Moral Injury: Haunted by an Emotional Trauma

Below are six common questions that are often asked about moral injury.

1. What causes moral injury? There is no predictable set of causes, but the main factors involve high stakes situations, such as life and death, a high risk for failure, no clear right and wrong choices, and harm done. A person can feel afflicted by conscience not only from directly inflicting harm, but also from witnessing it happening, hearing about it, or surviving being harmed. Victims of harm can also experience moral injury—they may feel ashamed of being contaminated by evil, believe they caused the harm, or do things to survive that violate their conscience.
2. What are the symptoms? Rita Brock, Volunteers of America's Senior Vice President, Moral Injury Programs, notes that people will often feel grief, as well as negative moral emotions such as guilt, remorse, shame, outrage, and despair. They lose trust in themselves and their moral foundations, which disrupts or destroys their relationships because they cannot trust others not to judge them. They may self-medicate their inner pain with alcohol or drugs. They can become alienated from societal norms and lash out in anger at the slightest provocation.
3. How is it different from PTSD? Post-traumatic stress disorder is fear-based. Moral injury is not. They can share some symptoms, like anger, addiction, or depression, but moral injury has no diagnosis or treatment protocols. PTSD protocols can involve reliving the traumatic incident in a safe environment to defuse the fear. Dr. William Nash, a psychiatrist and expert on moral injury, points out that the very same therapy can sometimes aggravate moral injury, repeatedly “bringing it emotional immediacy” that makes it harder to address.
4. What is the best treatment? With something as complicated as moral injury, there is no single best agreed-upon treatment, but this complexity means that it can be processed in a number of ways. When people have trouble accessing what is wrong, having them create an image, go through a guided meditation, or write a poem or story can help them access a fuller memory. Prayer, chanting, and various forms of meditation offer collective ritual processes for calming inner turmoil and restoring capacities to reflect on and make sense of inner pain. A conversation with a benevolent moral authority, such as a chaplain or religious leader can help, but this will not be helpful if they impose their religious views. Helping people think is important; telling them what to think can delay or derail recovery. At some point, the precipitating incident(s) must be shared, talked about, and looked at reflectively. This sharing requires people prepared to listen deeply, with an open heart and without judgment. But how such sharing and listening are structured can vary by culture and spiritual tradition. Affinity groups can provide an effective point of entry for building trust so that sharing is easier, for example, veterans who share military culture, refugees from a particular region, or survivors who share a common experience. As Brock says, “Recovery is a lifelong process because it requires the restoration of love and empathy.”
5. Does it apply only to soldiers? Not at all. Under duress, people can violate their moral code in many situations. For example, a doctor addicted to drugs steals them from his office; a mother living in poverty abandons her children; an office worker fabricates documents for fear of losing a job; an expectant mother has to abort a problem pregnancy; a minister has an affair with a parishioner; or a train conductor fails to see a warning light and crashes his train.
6. How can you help a loved one who suffers from moral injury? Attending to the behavior of someone you love is important. If they seem distant, reluctant to share, preoccupied, controlling, cold, drinking too much, overworked, or otherwise not able to be present, that may mean they have shut down because of inner emotional pain. They may be unaware of why they feel terrible, or they may be reluctant to share what bothers them if they believe you will think less of them or will be disturbed by what they hear. Ask them if they’ve heard of moral injury. Brock has noticed that when people are introduced to the term, their eyes light up in recognition. “They know it for themselves,” she says, “or they know someone who has it.” Ways to introduce it include films, books, blogs, essays, stories, and conversations with someone who has experienced it. Just remember that you may not be the person they want to talk to, but make sure they have someone to talk to.

Learn how, to start a national conversation about moral injury, we had to find a method to convey basic information about moral injury and then facilitate group discussions.

Our Growing Understanding of Who is Impacted By Moral Injury

At Volunteers of America, we have wide-ranging experience with people who are suffering. We have helped the most vulnerable among us at the points when they needed it most. We have stood with people in crisis, listened to them, and tried our best to alleviate their pain and isolation. But we have begun to wonder, what happens when the moment of crisis passes? What happens to those of us who have started to recover physically or financially but continue to carry the emotional and spiritual burdens of the events that led to the lowest points? Sometimes those burdens make day-to-day life as painful, as filled with suffering, as the crisis itself.

