The Moral Injury Comeback

8 min readJul 30, 2021

A 300- pound medic straddled a pygmy woman in a Southeast Asia hospital during Vietnam. It was the early morning, and I (an Air Force medic) and the larger medic were transporting the pygmy woman on her gurney to x-ray. When the elevator got stuck, he swiftly jumped on top of her. Why was he straddling her body, pounding his fists into her? I heard a low “buzz” and experienced the sense that the room was spinning. “Stop! I yelled. But I couldn’t make my voice loud. I couldn’t make myself move to push him off. “I’m going to report you!”

The patient died, I reported him, and nothing was done. For much of my adult life, two questions took me hostage each time I remembered what happened: “Why didn’t I protect her?” “Why didn’t the Air Force hold him accountable?”

This story, however, is not about the war — but about all those times when we find ourselves in high stakes situations that violate our moral values. The injury that we experience when our ethics or moral values are severely violated is called a moral injury. Our understanding regarding the nature of moral injury, like much of our understanding about mental health has blossomed out of challenging experiences of soldiers and the doctors who treated them.

Examples of Moral Injury

You can experience a moral injury as a result of something you did or another person did either intentionally or unintentionally. The victims of moral injuries that have received the most attention include soldiers, healthcare workers (during the pandemic), and parents (and other caregivers). Moral injuries are very penetrating and impactful, and we all experience them as part of life. Some of these examples may feel familiar:

You experienced abuse or neglect or other adverse experiences as a child that you have not been able to heal.
You were involved in an acrimonious child custody battle and lost.
You are aware your child saw you involved in domestic violence.
You regret that as a parent, you had a mental health or substance abuse problem.
A crime was perpetrated against you or someone you love.
You acquire a better understanding of how you have hurt others.
Your family income is inadequate or you can’t afford the lifestyle you want for your child.
You had an accident that injured your child or someone else.

Moral injuries leave adverse effects on our lives, and those effects are symptoms. The symptoms may be severe enough to affect your social, cognitive, emotional, or physical well-being in life, and may even present as Post Traumatic Stress Disorder.

The Reservoir of Emotional Pain

The pit created by the moral injury, however, can become a deep reservoir of pain. Our moral foundation — the mental scaffolding that sustains our personal and social identities, can be shredded. Moral injury tears us apart at our moral foundation, robbing us of some of the resources that have helped us feel safe in the past

A sense of being a good and worthy person
The integrity of our spiritual beliefs
Our epistemic trust, or willingness to trust the learning acquired from mentors, leaders, or attachment figures

The fragmented self can become like kindling wood, laid bare and vulnerable to the flames of recurring events challenging our sense of self and community. Holding the pain inside and suffering in silence does not resolve the grief and pain of moral injury.

Moral injury can can make us feel unworthy, wounded, fragmented. Dombo, Gray and Early, authors in a professional journal about sociology, remind us that we are more than our moral injury.

Moral injury can cause deep pain and suffering; it is experienced by those who have strong ethical values and a capacity for empathy. This capacity is a strength, an example of character and resilience within the individual and should be treated as such.

The Path to Overcoming Moral Injury

I began this essay with a description of a moral injury that shaped the course of my life. I am also a therapist and I teach counseling to graduate students. My 68 years of life and my 35 years of clinical experience makes me optimistic that I might share ideas you can use to fully recover from moral injury. I recommend a three-pronged approach, and encourage you to take all three steps.

Seek out sensitive, response others with whom to share your experience.
Learn skills from therapy that will give you control over your emotional pain.
Mentally reorganize your trauma into a meaningful story of your life.

Seeking out others as a safe haven hails back to instinctual behavior that kept us safe during infancy. Even animal babies seek out their caregiver when feeling threatened. As we continue to develop in childhood and into adulthood, we are programmed to seek out friends and more experienced others for advice and protection. At some point, most of us will feel a desire to unite with a partner or spouse who we can rely on to be there for us on a more permanent basis.

If we are convinced that we are bad or worthless, we may be tempted to settle for anyone who happens to be available from whom to seek advice and protection. By so doing, we might enter a situation where we continue to get hurt. Please seek out persons who are sensitive and responsive — persons who have acknowledge your worth and promote your growth and development.

Learning skills in therapy is an option that, at first pass, triggers the part of you that already feels inadequate. Some cultures inculcate the type of “do it yourself” approach to life that may not promote an attitude of willingness to receive help, and you may not be able to get past your culture meme. The advantage of therapy is that people usually see substantial progress after relatively short course. Further, the skills you learn in therapy can put you back behind the steering wheel of life, so that you have effective tools that will decrease or eliminate the emotional pain when it intrudes into your life.

Most therapists would agree that it is not the type of therapy that you receive, but the relationship you have with your therapist. If you experienced moral injury perpetrated by others, you must have the trust in your therapist that you lost. If you experience shame, guilt, or regret about your role in the moral injury, you must find a therapist who is noncritical and who can inspire you with confidence. Additionally, you should consider whether you would best respond individual therapy, group therapy, or both. Your therapist might help you figure this out.

