Moral Injury
Moral injuries are not a new phenomenon. Shay (1991) introduced combat stress described in Homer’s Iliad and a betrayal of ‘what is right’ to experiences Vietnam veterans express during treatment. According to Shay (1991), “…chronic combat PTSD usually reflects moral and philosophical injury, and ‘shattered assumptions’ about self, world, and their relation” (p. 563). A seminal paper written by Litz et al. (2009) brought the problem of moral injury and moral repair back into mainstream thought. Veterans might not talk openly about moral injuries due to feelings of shame and guilt or concerns about adverse outcomes such as being ostracized by their friends or just misunderstood (Litz et al., 2009). It was thought that mental health clinicians, when treating Vietnam veterans, believed moral boundary violations were outside of the clinician’s realm of expertise and preferred to refer the client to religious counseling; or that the focus on life-threatening traumatic experiences garnered greater attention than the moral injurious events (Litz et al., 2009).
Moral injury is an event which occurs when a person experiences an incident which does not fit within their moral viewpoint of the world or of themselves (Bryant, 2021). Moral injury may involve existential, cognitive, or spiritual struggles which impact the psychological, spiritual, and social aspects of life (Lentz et al., 2021). Posttraumatic stress disorder (PTSD) symptoms involve a fear based response and hyperarousal symptoms, whereas with moral injury involves guilt and shame (Bryant, 2021; Lentz et al., 2021; E. Murray, 2019). Individuals who experience morally injurious events often express the feelings of not being worthy of compassion and spend considerable time in bed due to poor sleep, lack of motivation, and associated depressive symptoms (Dentry et al., 2017).
Bryant, R. A. (2021). Treating PTSD in first responders: A guide for serving those who serve. American Psychological Association.
Dentry, S., Joannou, M., Bessemann, M., & Kriellars, D. (2017). Project Trauma Support: Addressing Moral Injury in First Responders. Mental Health in Family Medicine, 13, 418–422.
Lentz, L. M., Smith-MacDonald, L., Malloy, D., Carleton, R. N., & Brémault-Phillips, S. (2021). Compromised Conscience: A Scoping Review of Moral Injury Among Firefighters, Paramedics, and Police Officers. Frontiers in Psychology, 12, 639781. https://doi.org/10.3389/fpsyg.2021.639781
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. https://doi.org/10.1016/j.cpr.2009.07.003
Murray, E. (2019). Moral injury and paramedic practice. Journal of Paramedic Practice, 11(10), 424–425. https://doi.org/10.12968/jpar.2019.11.10.424
Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182–191. https://doi.org/10.1037/a0036090
