, understand where you are coming from, and can validate your feelings.

Find new purpose Finding activities you can engage in that align with your moral values, such as doing volunteer work for a cause you believe in, can help restore your sense of purpose.

Consider counseling A trained mental health professional can help you address and process the roots of your moral injury, make sense of what happened, see it from a broader, more realistic perspective, reframe self-blame into self-compassion, and rebuild a sense of purpose.

Best Therapies for Treating Moral Injury

Two of the most effective therapeutic interventions for moral injury include trauma-informed guilt reduction therapy and acceptance and commitment therapy.

Trauma-informed guilt reduction therapy (TriGR) Trauma-informed guilt reduction therapy is an evidence-based form of psychotherapy that focuses on identifying, addressing, and processing distressing emotions such as the guilt and shame you feel following a moral injury. Its primary goal is to help you accurately appraise your role in the traumatic experience and re-engage with your core values so you can live a more meaningful life.

Acceptance and commitment therapy (ACT) Acceptance and commitment therapy is a mindfulness-based intervention that teaches you how to accept uncomfortable thoughts and emotions rather than try to fight them or get rid of them, which tends to only make them worse.

It focuses on helping you build psychological flexibility so you can adapt to the challenges of life and live in a meaningful, productive way, despite them, that is aligned with your personal moral beliefs and values.

If you have questions or would like to set up a risk-free appointment to meet with one of the faith-based counselors in our online directory, please call the reception team.