Moral Injury and the Agony and Power of Love

The definition of moral injury is still being debated more than three decades after Johnathan Shay first coined the phrase. Moral injury is commonly understood as a violation of a person’s core moral foundations in high-stakes situations that recasts how they see themselves, others, and the world. Such violations could result from a person’s own actions, things they witnessed (including betrayal) or were made to do against their will, or things they couldn’t prevent.

Some consider moral injury a dimension of posttraumatic stress disorder (PTSD) because the principal symptoms (i.e., shame, guilt, anger) are already embedded in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)’s category for PTSD; likewise, because the DSM-5 no longer considers PTSD a fear-based anxiety disorder and because it offers a new category, “Trauma and Stressor-Related Disorders,” that correlates with broader moral injury symptomology. Others consider moral injury a standalone condition that belongs alongside PTSD in the DSM-5. Conversely, a growing number of voices see moral injury as simply an internal ethical or existential experience or a universal human struggle that should stay clear of any mental health classification.

Regardless of where one comes down on the definition and categorization of moral injury, what has become increasingly clear is that at its heart, moral injury is relational. Whereas PTSD is situated around physical threats or bodily safety, moral injury is about trust — specifically, the loss of safe connection with self, society, and/or the world. The clash between a person’s conscience and overwhelming “edge” experiences, which uniquely defines moral injury, alienates them from life-sustaining relationships.

Take, for example, a warfighter who makes the excruciating decision to shoot a young child who is wrapped with explosives, ready to detonate, and then later returns home and is repulsed by looking at their own child because it’s a reminder of that act of transgression. Or a medical examiner for a mass shooting who becomes so haunted by the images of the victims that they can no longer form close relationships, feeling divided between and isolated from a world they thought existed but realized didn’t and could never. Or the doctor who was forced to “play God,” deciding who lived and died, during the COVID-19 frontline when there weren’t enough ventilators for the surge of patients. One such doctor told me, “It’s as if part of my soul had been shredded with a knife, the part that holds me in relation to my Hippocratic oath and personal values. I don’t know who I am any more … just a monster in scrubs.”

The Importance of Connection and Love

Connection is a biological imperative and vital to survival; through connection human beings create a shared sense of safety. Isolation or aloneness, or even the perception of social separateness, that often develops with moral injury, can negatively impact psychospiritual, emotional, and physical well-being.

Moral values are a way of establishing normative boundaries to protect our social identities and our existential selves. When moral values are transgressed, distancing ourselves from others who would “break the rules” and potentially put us in danger, can instinctively serve as a form of self-protection. Similarly, self-isolating, that is pulling away from others when our actions “break the rules,” can also be a form of protection — our way of keeping those we love and are connected to from possible harm.

Moral values and the identities that sustain our relationships are the most important aspects of our lives; they constitute what is most sacred in us. Our sense that we are worth something and beloved by others lies at the core of our relationships to them and the world. The violation of that worth — whether by our own actions or the actions of others — is an act of desecration. Healing hearts requires a holistic process of reconnection to self-worth and life-sustaining relationships.

Conscience is the indestructible core of our personal identity and our sense of agency in the world. When it passes judgment against us or others, it generates inner conflict (i.e., moral injury). Its emotions are so powerful and destructive that facing them is akin to sitting in a consuming fire that threatens our very existence. Only when we can feel, acknowledge, and share our emotional pain with others by sitting in that fire, can we burn clean and rise from the ashes to find new meaning in life, like the fabled ancient Phoenix that emerges from its own ashes renewed. With moral injury, renewal means integrating our devastating experiences as sources of wisdom and guidance that enable us to maintain our relationships with ourselves, families, and communities — with the whole world, really.

No one can rise from the ashes to build a new moral identity without relationships, without love. Therein lies a paradox about those suffering from moral injury. Many with moral injury may not share their experiences with their families and friends out of concern that they may contaminate them with their own terrible memories. They may fear they will be judged and rejected. They may also worry their anger will overtake them.

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Such hesitations are not unwarranted. Stories of moral injury can be excruciating or disturbing to hear, and any sign of repulsion or judgment from a friend or loved one risks derailing the healing process. Many people will not even tell a therapist about their moral injury for fear of being diagnosed, evaluated, or condemned. Similarly, families may withhold their own feelings of moral injury out of concern of making things worse for their loved one.

Reconciling difficult truths, honoring pain, transforming ways of thinking and being, and restoring moral integrity require, in part, trustworthy people who can listen to moral suffering empathetically even when words may be lacking, and hearts are crushed. Trustworthy listeners enable the telling and retelling of moral injury experiences. For instance, peer specialist programs that train veterans to support other veterans can be especially effective as the first step toward healing; fortunately, such programs are growing. Military families are also using parallel peer specialist programs to help them negotiate their own suffering, which yet are far too few. Other populations (e.g., healthcare workers, social workers, clergy, law enforcement, victims of abuse) with moral injury are also developing such programs.

As moral injury is processed, it can be integrated into life stories that put moral injury into larger narratives of relationships. As the stories are told and evolve, sharing them becomes easier without retraumatizing suffers or traumatizing listeners. The sharing can then deepen bonds of love and open possibilities for a future worth living into together. This integrative relational process provides resources of resilience for everyone who has been burned by moral injury so they can move forward in life strengthened and renewed and better equipped for the challenges of life that are inevitable.

(Parts of this post were originally shared in a previously published article co-authored by Michele DeMarco, author of Soul Console Blog, and Rita Brock, Senior Vice President and Director of the Shay Moral Injury Center at Volunteers of America and co-author of Soul Repair: Recovering from Moral Injury After War (Beacon, 2012)

About

Dr. DeMarco is an award-winning writer, and a therapist, clinical ethicist, and trauma researcher specializing in moral injury and moral distress. She is the author of the Psychology Today blog “Soul Console: Healing from Moral Injury” and one of Medium’s Top Writers for Mental Health and Health, respectively. Her writing has appeared in national and international publications, including the New York Times, POLITICO, The Boston Globe, Psychology Today, and The War Horse, among others. She’s also been featured as a trauma, health, and spirituality expert for MindBodyGreen, Integrative Practitioner, Lifehacker, Bloomberg/WNBP Radio, Partners HealthCare, and the American Heart Association. Her new book Holding Onto Air: the Art and Science of Building a Resilient Spirit is now available.