Volunteers of America is dedicated to helping those in need to rebuild lives and reach their full potential. Since our founding in 1896, we have supported veterans, at-risk youth, the elderly, people leaving prison, homeless individuals and families, those with disabilities, and those recovering from addictions, now reaching almost 1.3 million people per year through 32 affiliates in 46 states with more than 16,000 professional employees. Our mission has endured throughout our tenure, adapting as times change, yet fully committed to our ministry of faith-based, practical assistance as we meet people where they are and help them get to where they want to be.

Since the post-Civil War era, veterans and their families have been an organizational priority. Today our programs reach more than 40,000 veterans and families annually. Our broad scope of services includes: peer support; case management; care coordination; service centers; emergency, transitional, and permanent housing; health and mental health care; education, training, and employment services; legal and benefits assistance; and specific services for female veterans, veterans with families, and elderly veterans.

Innovation is a hallmark of our service to veterans: Volunteers of America was among the first providers to make low-barrier, low-demand transitional housing and housing-first options available to homeless veterans and to use service-enriched housing to help women veterans suffering from post-traumatic stress disorder (PTSD) and military sexual trauma. We also connect those living in rural areas to counseling and supportive services through telehealth to mitigate geographical challenges.

In our ongoing efforts to reach the veteran population, in 2009, we sought and received a grant from the US Department of Labor’s Homeless Veterans Reintegration Program to provide education and job training. In 2010, we organized 35 nationwide programs to serve over 7,700 homeless veterans, offering transitional housing, employment training, substance abuse treatment, and mental health counseling.

As we pursued our work with veterans, we encountered many people struggling with PTSD, a natural response to the traumatic experiences they endured that nevertheless affected their ability to navigate their daily lives without fear and restrictive accommodations to manage their anxiety. As we dove deeper into the continuing issues of the veteran population, we also encountered moral injury. At the time, we did not know what to call it. We only knew our veterans were suffering from symptoms that sometimes accompany PTSD but may also exist on their own—a kind of soul wound characterized by a loss of faith, depression, anxiety, shame, guilt, self-sabotaging, and self-destructive behaviors. From the outside, we might only see anger or apathy, but inside, our veterans are still at war with themselves.

We knew that to help, we needed more information, so we identified the Soul Repair Center as a thought leader on moral injury. Founded in 2012 and located at Brite Divinity School in Fort Worth, Texas, the Soul Repair Center is dedicated to research and public education about recovery from moral injury. In September 2015, Volunteers of America partnered with the Center and the Tarrant County Spiritual Care Network to provide training on addressing trauma and moral injury for our affiliates in Louisiana, Texas, and Oklahoma. Over two training days, we explored various definitions of and responses to moral injury. Experts in the fields of substance abuse, psychiatry, psychology, law, and theology discussed diverse topics such as the potential impact of court-ordered treatment on moral injury; secondary trauma and spiritual resilience in caregivers; shame; and the neuroscience of trauma.

Our initial training around moral injury convinced us that we needed to do even more with moral injury—not just for our veterans but for many of our clients.

As we delved into its definition, its hallmarks, and its manifestations, we realized moral injury underpins so much suffering in the world, particularly so for the people Volunteers of America serves who need our help most. We realized that to bring an understanding of moral injury to the general population, we needed to talk to people who, as we do, see it every day without knowing what to call it.

With this realization in mind, we devised a series of convenings to talk about moral injury: what it is, how it manifests in our populations, and what we can do to address it. We gathered representatives from Volunteers of America affiliates and leaders of organizations from myriad fields, including diverse nonprofits serving veterans, people with dementia and their families, children and families, and from the business sector, including leaders in banking and finance, as well as a documentary film team. We met with 25 to 30 participants per meeting in Washington DC, Los Angeles, New York, and Chicago in lively interactions in which we pooled our knowledge and explored the challenges of understanding moral injury and what we can do to help its sufferers.

For four hours in each venue, we considered the term itself, stretched its current definitions to reflect the dimensional realities of moral injury, and challenged one another to break through to a new viewpoint that is just beginning to recognize that the suffering created by moral injury underpins so many emotional, physical, and spiritual issues. We now believe addressing the ramifications of moral injury in the context of myriad issues—from homelessness to suicide to caregivers’ and survivors’ guilt, as well as through the lenses of specific populations such as veterans, people who identify as LBGTQ, people who come from strict religious communities, and so on— can revolutionize our service approach.

