Moral Injury is a term that is starting to be more commonly used in relation to a collection of behavioral responses to traumatic events. The term developed from research studies conducted with military personnel who had witnessed, or been involved in, violent conflict. Moral injury involves the damage done to conscience or moral compass when a person perpetrates, witnesses, or fails to prevent acts that transgress ones’ own moral beliefs, values, or ethical codes of conduct.
It is not yet considered a mental disorder, however, it may share common symptoms with PTSD. Some of those shared symptoms include avoidance, hypervigilance, intrusive thoughts, distressing dreams related to the event, and social problems (1).
This document to help individuals, leaders, and teams to:
- Define moral injury and its characteristics.
- Know the most common signs and symptoms of moral injury for self-recognition.
- Understand the different helpful tools for the healing process.
- Recognize when they should seek further help in the healing process.
“…it is important to separate experiencing a potentially morally injurious event from developing moral injury. This is similar to PTSD. Experiencing a trauma does not inevitably lead to developing PTSD. Whether a moral injury develops is determined by how the individual interprets the potentially injurious event. The appraisal process determines whether the event generates significant dissonance with the individual’s belief system and worldview .”(2)
Events with a potential for Moral Injury (3):
Perceived Betrayal (by peers, leadership, or self)
Witnessed acts of disproportionate violence perpetrated on others
Engaging in, or witnessing acts that violate personal moral beliefs
Regretting inaction that may have prevented harm
Medical personnel may feel guilty about life and death decisions that they have had to make.
Survivor’s guilt is common: this is when we start to wonder why we have blessing and privilege that are not afforded those we work with, or why we have survived a tragedy when another did not.
Guilt may be experienced when you are forced to tell someone that you cannot meet their needs due to insufficient funding, narrow scope of a project, or other reasons that are beyond your control.
Personnel may feel guilt and shame when catastrophic events take place at home while they are abroad.
Workers may be left confused and frustrated at having to leave behind friends in the event of an evacuation.
Some personnel may feel betrayed by decisions that are made by leadership that limit the ability to meet the needs of some beneficiaries.
Doctors and nurses may feel burdened to work with very little rest because they see themselves as the only source of help for people. “If I take a break, people die”.
Personnel may have witnessed acts of oppression or violence and wish they had done something to stop it
Many of us, as Christians, turn to our foundational beliefs in God, divine justice, and ethical standards for comfort in times of crisis and traumatic events. Moral Injury is a common component of spiritual crisis. When theological beliefs are opposed to all options in a given situation, it puts a person in a ‘no win’ situation. Questions about God are natural responses. These questions and the process of recalibrating core factors in an individual’s worldview can cause significant stress. This is sometimes referred to as spiritual injury or a wound of the soul.
If you are suffering from moral injury, you may notice the following types of responses (4):
People may not be aware they have a moral injury for some time after the event that causes it. Eventually, they might begin to experience emotional pain, often in the form of deep guilt and shame.
Other responses that are often significant in processing moral injury are betrayal (by another or oneself), loss of meaning, loss of trust (in others or oneself), and difficulty forgiving (oneself or others).(7)
Helping yourself through Moral Injury:
The following are three key ways to engage in recovery, growth, and building of moral courage: lament, connectedness, and forgiveness. As you review each of these, remind yourself that it is common to experience or deal with moral injury. We were not created for suffering and pain, yet as a result of the Fall, suffering and pain is a part of our reality. It is normal to see and struggle with events that highlight the ‘wrongness’ of the world. As you review each of these practical engagements, we encourage you to invite Jesus into your processing and pain. You are not alone.
Lament is a practice we see throughout scripture. In short, it is the process of grief at the suffering and tension of sin in the world. Lament works in several ways to help process through the stress of moral injury.
- It reminds us of who God is and who we are.
- It allows for the honest expression of emotion.
- It gives someone to talk to, allowing for the verbal processing that many need in order to deal with the pain.
- It affirms the commitment to trust God even if things do not get better and there is a lack of understanding.
