What is Moral Injury?

Moral Injury

Written by Steve Rose

Steve Rose, PhD, is an addiction counsellor who assists those struggling with substance abuse, gambling, gaming, and internet addiction.

“… I started thinking God hates me… I’m not religious or anything, but I felt like there was this hate for me…” – Sergeant Brendan O’Byrne on life after deployment

A new invisible injury is grabbing the attention of military psychologists. The concept of ‘moral injury’ is gaining traction in recent academic literature surrounding the mental health of combat veterans.

What is moral injury?

Litz (2009) defines moral injury as, “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”

Let’s take a closer look at how it is unique.

PTSD vs. Moral Injury

In the DSM-5, PTSD is conceptualized as a fear response resulting from the perceived threat of death or serious injury. Rather than a fear response, the concept of moral injury illuminates the importance of guilt and shame.

Although many of their symptoms overlap, moral injury is distinct since it results from what a person has done, rather than something that has been done to a person.

While PTSD is an anxiety disorder triggered by an instinctual fight or flight response, Moral injury deals with the uniquely human capacity of moral conscience. As Charles Darwin said:

“I fully … subscribe to the judgment of those writers who maintain that of all the differences between man and the lower animals the moral sense or conscience is by far the most important.”

For example, dogs and humans may both develop an anxious response to repeated nearby bomb explosions. When confronted with actual bombs, this is a useful survival strategy.

But if the response continues when the actual threat is removed, this is anxiety (e.g. a slamming door may trigger the fight or flight response). This is how PTSD works at its basic level. It has actually been reported that deployed military dogs also suffer from PTSD.

Human intellectual capacity for ethical reflection, and our placement in cultural belief systems complicate the simple fight or flight response.

Moral injury is unique to humans because it is characterized by deep internal conflict, threatening to overthrow one’s sense of identity and communal belonging.

Guilt and shame drive the person with moral injury toward isolation, making them feel unworthy of pleasure and perhaps even self-sabotaging or engaging in self-harm. This makes moral injury an empirically dangerous affliction, particularly in terms of suicide risk.

While PTSD can be characterized as an overactive fight or flight response, moral injury is a profound internal conflict. For a powerful narrative illustration of moral injury, see the Public Insight Network.

Why is Moral Injury so Dangerous 

Moral injury often lurks under the radar, taking lives and leaving survivors unable to make sense of the tragedy. Since moral injury has not yet been officially adopted into the Diagnostic and Statistical Manual of Mental Disorders, mental health professionals have not been able to properly diagnose this invisible injury.

Defined as a profound experience of guilt/shame or an institutional betrayal, persons who suffer from moral injury often blame themselves for an incident they did not have control over or become disillusioned and lose a sense of identity or meaning in their lives.

As previously discussed, this is common among those on the front lines of our nations conflicts who are often tasked with making life-or-death decisions amidst the fog of war.

Moral injury is so dangerous because its symptoms align with the interpersonal causes of suicide. As discussed by Thomas Joiner in his book Why People Die by Suicide, suicidal desire stems from two factors: 1) thwarted belongingness; and 2) perceived burdensomeness.

Moral injury deeply impacts both of these factors by making sufferers feel isolated due to their perceived transgression, as well as making them feel like a burden on others due to their suffering or perceived lack of propriety.

Morality, the social consensus of right and wrong, is the glue that bonds social groups. Our moral community is comprised of everyone we trust to conduct themselves in alignment with a code of unwritten rules.

Beyond the legal system, morality gets to the heart of our sense of identity and our ability to trust. It is like a sacred canopy we all stand under, giving meaning and purpose to our communal lives, to borrow a concept from Peter Berger’s definition of religion.

Beyond any religion, the moral code of universal human dignity largely governs us on a global scale.  As Karl Marlantes states in What it is Like to Go to War:

“…any conscious warrior of the future is going to be a person who sees all humanity as brothers and sisters.”

Throughout the history of human evolution, our instinctual drives recede like melting ice, exposing the fertile ground of moral consciousness. Rather than simply responding to instinctual reflexes, we now have the conscious ability to contemplate the ethical consequences of our actions.