We will continue helping people meet their basic needs. But now, we will attempt to bring a new component to our work that reaches beyond physical requirements to address the emotional, spiritual, and existential suffering that makes it so difficult for our clients to find their own housing, to get and keep a job, to make emotional connections with family and community members, and to eschew the momentary freedom from pain that substances provide. Many of the behaviors that lead to these circumstances are symptoms of an internal wound. We believe that if we can help people recover from this wound or at least change their relationship with it, we can help them regain their hope and purpose—we can help them recover themselves.

Out of these convenings and our growing understanding of moral injury’s pervasiveness will come a Moral Injury Healing and Outreach Center where we will continue to explore the effects of moral injury and the ways in which we can reach sufferers, discover new pathways toward healing, and educate the public. The Center, working through Volunteers of America’s extensive and robust infrastructure and in collaboration with partners from various sectors, will perform many functions. It will serve as a repository for information about moral injury and conduct original moral injury-related research; it will be a leader in the development and dissemination of innovative approaches for addressing moral injury in veterans and civilians; and it will function as a hub for the provision of training to community leaders, family members/caregivers, and direct care staff about moral injury and its effects.

Our expectation is to become a beacon for families, educators, practitioners, and faith communities as they wrestle with how moral injury affects them and their environment. Our hope is that by naming moral injury and exposing the darkness it brings to its sufferers, we can continue a national conversation that leads to healing for individuals, for nations, and for the world. We have a lot of work ahead of us. With these convenings, we have taken the first steps of a long and rewarding journey.

Moral Injury: What It Is, How It Affects Us, Why We Need to Address It

Our world is in the midst of great change. Strong media presence in a 24/7 news cycle focuses our attention on violence, economic problems, political upheaval, social revolution, advancing technology, and a host of additional factors that are reshaping our understanding of who we are. As the winds of change blow globally, people become more anxious and fearful about the unknown. Navigating our way through the tumult requires from us a deeper understanding of one another and ourselves to help develop resilience to face and address our individual, community, national, and global problems.

Volunteers of America has long looked to address the fallout from the upheaval of change, including war, imprisonment, substance abuse, homelessness, and other issues that impact vulnerable populations. Moral injury is an intangible residue of such upheaval, and while it is not a diagnosable psychological disorder, left unspoken and unresolved, moral injury may play a significant role in the manifested symptoms of mental health problems and increases in suicides.

Moral injury is a natural, human response to a traumatic event or events. In identifying moral injury as both a factor in many problems and a key to unlock pathways to greater resilience, we concurrently aim to get at one element that may lie at the root of depression, anger, apathy, despair, guilt, shame, and isolation that leads to physical, emotional, mental, and spiritual suffering.

Jonathan Shay, then a psychiatrist with the Department of Veterans Affairs (VA) in Boston, first identified moral injury in Vietnam-era veterans in the late 1980s. In his book, “Achilles in Vietnam,” Shay defined moral injury as the response that arises when a person in a position of authority violates what we believe to be right in a high-stakes situation.

This sense of violation is specific to the individual, which is an aspect of moral injury that can make it difficult to identify and discuss clearly. Based on Shay’s definition, a military example of moral injury may occur when a commander makes a bad decision that results in the death or injury of soldiers. In a civilian setting, it may happen when a parent abuses, neglects, or betrays the trust of his or her child.

In 2009, building on Shay’s work, Boston VA psychologist Brett Litz and his colleagues formulated another definition of moral injury: people can suffer moral injury when they participate in, fail to prevent, witness, or learn about acts that violate deeply held moral beliefs and expectations. Therefore, just about anyone who engages in or witnesses violence, abuse, or sexual assault or anyone who learns about this happening to someone close to him or her is at risk for moral injury.

Moral injury’s effects are not limited to active military personnel or veterans. We see its hallmarks in first responders, police, medical practitioners, litigators, and other professions—or situations such as becoming a caregiver for a parent—where people must make decisions that can severely affect another’s or our own lives. We see moral injury in people who come from neglectful, abusive, pervasively violent, and/or impoverished backgrounds. We see it in people who experience a singular trauma or multiple instances of suffering.

