There are no predictable causes, but there are risk factors for moral injury. They include: high stakes situations, such as life or death; pressures to act quickly without time to think; no clear right and wrong choices; failure to prevent serious harm; and conditions in which doing the right thing is impossible and doing nothing feels terrible. A person can experience moral injury from witnessing it happen, hearing about it, or surviving when others did not. People may do things to survive life threatening conditions that violate their conscience. Moral injury also can involve betrayal by people with power who fail to do the right thing.

Painful emotions such as guilt, remorse, shame, outrage, disgust and despair are common with moral injury. However, because these feelings come from moral judgments, a person might be able to push them aside to avoid the pain of facing them. A person experiencing moral injury may not be as emotionally available to others as they were and seem distant or different. Their relationships may be disrupted because they fear others will judge them, and they self-isolate. Or they may no longer trust others or themselves and become cynical. They may mask their inner pain with alcohol or drugs or become emotionally numb. They can become alienated from societal norms and lash out in anger at the slightest provocation. They may lose their moral foundations or faith, leave careers they once loved or have suicidal ideation.

Post-traumatic stress disorder is fear-based and involves the lingering impact of feelings of terror after the traumatic event has passed. Moral injury is based in judgments of conscience and emerges in the aftermath of traumatic events, when a person has time to evaluate the experience. PTSD has a diagnostic profile and research-based treatment protocols. Moral injury does not, but addressing moral injury during therapy for PTSD can improve treatment outcomes because people may concurrently experience PTSD and moral injury.

“Treatment” is associated with a clinical condition, but moral injury is not a mental health disorder. Moral injury is a normal response of profound suffering to devastating and harmful life conditions or systems. It affects the whole person: body, mind, psyche and spirit.

With something as complex as moral injury, there are many ways it can be processed. Recovery begins with accepting what happened and processing the painful moral emotions involved, such as shame, guilt, outrage, sorrow, disgust and despair. It may also include outrage and a commitment to changing harmful systems to prevent future harm.

Veteran’s Affairs clinicians have been suggesting two processes clinicians can integrate into mental health therapy to address moral injury: “adaptive disclosure” and “the impact of killing.” These may also be helpful to people in therapy who are not veterans, but whose work or life conditions involve high stakes and killing.

At VOA, we have focused our research and strategies for recovery on peer support, the use of rituals and chaplaincy services.

Moral injury applies to everyone. Under duress, people can violate their moral foundations in many situations. For example, the COVID pandemic has caused or aggravated such conditions for first responders, healthcare workers, chaplains, parents, teachers and frontline workers.

If their behavior changes, and they become emotionally distant, preoccupied, controlling, easily angered, cynical, not able to be present and not their usual selves, it may mean they are experiencing inner emotional pain. They may be unaware of why they feel terrible, or they may be reluctant to share what bothers them, especially if they believe you will think less of them or will be disturbed by what you hear.

If they seem open to talking, ask them if they’ve heard of moral injury. When people are introduced to the term, they may find it helps focus what they are feeling. If they share with you more deeply, listen with an open heart and quiet mind, with empathy that validates the truth of what they feel, and without judgment, horror, reassurance, or a need to fix. If you are not the person they want to talk to, make sure they have someone else to talk to. 

VOA offers peer-facilitated, confidential, hour-long small-groups online, where people can unburden themselves of feelings of moral distress: VOA ReST, ReST 4 Vets and ReST 4 FirstResponders. We also offer organizations in-person, peer-facilitated programs via our Recovering Resilience After the Pandemic (RRAP) service and online courses that teach peer-support strategies.