Moral injury: violating your ethical code can damage mental health – new research
Should a soldier shoot the child who is pointing a gun at them and their colleague? Should a photographer film the aftermath of a terrorist attack or help the injured? Many situations present professionals with ethical dilemmas – and the decisions made can have profound psychological consequences.
For many years, researchers have looked at the impact of traumatic events and the onset of post-traumatic stress disorder (PTSD). But until recently, feelings of deep shame and guilt, stemming from doing things you believe are “wrong” and which are often a feature of trauma exposure, have not been studied to any great extent.
Moral injury is defined as the psychological distress which results from actions, or the lack of them, which violate your moral or ethical code. For example, due to a lack of resources, a humanitarian aid worker may be unable to provide adequate healthcare to all of their patients.
Unlike PTSD, moral injury is not a mental illness. But such experiences can lead to negative thoughts about oneself or others (for example, “I am a terrible person” or “My colleagues don’t care about me”) as well as deep feelings of shame, guilt or disgust. These, in turn, can contribute to the development of mental health problems, including depression, PTSD and substance abuse.
Moral injury is not unique to any particular profession. Our recent review found moral injury was experienced by a wide range of people in different professions, including journalists, police, teachers, military personnel and veterinarians from several countries.
We found that most evidence of moral injury, and its impact on well-being, so far stems from studies conducted with US military personnel and veterans. Research in this population has shown moral injury can be caused by a range of experiences (for example, committing harmful acts, failing to stop the harmful acts of others or bearing witness to human suffering), with moral injury linked to poor mental health outcomes.
Limited UK research has also found that moral injury is considered to be fairly common and has negative implications for mental health in British military veterans. Morally injurious events for British veterans included: disrespecting dead bodies, witnessing human suffering, mistreating civilians or captured enemy combatants, being ordered to break rules of engagement, and beliefs that command gave negligent orders or did not adequately supply troops.
British veterans with moral injury described experiencing profound psychological distress, including intense feelings of shame, guilt, self-loathing or worthlessness.
Moral injury was also found to be one of the greatest challenges faced by UK journalists covering the 2015 refugee crisis. The most commonly reported difficulty experienced by journalists was witnessing behaviour among colleagues, aid workers or the local population that they considered to be morally wrong.
Despite this, how other UK professionals who are often exposed to challenging workplace events – such as police officers, fire fighters and paramedics – experience and respond to moral injury remains unknown.
What support is available?
Getting support for moral injury-related mental health difficulties can be challenging for a number of reasons. First, as moral injury can cause intense feelings of shame, guilt and disgust, those who are struggling may find it especially difficult to seek help. Those affected may also have concerns about the potential social and/or legal consequences of sharing what has happened.
Second, standard psychological treatments may not work for disorders caused by moral injury. For instance, some typical treatments for PTSD may focus on exposing an individual to the emotions – such as shame or guilt – associated with a traumatic event, without helping the individual make sense of these complex emotions and thoughts. This can make symptoms worse in cases of moral injury.
Finally, there is currently no established treatment programme for treating patients with moral injury – although research carried out with clinicians suggests that they use a combination of approaches (for example, responsibility pie charts and compassion-focused therapy) to treat specific symptoms and responses, such as feelings of guilt, shame and worthlessness. Whether such interventions are helpful to patients’ long-term recovery, however, is unknown.
Nevertheless, some promising interventions are currently being developed in the US, such as the Impact of Killing method, which uses a cognitive behavioural therapy (CBT) approach to address self-forgiveness, and adaptive disclosure, where patients take part in exercises involving imagined conversations with a forgiving moral authority.
If you, or someone you know, may be experiencing difficulties after a potentially morally injurious event it is definitely worth seeking professional help. Even though there are no established approaches to treatment, more experienced trauma therapists are likely to be able to adapt standard treatments for any patient’s particular needs.
Positively, there is also evidence that sometimes people can “psychologically grow” after traumatic experiences and seeking professional help, if you need it, may help such growth to occur.
The next steps
Instances of enduring guilt and a sense of having lost one’s moral compass have been documented for centuries.
Despite this, research into moral injury is still in its infancy and several gaps in our understanding remain. Until a reliable assessment tool for moral injury is created, we cannot know how prevalent moral injury is among people with, and without, mental health problems, and whether some people are more vulnerable than others.
It is only by beginning the discussion about the challenging ethical dilemmas that many of us face, that we can uncover what causes moral injury, and the mental illness associated with it. We can then ensure that effective help is available for those who need it.
Victoria Williamson has received research grant funding from Forces in Mind Trust.
Neil Greenberg has received grant funding from the Forces in Mind Trust and the Ministry of Defence . He is also affiliated with a psychological health company called March on Stress and carries out periodic expert witness work which can be related to moral injury.
Sharon Stevelink is part funded by the UK Ministry of Defence (MoD) and the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health and Social Care or the UK MoD.
Dominic Murphy does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.