We see moral injury as a survival reaction: the trauma experienced that gives rise to moral injury changes how we see the world and our place within it and can fundamentally change how we see ourselves. It’s a natural response to an extraordinary event, and we need help determining how to integrate the paradigm shift into our worldview before we become isolated from our self and from others in a way that generates symptoms of disorder or disease. Currently, we don’t know the prevalence of moral injury in our culture—most people do not know what it is, let alone have a vocabulary for discussing it. Yet each time we describe the emotions and experiences that characterize moral injury, we see a combination of recognition, relief, and at least a momentary sense of ease that someone grasps the suffering the person is enduring or has seen in others.

Many people experience moral injury as a religious or spiritual wound—a soul wound—characterized by loss of meaning, loss of faith, and feeling angry at or abandoned by God. For these individuals, theologian Dr. Rita Nakashima Brock’s term “soul repair” may resonate.

Soul repair can include many practices, but all forms tend to avoid extremes between moral condemnation and unmindful forgiveness, attempt honest exploration of the theological aspects of moral injury, and work toward restoration of relationship with God and a religious or spiritual community.

At Volunteers of America, we see firsthand the burden of carrying suffering and the multiple ways it prevents us from becoming our best selves and reaching our fullest potential. If, as we believe, moral injury underpins so many mental health symptoms, we also believe that beginning to discuss moral injury and developing approaches to ameliorate its effects, increasing our resilience against these mental, spiritual, and physiological effects, and discovering ways to empower people can foster better personal choices. From these better choices, we also believe people will choose to invest themselves more in their relationships and in their communities, with the potential to find paths other than violence to solve problems at communal, national, and global levels.

In reaching out to leaders in a variety of nonprofit and business roles and asking them to explore moral injury with us, we have started a national health care conversation. In each of the four cities we visited, we witnessed the lights of understanding flash on as participants spoke of their own encounters with moral injury, wrestled with its meanings and applications, and considered how to apply what they are discovering to their relationships and professional roles.

The clear message we received is that moral injury is real, it plays a role in the anger, apathy, violence, fear, and suicides we continually witness in the world, and we have the potential to generate a significant difference in people’s lives by acknowledging and addressing the experiences that left them feeling cut off from themselves and their environment. The pages that follow capture common themes that arose from our conversations and the challenges we face in helping our organizations and the wider world understand what it is and why we must address it.

Moral Injury: A Continuum?

Moral injury can arise from a single event, usually catastrophic in nature and able to create such a division in people’s lives that they feel as if there is a before and after—they can pinpoint the moment their lives changed.

For some people, however, moral injury arises over a longer time through a series of traumatic events that strain the person’s sense of justice and identity, moving from tension to distress and finally to moral injury. People do not need to progress through the stages in any kind of order because the perceived level of suffering can change rapidly in response to events.

Yet it is important to consider how moral tension over time can escalate into moral injury, particularly in situations where people feel trapped, such as when they live in strained socio-economic circumstances or when they become a caregiver due to illness or accidents. Even if the situation improves, people may experience a moral residue that increases the possibility of experiencing moral distress or injury in other situations. Finding pathways to address moral tension and distress as well as moral injury may increase resilience.

A Historical Perspective on Moral Injury and Current Definitions

Though the term moral injury is a recent construct (1994), its affects are traceable at least to the ancient Greeks in literature such as Oedipus Rex.

In the play, the mighty king unwittingly commits an act of transgression against his family so egregious that he takes his own eyesight and exiles himself, convinced he should never have been born, should never have lived, and should now enjoy no comforts of the world.

Oedipus’s rage against the gods and his unremitting despair illustrate an aspect of moral injury from the perspective of a perpetrator who later understands what he has done and cannot bear the pain of it.

Current Definitions

1. “[The…M]ost precise (and narrow) definition of moral injury has three parts. Moral injury is present when (1) there has been a betrayal of what is morally correct; (2) by someone who holds legitimate authority; and (3) in a high-stakes situation.” (Shay, 1994 and following).
2. “[P]erpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (Litz et al., 2009).
3. “Disruption in an individual’s confidence and expectations about one’s own or others’ motivation or capacity to behave in a just and ethical manner. This injury is brought about by bearing witness to perceived immoral acts, failure to stop such actions, or perpetration of immoral acts, in particular actions that are inhumane, cruel, depraved, or violent, bringing about pain, suffering, or death of others.” (Drescher, et al., 2011).

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