What is moral injury?

Like posttraumatic stress, moral injury (MI) is a type of stress response that follows a morally distressing situation. It feels like an injury to your moral compass.

Morally distressing situations, also known as morally injurious events, arise when you feel your morals are being violated. They make you question right and wrong and challenge your faith in the goodness of yourself, others, or the world. 

Not everyone who experiences trauma goes on to develop posttraumatic stress disorder (PTSD). Similarly, moral violations and moral pain do not always mean you will develop a moral injury.

Moral pain exists on a spectrum. On one end there are common moral challenges and resulting moral frustrations. (For example, you may experience guilt if you call in sick or feel angry when a request for time off is denied.) At the other end of the spectrum there are more severe moral violations, including morally injurious events that result in moral injury.

What’s considered a morally injurious event?

Morally injurious events can be grouped into two kinds of situations.

Perpetration

Perpetration events occur when you do something that violates your morals by:

• Commission (e.g., doing something that hurts someone else)
• Omission (e.g., not doing something that helps someone else)
• Failing to prevent a perceived immoral act (e.g., not doing something that prevents harm to someone else)

Betrayal

Betrayal events occur when your morals are violated by someone or something you trust, like a family member or close friend or a powerful institution or organization.

What are the symptoms of a moral injury?

A moral injury can result in symptoms across multiple domains of your mental well-being. You may experience:

Emotional changes

• Guilt 
• Shame
• Anger
• Hopelessness
• Anxiety

Cognitive changes

• Loss of trust in yourself or others
• Existential crises (e.g., questioning your purpose and/or the meaning of life)
• Spiritual questioning or doubts (e.g., querying your faith in a higher power)
• A difference in the ways you evaluate the integrity of yourself or others
• Feeling like the world is an unsafe or unjust place

Behavioural changes

• Social withdrawal, isolation, or disengagement
• Self-harm

Activities

Create a responsibility pie chart

Use this technique if you experience emotions like guilt, shame, or anger about who to blame for a challenging event or situation.

1. Make a list of all possible factors that contributed to the challenging situation, even if you think they are only one percent responsible.
2. Roughly estimate the percentage of responsibility you can assign to each possible factor.

3. Assign yourself the remaining percentage once you have listed all other factors.
4. Draw a pie chart with each factor claiming its appropriate size of slice.
5. Now that you see the full picture of all contributing factors, is there as much blame left for yourself as you initially thought?

Connect with gratitude

Gratitude can counteract many of the negative emotions we experience. Take five minutes each day to identify three things you feel grateful for.

Writing prompts

1. Process a difficult decision you’ve had to make. Include the internal struggle, your own feelings of responsibility, and how your decision impacted the way you feel about yourself and others.
2. Similar to the responsibility pie chart described above, write a short letter describing the challenging event or situation and all the factors that contributed to it. Pay attention to which factors were in your control and which ones were not.
3. Morally challenging situations can lead to feelings of shame, worthlessness, or a loss of trust in yourself. To challenge some of those feelings, make a list of things you like about yourself. Put simply, what about you makes you feel worthy, valued, and proud?