With this evolutionary development, like the spring thaw, comes the increased responsibility of cultivation. As this moral consciousness expands to embrace an ethic of universal humanity, we must now consider others beyond our local group or nation. This consciousness forces us to readjust to a moral reality where we cannot simply label outside groups as subhuman.

One form of reaction to this increasingly globalizing world may be to simply deny an ethic of universal humanity, reaffirming a strengthened ethic of exclusion to bolster an identity based on hatred. But this merely works to cut ourselves off from our own humanity. By neglecting the humanity of others, we neglect our own humanity.

In the case of moral injury, the ethic of humanity is strongly upheld. Although it is a good thing to have a “conscious warrior,” who holds a global perspective, this awareness also makes it difficult to cope with perceived moral transgressions amidst the fog of war, causing the victim of moral injury a great deal of pain due to the experience of shame.

Shame is one of the most powerfully isolating emotions. In the case of moral injury, it cuts one off from a sense of belonging to under the sacred canopy of universal humanity. It strips one of a sense of identity as a decent human being, leading to profound sense of isolation. This is why it is so dangerous.

Recovering From Moral Injury

Luckily, there is hope of recovery. Part of this recovery requires one to recognize the broader forces that contributed to the incident in order to remove the sense of self-blame.

The need to make a decision in the fog of war is something that happens to an individual. Specialist Joe Caley, U.S. Army. 1st Cavalry, 25th Infantry realized his lack of agency, stating:

“It’s not what I did in the war, it’s what the war did to me. That was a self-revelation.”

In the book, Soul Repair: Recovering From Moral Injury After WarRita Nakashima Brock and Gabriella Lettini provide insight into the power of community in healing from moral injuries. It is this sense of community we may be sorely lacking in the modern world. They state:

In many traditional societies, all returning soldiers were required to undergo a period of ritual purification and rehabilitation before re-entering their ordinary lives after war.

Religion developed as an institutionalized means of ensuring social solidarity in traditional contexts where widely shared moral precepts regulated behaviors, integrating individuals into communal life. The Christian church developed their own version of ritual purification. The authors state:

Christian churches in the first millennium required anyone who “shed human blood” to undergo a rehabilitation process that included reverting to the status of someone who had not yet been baptized and was undergoing training in Christian faith.

This form of ritual serves powerful cognitive and communal functions. It allows individuals to process difficult experiences, facilitate grieving, and integrate the individual back into a larger communal whole.

In modern society, traditional institutions have taken a back seat to secular systems that often fall short on effective methods of reintegration. Psychological screening and preparatory transition courses are beneficial, but they focus on the head, often neglecting the metaphorical heart. Rita Nakashima Brock and Gabriella Lettini state:

…many veterans do not believe their moral struggles are psychological illnesses needing treatment. Instead, they experience their feelings as a profound spiritual crisis that has changed them, perhaps beyond repair.

The concept of spirituality often varies, but citing Robert Wuthnow in his book, After Heaven, he argues that

“…at its core, spirituality consists of all the beliefs and activities by which individuals attempt to relate their lives to God or to a divine being or some other conception of a transcendent reality.”

This concept of a transcendent reality is composed of an idea regarding the “true” nature of reality. This often anchors our moral precepts, guiding our concept of what it means to live a good life.

Traditionally, religious communities provided the foundation to our spirituality, providing us with rituals, texts, and creation narratives. In modern society, spirituality has become relatively detached from religion and many people are turning to individualized forms of experiencing the sacred.

The problem is that we cannot simply do away with institutional life and the meaning-systems that have oriented our communal lives. This is especially relevant for those undergoing fundamental life transitions, finding themselves disoriented in a world that no longer makes sense.

Whether provided by religion or a secular institution, we require a sense of the sacred to regain purpose.

In this sociological sense, the word ‘sacred’ simply refers to something collectively regarded as special, held in high regard, and is often associated with an idea of purity. A sense of service to the modern sacred ideal of universal humanity can fulfill this purpose.

