Moral injury is the suffering caused by acting in ways that violate our strongly held beliefs about right or wrong. It often involves perpetrating acts of violence or a feeling that we’ve failed to prevent wrongdoing by others. It may also include feeling betrayed by authority figures in whom we had placed our trust or even our lives. Moral injury frequently involves feelings of guilt, shame, loss of trust, and existential or spiritual distress such as doubt or loss of faith. It overlaps with PTSD but is largely distinct from it (Koenig & Zaben, 2021).
Moral Injury During the Pandemic
Although first developed to describe the moral and spiritual pain experienced by war veterans, there are many other potential situations that could be morally injurious. During the pandemic, health care workers have had to make high-stakes, life-or-death decisions about who receives certain kinds of treatment.
Many other workers have not had the authority to make such decisions but had to be the ones to carry them out, to inform patients and their families, to deal with the fallout, even when the decision is not one they would have made themselves. Sometimes the requirement to follow instructions from the patient themselves or their families, e.g., following a do-not-resuscitate order (or not), can go against a health care worker’s moral compass.
People may also blame themselves for the deaths of their patients or feel bad for having not fought harder to prevent bad outcomes that they had anticipated – or believe they should have. Even outside of health care, many of us have faced difficult moral dilemmas in our personal lives as we have tried to mitigate risk to keep ourselves and our families safe.
Exposure to such experiences does not guarantee moral injury, and many individuals will be able to capably navigate such challenges and emerge with their prior well-being intact. Several interventions have been developed for those who need help in their healing process. Koenig and Zaben (2021) wrote a recent review article describing many of these and breaking them down into three broad categories of treatment: secular psychological treatment, spiritually integrated therapies, and pastoral care.
Psychological Treatment
Psychological treatments help individuals process their morally injurious experiences both mentally and emotionally. Problematic, emotionally charged assumptions (e.g., “I should have known better”) are explored to help the person develop a more adaptive point-of-view and make peace with their perceived moral transgressions (i.e., in adaptive disclosure therapy). Individuals may also be encouraged to explore their values and cultivate mindfulness and psychological flexibility (i.e., in acceptance and commitment therapy) or revisit memories of traumatic events to process them more fully (i.e., in eye movement desensitization and reprocessing prolonged exposure, or cognitive processing therapy). Another intervention focuses on developing forgiveness and integrating family supports (i.e., healing through forgiveness). These interventions can be consonant with a wide variety of spiritual beliefs, but their focus is primarily on psychological processes.
Spiritual Treatment
Spiritual treatments of moral injury are rooted in the idea that an individual’s experience of moral transgression will be based largely on their religious, spiritual, or existential worldview. Treatments may help build individual spiritual strengths (i.e., in building spiritual strengths) and can even be integrated with more traditional psychological interventions (i.e., in spiritually-integrated cognitive processing therapy or religiously integrated cognitive behavioral therapy).
Pastoral Care
Pastoral care can be beneficial given the spiritual dimension of moral injury, and chaplains are often well-positioned to offer help. Chaplains or other faith leaders may offer a ritual penance to aid in self-forgiveness and spiritual healing (i.e., pastoral narrative disclosure). Other treatments integrate confession, grief work, and spiritual training (i.e., in moral injury reconciliation therapy), integrate relevant scriptures (i.e., in structured pastoral care), and even integrate the idea of community responsibility and community healing (i.e., in moral injury group intervention).
Many of the interventions described here are still quite new and not widely available. Nonetheless, given the high number of moral dilemmas and potential moral injury present during the pandemic, it is hopeful that so many potential directions for healing are being explored. Particularly given the diversity of spiritual beliefs and preferred healing methods, it is good to see methods being developed across multiple disciplines.
Taken together, these treatments summarized by Koenig and Zaben (2021) also offer a comprehensive view of what healing from moral injury might look like and provide hope that healing is possible.
References
Griffin BJ, Purcell N, Burkman K, Litz BT, Bryan CJ, Schmitz M, Villierme C, Walsh J, Maguen S. Moral Injury: An Integrative Review. J Trauma Stress. 2019 Jun;32(3):350-362. doi: 10.1002/jts.22362. Epub 2019 Jan 28. PMID: 30688367.
Koenig HG, Al Zaben F. Moral Injury: An Increasingly Recognized and Widespread Syndrome. J Relig Health. 2021 Oct;60(5):2989-3011. doi: 10.1007/s10943-021-01328-0. Epub 2021 Jul 10. PMID: 34245433; PMCID: PMC8270769.
Note: This article first appeared in February 2022 on Psychology Today.
Katherine King, PsyD is an assistant professor of psychology at William James College, and founding director of The Well Helper.