Reorganizing your moral injury into a meaningful narrative that helps you clearly articulate what happened to you and how it benefit your life. We create meaning in life through the stories we tell ourselves and others. Reorganizing a story about trauma we have experienced is accomplished by integrating significant trauma events in chronological order. Links are established between the events that help us reconcile and accept the realities of ourselves, others, and the world. Elements of the storytelling that can help us achieve this integration involve crafting our links to meet these criteria:

The links support a theme
The events that occurred are linked to your thoughts and your emotions
The story describes how your viewpoint changed over time

The Reservoir of Acceptance

Like others experiencing moral injuries in war, my impaired sense of self and the integrity of my spiritual beliefs cleared the path for other moral injuries. I never expected another episode or flareup of the injury — but they were ignited at a deeper level than my awareness. As life went on, and I encountered several morally injurious events that became part of that deep reservoir of pain.

Over time, I realized that in order to do better than merely manage the emotional pain, I must lose my fear of encountering the triggers. My avoidance of triggers was costing me too much: One strategy, described as moral disengagement, was to cut my brothers out of my life. I was associating my brothers with the time I found another brother dead from a heroin accident. Gosling, Grunhaus & Guttierez, authors in a professional journal about mental health, describe how strategies such as moral disengagement signal us that we need to continue our efforts in resolving our injury.

A partial resolution to moral injury is not a feasible long-term possibility for the vast majority of adults. The severity of a moral injury . . . warrants an entire overhaul of one’s sense of self or the world…no half measures will suffice. As long as a person remains engaged in the process of resolution, however, the prognosis should remain optimistic that they will overcome and integrate their experiences.

The target in healing is to completely overhaul one’s fragmented sense of self, other, and the world. There are many words to describe what happens to the fragmented self through this journey, but I recognized the feeling of the healing as acceptance. The struggle to resolve moral injury can lead to the strength of accepting the dichotomies of life: right vs wrong, fairness vs injustice, victories vs defeats, and strength vs vulnerability.

Moral injury, like bereavement, must be integrated into meaningful understanding of how our losses were related to our life journey. Erik Erikson, an iconic psychoanalyst, taught how our journey through the challenges of life can resolve in a stage of life called Integrity. This stage occurs if we are able to integrate all the pieces of inconsistencies and unfinished business in life. When I learned to accept and value the vulnerabilities and pain as much as I accepted and valued the joy in life, I felt the fragmented pieces of my self come together and integrate. The reservoir of pain became a reservoir of joy. Drawing from the reservoir of joy allowed me to replace the anger and fear with feelings of peace and comfort and mastery.

The Take Away of the Resolution Process

Describing my journey to resolve moral injury allowed me, as an author, to share wisdom accumulated as a therapist, a mother, and a human being. I want to say something to you personally, in conclusion:

Your pain and struggle with moral injury can become the learning activity in life that leads to an acceptance of the flaws and failings of real life. Please continue to prepare yourself to achieve acceptance. When you feel ready, hold your arms wide open to embrace what happened to you as having a purpose in your growth and development.

References

American Psychiatric Association. (n.d.). What is PTSD? https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd

Dombo, E. A., Gray, C., & Early, B. P. (2013). The trauma of moral injury: Beyond the battlefield. Journal of Religion & Spirituality in Social Work: Social Thought, 32(3), 197–210. https://www.tandfonline.com/doi/abs/10.1080/15426432.2013.801732?journalCode=wrsp20

Fivush, R., Booker, J. A., & Graci, M. E. (2017). Ongoing narrative meaning-making within events and across the life span. Imagination, Cognition and Personality, 37(2), 127–152.
https://journals.sagepub.com/doi/full/10.1177/0276236617733824

Gerben J. Westerhof, Ernst T. Bohlmeijer, Dan P. McAdams, The Relation of Ego Integrity and Despair to Personality Traits and Mental Health, The Journals of Gerontology: Series B, Volume 72, Issue 3, 1 May 2017, Pages 400–40. https://doi.org/10.1093/geronb/gbv062.

Gosling, D., Grunhaus, C., Guttierez, D. (2019). Toward a spectrum of moral harm: A new paradigm. Journal of Ethics in Mental Health. 10. https://jemh.ca/issues/v10/documents/JEMH%20article%20gosling.pdf

Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz, M., … & Maguen, S. (2019). Moral injury: An integrative review. Journal of Traumatic Stress, 32(3), 350–362. https://pubmed.ncbi.nlm.nih.gov/30688367/

Grinker, R. R. (2021). Nobody’s normal: How culture created the stigma of mental illness. W. W. Norton & Company. https://wwnorton.com/books/9780393531640

Jeffry, J. (2020, June 23). The trauma of moral injury: Beyond the battlefield.
https://thehumanist.com/magazine/july-august-2020/features/beyond-the-battlefield/