The process of lament:
1. Cry out to God (your address to God) – be real and honest. He sees you suffer and knows what it is to suffer. He has gone through it Himself.
2. Complaint (your anger, pain, heartache, or sadness)
3. Affirmation of trust (your remembrance of God’s presence in your past)
4. Petition/Request (your deepest desire)
5. Additional argument (anything more, why should God intervene?)
6. Promise to offer praise to God (your promise to honor him)
7. Assurance (the attribute of God you are most thankful for)
Tell your story to someone you trust (7). Rarely can a person truly heal from a moral injury without talking it through. This is even true for those that would describe themselves as internal processors. Confess your actions to someone you respect as a moral or spiritual leader. And in general, pursue opportunities to connect with others doing activities you enjoy or getting an update on how your loved ones are doing.
Forgiveness is arguably the largest part in healing from moral injury. There are two facets: forgiveness of others that a person may see as betraying them or coercing them into a decision they regret, and forgiveness of ones’ self for that regretful decision or sense of inability to meet a need. The second part is often a harder process than the first.
The forgiveness process:
While we want to articulate a process for working through forgiveness, we also want to emphasize that true forgiveness involves transformation of the heart and mind, which is the work of the Holy Spirit. The very first thing that must be assumed for forgiveness to happen is that a person is willing to submit to His work in their heart and mind.
- Ask God for His help: Forgiveness doesn’t happen apart from God. We need him and cannot do this alone.
- Recognize the hurt: A key piece to forgiveness is to know and be able to clearly articulate what was done wrong. Many people cannot get past the feelings of anger or resentment to really understand why they are having those emotions. This leads to a position where reconciliation can only be found in the change of feelings, which is at best vague. In order to deal with the problem, the problem must be clearly defined.
- Let go of the need for justice and/or vengeance: Scripture tell us that judgement and vengeance are God’s responsibility. Trust that He will make it right. This step is easier said than done. It can be incredibly difficult and complex to let go of the need to see a wrong made right, especially when you have offended yourself. Shame is often the tool we use on ourselves to enact justice and vengeance.
- Remember the image of God created in the offender: Can you see the offending individual with the love of Christ? Do you want the best for them? If not, then you may need to go back to the previous step and work to release your need for justice. We need to be able to see people in the same way that Jesus saw those that hurt Him, and cry with Him, “Lord, forgive them for they know not what they do.” or, “Lord have mercy on me, a sinner.” This aides our ability to show empathy to others and to self.
- Make a conscious choice to forgive each day: Often, people seek a ‘once and done’ answer to forgiveness whether for themselves or others. This rarely happens. Usually, it is a process that involves the choosing and re-choosing to forgive. Commit and hold onto forgiveness.
It is rare that someone can work through significant moral injury on their own. Most need at least community support. If you are experiencing symptoms that are highly distressing or have been persistent for some time, you may need to talk to a mental health professional.
The Resilience Resource team can help you process through moral injury.
1. Definition taken from: https://moralinjuryproject.syr.edu/about-moral-injury/ . What is Moral Injury. Syracuse University
2. Barnes, Dr. Haleigh et.al. 2016. Moral Injury and PTSD: Often Co-occurring but Mechanistically Different. Psychiatry Online
3. Common reaction list taken from: Brock, Rita PhD. et al. Moral Injury. Alexandria, VA. Volunteers of America
4. Potential moral injury events taken from: Norman, Sonya PhD. Moral Injury – presentation. National Center for PTSD
5. Taken from: Hill, Harriet, et.al. 2016. Healing the Wounds of Trauma. Philadelphia, PA. American bible Society.
6. Drescher, Kent & Foy, D.W.. (2008). When they come home: Posttraumatic stress, moral injury, and spiritual consequences for veterans. Reflective Practice: Formation and Supervision in Ministry.
7. Koenig, Harold. 2018. Measuring Symptoms of moral Injury in Veterans and Active Duty Military with PTSD . Basel, Switzerland. MDPI