When this sacred obligation is transgressed during the fog of war, individuals need to reorient themselves by grieving any losses and undergoing a form of atonement that brings them back within the sacred ideal.

At its etymological root, to atone means to be “at one.” Reentry into communal life requires one to regain a sense of service to a sacred ideal. Rita Nakashima Brock and Gabriella Lettini state:

A society that ends a war with a parade and returns to its entertainments, consumerism, celebrity worship, and casual commitments in order to forget its wars offers no purpose worth pursuing.

Harms from war are not just part of an individual diagnosis, rather, we need to look at how social processes produce individual and collective problems. This requires not only thinking more carefully about our reasons for going to war but also about the institutional gap our veterans are expected to navigate during the transition home. As one Veteran states in Soul Repair:

I belonged. I knew what was expected of me, and I had become ruthlessly proficient at fulfilling those expectations. Here I am a misfit, an aberration, isolated and alone.

Lucky, in the U.S, U.K, and now in Canada, we are making progress building transition programs that help bridge the institutional gap. Team Rubicon is making great strides allowing Veterans to regain a sense of humanitarian service through being redeployed to assist in disaster relief, allowing them to use their skills to help others in need.

Recovery from moral injury cannot happen in isolation. We need to consider forms of counseling, group therapy, and innovative programming that allows individuals to regain a sense of service upon leaving the service.

A sociological perspective may also help in recovering from moral injury.

The practical value of sociology goes beyond policy recommendations. It can help individuals recover from moral injury by changing the way they see themselves in the world, allowing them to move away from ongoing destructive feelings of shame from self-blame.

By demonstrating how larger social forces shape our private lives, sociological insight can help individuals realize they are not personally responsible for certain failures.

For example, sociology has a long history of disproving the ‘American dream’ of unrestrained economic freedom by showing how structural barriers make it more difficult for certain minority groups. Therefore, there are forces beyond their control contributing to their relative lack of privilege.

In the case of moral injury, a sociological perspective can show how an individual’s agency is influenced by broader structural forces.

Imagine the following scenario. In training, a soldier is equipped with the necessary skills to navigate difficult combat situations. In the field, these skills are put to use when the soldier decides to shoot the driver of a car speeding toward him since it appears to be a car-bomber.

Upon inspection, the driver turns out to be an innocent civilian with impaired eyesight. The civilian dies by blood loss shortly after and his family is devastated upon hearing the news. The soldier’s training had lead him to take the proper course of action since the risk was too high, but this action lead him to break his moral belief against harming non-combatants.

This cognitive dissonance results in self-blame and feelings of shame. The internal attributions of agency that occur in moral injury are destructive. In order to recover, individuals need to come to a more realistic view of their role in the conflict.

Rather than an overblown view of argentic control, the individual must come to see themselves as imperfect human beings within a complicated social environment that is impossible to navigate with certainty.

As stated before, the need to make a decision in the fog of war is something that happens to an individual.

This does not mean sociology is interested in abolishing the concept of agency and discounting guilt as an illusion. Without moral agency, individuals would be mere cogs in the social machine.

The feeling of guilt is often healthy since it means the person has high standards in their commitment to a moral code. The problem of agency arises when it is overblown and results in destructive thoughts and behaviors that prevent the individual from properly recovering from the conflict.

A sociological approach to moral injury can assist individuals in this recovery by showing how their individual lives are shaped by larger social forces.

Conclusion

Although it is not highly recognized, compared to PTSD, moral injury is an important concept when it comes to recovery from difficult moral situations in the military.

Rather than a fear-response, moral injury provokes a deep sense of guilt or shame, isolating a person from a sense of community and making them feel like a burden in life.

Because of its tenancy to isolate a person, it can be dangerous, increasing one’s risk of suicide.

Recovery from moral injury is possible and requires reintegrating the person into a sense of community, in addition to coming to terms with their position within a situation beyond their control.

If you are interested in reading more of my articles on veterans in transition, you can find them here.

Also, I have listed my favorite books on moral injury below, if you would like to read more on the topic.

Books on Moral Injury 

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Curious if online counseling works? I wrote an article here, looking at the evidence.


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