What is ‘moral injury’ and how do I work with it?
Usually, moral injury is defined as the profound psychological distress that can arise after perpetrating, failing to prevent, or witnessing events that transgress an person’s moral or ethical code (Litz et al, 2009) including experiences of ‘betrayal of “what’s right”’ by leaders’ (Shay, et al., 1994). Although the concept of ‘moral injury’ is not new, the term is becoming increasingly common, and much has been written in recent years around how it is defined and how to treat it. Most research so far has focused on military personnel, who tend to encounter lots of potentially morally injurious events in their work, like killing or injuring other people, witnessing terrible human suffering and not being able to help, or feeling like their leaders have made mistakes, betrayed them, or let them down.
But other people can develop moral injury too. For example, it was reported quite frequently during the COVID pandemic by healthcare workers who witnessed harrowing scenes and felt that they were not able to help to the best of their ability, had let patients down or themselves were let down by their bosses and the government. And it isn’t only in occupational settings that a moral injury might occur. For example, people who kill or harm someone accidentally might experience moral injury, or those who have been badly betrayed by a loved one.
In terms of treatment, there isn’t yet much research on interventions specifically for moral injury, apart from some small studies (mostly with military veterans) either testing new approaches designed for moral injury, or adapting existing treatments like prolonged exposure or cognitive processing therapy (see Jones et al., 2022 for a review). We’ve also written a paper about how to adapt cognitive therapy for moral injury (Murray & Ehlers, 2021, also a chapter in our book) and this is the approach we’ll talk about here. It’s worth noting though that, although this treatment is based on a well-established and evidence-based approach (cognitive therapy for PTSD or CT-PTSD), and we’ve been using it clinically with people who have both PTSD and moral injury, it hasn’t been subjected to a specific clinical trial with this population.
As usual, CT-PTSD focuses on the very personal ‘meanings’ an individual attributes to the trauma and its consequences. In moral injury, typically they have interpreted an event in a way that leads to a sense of threat (either internal or external) through developing beliefs like ‘I’m a disgusting person for what I did’, ‘My soul is permanently damaged and I am going to hell’, or ‘people you trust will always betray you’.
Some people writing about moral injury have suggested that cognitive techniques aren’t helpful with these clients because often the surface interpretations of the event are accurate (e.g. ‘I’ve killed someone’ or ‘I made a terrible mistake which led to their death’). So, where appraisals of a trauma are completely accurate (and not just in moral injury examples), cognitive therapy doesn’t seek to restructure them. Rather we try to identify and address underlying distorted appraisals that might be fuelling the sense of threat and ongoing distress.
For example, if someone kills a person while fighting in combat, there is an objective truth that they have killed and are unlikely to ever forget such a life-changing experience. However, if the person also comes to believe ‘this means I can never be forgiven’ or ‘I’ve lost my soul’, then therapy can focus on these secondary appraisals, as potentially distorted or unhelpful self-evaluations that may be driving distress. These are usually identified by following the ‘downward arrow’ of implications from the initial accurate appraisal to the secondary very personal meanings, repeatedly asking “and what is the worst thing about that for you?”
In our work with moral injury, we therefore often think about 3 steps to the work. The first is addressing the profoundly distressing, and often existential, meanings associated with the ‘wrongness’ of a moral injury, as described above. Here, we might use some of the techniques we commonly use when treating guilt and shame in PTSD, like responsibility pie charts, surveys and addressing thinking errors like hindsight bias and generalisation. We also often use an imagery exercise which Litz et al. (2016) describe in their ‘adaptive disclosure’ treatment for moral injury, whereby the client identifies a person in their life who has ‘always had their back’.
In imagery, the client explains the traumatic event, their role in it and the moral dilemmas it left them with, and receives feedback from imaginary figure. They can ask specific questions that struggle with, like ‘does this mean I am an awful person, or ‘how can I move forward from this?’ In our experience, the feedback is often very helpful and encouraging, and can help reframe their moral distress as a natural consequence of the impossibility of the situation. The technique appears to works well for both perpetration and betrayal type traumas.
The second step is about accepting genuine responsibility for perpetration, and/or allocating blame for betrayal or genuine fault in others. There are various ways to do this which will be personal to an individual, but they might include making or seeking amends via apologies or restitution, in reality if possible, or symbolically or in imagery if not. For example, a client of ours who had killed another person while drink-driving had participated in a restorative justice programme in prison, but the family of the victim had not wanted to accept his apology. After he was released, he felt that he had not atoned for his actions, so volunteered for a programme giving talks on the dangers of drink-driving, which the probation service helped to organise. He wrote a letter to the woman who had died, apologising, and read it to her in imagery. He planted a tree in her honour and visited it annually on the anniversary of her death, to pay his respects. He did not expect to receive forgiveness, or believed he deserved it, but committed to using his experiences to guide his own behaviour in future.
The final step relates to helping people move forward from moral injury. This might include considering the pros and cons of continued self-punishment or brooding self-attack to atonement; and helping people reclaim their values and reconnect with relationships, as people with moral injury often isolate themselves fearing others’ judgements or further betrayals.
Again, this step will look different for everyone, but generally focuses on the idea that blameful brooding is unhelpful, neither creates restitution or restores ‘balance’, serves neither victim nor perpetrator and instead tends to have a negative impact on all concerned. Instead, channelling energies towards learning from the experience and using it to stimulate positive action is discussed.
This approach is quite nuanced and personalised to the individual circumstance of each client, so good supervision is essential when you work with moral injury. Supervision is also important because these cases can be quite challenging for therapists – we are often hearing quite upsetting material and will have our own emotional reactions, including those based on our own personal moral viewpoints. On top of this, there will sometimes be questions about when or how to break confidentiality if a crime is disclosed to us (we recommend this paper as a good starting point to considering this issue).
· Moral injury is the psychological distress that results from perpetrating or witnessing events that transgress our moral code, or from being betrayed
· It has been mostly researched in military populations but is also common in other occupational groups and in civilians
· Treatment research is very limited, but some PTSD treatments have been adapted to also treat moral injury
· Cognitive Therapy for PTSD can be used for moral injury alongside PTSD
· We address it through 3 steps: addressing any distorted appraisals, accepting/giving responsibility for genuine wrongdoing, learning how to move forward
· This work can be challenging for therapists so good supervision is important.
Jones, K. A., Freijah, I., Carey, L., Carleton, R. N., Devenish-Meares, P., Dell, L., ... & Phelps, A. J. (2022). Moral Injury, Chaplaincy and Mental Health Provider Approaches to Treatment: A Scoping Review. Journal of Religion and Health, 1-44.
Litz, B. T., Lebowitz, L., Gray, M. J., & Nash, W. P. (2017). Adaptive disclosure: A new treatment for military trauma, loss, and moral injury. Guilford Publications.
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706.
Murray, H., & Ehlers, A. (2021). Cognitive therapy for moral injury in post-traumatic stress disorder. The Cognitive Behaviour Therapist, 14.
Shay, J. (1994). Achilles in Vietnam: Combat trauma and the undoing of character. Simon and Schuster.