Moral injury

Moral injury often includes guilt and shame about one’s actions but is a broader construct than combat-related guilt. It also includes a number of other potentially detrimental reactions, such as moral outrage, anger, feelings of betrayal, loss of faith and grief.

In the context of war, moral injuries may stem from direct participation in acts of combat, such as killing or harming others, or indirect acts, such as witnessing death or dying, failing to prevent immoral acts of others, or giving or receiving orders that are perceived as gross moral violations. The act may have been carried out by an individual or a group, through a decision made individually or as a response to orders given by leaders.

Examples of moral injury:

1. Unintentional errors: Military personnel are well-trained in the rules of engagement and do a remarkable job making life or death decisions in war; however, sometimes unintentional error leads to the loss of life of non-combatants, setting the stage for moral injury
2. Transgressive acts of others: Service members can be morally injured by the transgression of peers and leaders who betray expectations in egregious ways

To elaborate on the notion of moral injury, three broad classes of morally injurious experiences have been identified:

1. Moral pollution: Refers to witnessing grotesque or catastrophic scenes but may also involve exposure to another person’s intense pain or grief, especially when one is able to make an empathic or personal connection with the other.
2. Moral betrayal: Refers to experiences of systemic failure, injustice or blame, particularly when this occurs in the context of high stress and physical danger. Moral betrayal is most injurious when it occurs at a time when one is most vulnerable and in need of ‘backup’.
3. Moral compromise: Involves one’s own or another’s action or inaction that violates deeply held values. Sometimes this comes as a result of loss of control, having to make a split-second decision in a crisis or being forced into a situation where no morally acceptable action is available.

These three categories of events can be experienced as psychologically violating, giving rise to feelings of shock, disgust, disempowerment and anger. A person may also experience this ‘lost goodness’ as a violent incursion on key beliefs and expectations about the world, or indeed themselves and others who inhabit it. 

What is the aftermath of moral injury?

In essence, moral injury makes it hard to transition from memory to the present; it confuses the old self and the new. The person grows to see themselves as the person who was capable of making the morally unjust decision when, years later, you know you could have made a different one.

In terms of the aftermath of moral injuries, transgressive acts may result in highly aversive and haunting states of inner conflict and turmoil. Emotional responses may include:

• Shame, which stems from global self-attributions (for example, "I am an evil terrible person; I am unforgivable")
• Guilt
• Anxiety about possible consequences
• Anger about betrayal-based moral injuries

Behavioural manifestations of moral injury may include:

• Anomie (for example, alienation, purposelessness, and/or social instability caused by a breakdown in standards and values)
• Withdrawal and self-condemnation
• Self-harming (for example, suicidal ideation or attempts)
• Self-handicapping behaviours (for example, alcohol or drug use or self-sabotaging relationships)

Are moral injury and PTSD the same?

More research is needed to answer this question. At present, although the constructs of post-traumatic stress disorder (PTSD) and moral injury overlap, each has unique components that make them separable consequences of war and other traumatic contexts. PTSD is a mental disorder that requires a diagnosis. 

Moral injury is a dimensional problem - there is no threshold for the presence of moral injury, rather, at a given point in time, a veteran may have none, or mild to extreme manifestations. Research suggests that a PTSD diagnosis does not sufficiently capture moral injury (shame, self-handicapping, guilt, etc.) and therefore differentiating the two allows the returning veteran to understand not only the trauma he or she experienced but also the damage left by the decision of war.

To understand moral injury and address its effects, we need to recognise that it exists. Research is currently exploring the differences between PTSD and moral injury as the existing treatments for PTSD are effective for those service members haunted by “should haves” (hindsight bias) and who are burdened by an excessive amount of perceived responsibility due to a known, unequivocal, noncontingent outcome. However, it is unclear how these therapies specifically address the core elements of loss and moral injury among service members. The understanding of these treatment differences into PTSD is still in early development and there is ongoing need to improve and evaluate models of PTSD and look further at ways of improving the effectiveness of treatment approaches.

If you believe you are experiencing symptoms of moral injury, PTSD or other mental health issues, remember that a Mates4Mates psychologist can help. 

If any content in this article resonates with you and you’d like to speak with someone at Mates4Mates about seeking support, contact us to find out more about our services.

All Mates4Mates services are available for current and ex-serving Australian Defence Force members with physical injuries or mental health issues, and their families.