Moral injury can happen when we experience something that violates their moral and ethical code. It involves a strong emotional and cognitive response of distressing feelings and thoughts. Moral injury has a profound and lasting impact on a person’s sense of self, well-being, and daily life.
We might experience moral injury when our own actions (or inactions) break our moral code or when we feel betrayed by the actions of another person. It causes a deep sense of broken trust in ourselves, our communities or our institutions to act in just ways. We may feel intense emotions of guilt, shame, and regret.
What Causes Moral Injury?
Moral injury can happen in many different contexts. It’s been most studied in occupations where people are exposed to distressing and high-stakes events, such as in health work, emergency services, or journalism. For example, many health workers experienced moral injury during the COVID-19 pandemic because they felt that the lack of adequate equipment and resources prevented them from providing effective healthcare. For journalists covering the 2015 migration crisis, moral injury was also a key source of distress.
Moral injury can also happen in close and intimate relationships. Women in abusive relationships often experience moral injury, coerced into acting in ways that violate their deeply held moral or spiritual values. Families may experience moral injury after witnessing the harmful actions of one family member, including deceptive sexual behaviours and manipulation.
How Is Moral Injury Different from PTSD?
Post-traumatic stress disorder develops when the body’s usual coping mechanisms, stress response systems and emotional processes are overwhelmed by fear. Traumatic memories are fragmented and incompletely stored, and the nervous system remains in a state of high alert even when the threat has subsided. Reminders of the traumatic event can trigger the nervous system to reexperience the emotional and visual aspects of a traumatic event in flashbacks and nightmares.
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, post-traumatic stress disorder symptoms fit into four categories:
- Re-experiencing symptoms, including flashbacks, intrusive distressing thoughts, and nightmares
- Avoidance symptoms, such as avoiding triggers, numbing emotions, and dissociation
- Cognition and mood symptoms, including a negative self-concept and the inability to find pleasure in previously enjoyed activities
- Hyperarousal, including hypervigilance and difficulties concentrating
PTSD is predominantly a fear-based disorder that’s closely related to our nervous system, particularly our stress response systems. Complex PTSD, a type of PTSD involving ongoing and sustained traumas that are usually interpersonal in nature, includes additional symptoms, including emotional dysregulation, feelings of worthlessness, and mistrust of other people.
Moral injury, on the other hand, arises from a moral conflict that deeply impacts a person’s self-concept. Some of the symptoms of moral injury include:
- Feelings of guilt and shame
- Feelings of anger and betrayal, towards oneself or others
- Social withdrawal
- Feelings of worthlessness or a ‘damaged self’
- Loss of sense of purpose or meaning
- Self-harm and suicidality
Moral injury and PTSD frequently co-occur. Traumatic experiences often include elements of both fear and ethical violations, contributing to both PTSD and moral injury. For example, abusive relationships may involve both the fear of a partner’s actions and coercion into taking actions against one’s moral code. Research has consistently found a positive association between PTSD and moral injury.
What Are the Consequences of Moral Injury?
Moral injury isn’t in itself a mental health disorder. But it can contribute to the development of mental health disorders and other detrimental emotional and social consequences.
Research has found that moral injury is associated with a broad range of mental health consequences, including:
- Mental health disorders, including depression and anxiety
- Suicidal ideation and suicide attempts
- Pain, burnout, and sleep disturbances
- Strong negative emotions, including shame, guilt, and outrage
What Are the Protective Factors Against Moral Injury?
Not all instances of moral violations lead to moral injury. Many people experience potentially morally injurious events but don’t go on to develop the symptoms of moral injury. This is similar to PTSD, where experiencing a traumatic event doesn’t always lead to the onset of post-traumatic stress disorder.
Different factors may come into play in shaping the aftermath of a moral violation. Someone who places more of their self-value and identity in their morality and principles may be more likely to develop moral injury than a person who affords them less priority. Other factors may protect against the development of moral injury, including:
- Self-esteem
- Strong social support systems
- Self-compassion and forgiveness
- Education
Risk factors for developing moral injury may include:
- A tendency to experience negative emotions, such as anxiety, low mood, or hopelessness
- Black and white thinking regarding morality
- Shame-proneness
Moral Injury and Betrayal Trauma
Betrayal trauma is a form of trauma that occurs when a person or institution that we depend on for emotional or physical security breaks our trust. We might experience betrayal trauma if our partner engages in deceptive sexual behaviours or a family member tries to harm us, emotionally or physically. We might also experience betrayal trauma if an institution we believe supports or protects us causes us harm.
Betrayal trauma often occurs as a result of childhood abuse or interpersonal violence.
Betrayal traumas and other interpersonal traumas have a particularly damaging impact on our mental health. The relationship between the perpetrator and survivor of a traumatic event affects the severity of trauma symptoms. When the trauma is caused by a person or institution that the survivor trusts or depends on for survival, they tend to experience more severe psychological outcomes.
Betrayal trauma frequently leads to moral injury. Sometimes, the moral injury stems from witnessing the moral violation of a trusted person, such as a partner or a parent. In other cases, survivors of betrayal trauma also experience a moral injury from failing to prevent these harmful actions and feeling complicit as events unfold. They may also be manipulated by the perpetrator into blaming themselves for events.
Survivors of betrayal traumas are more likely than other trauma survivors to blame themselves for the traumatic event and its consequences, making moral injury more likely.
Betrayal Trauma, Moral Injury and PTSD: the Role of Shame
Shame is a distressing emotion rooted in a negative evaluation of ourselves as inadequate or flawed. It’s independently linked to betrayal trauma, moral injury, and PTSD. Shame can function as a coping mechanism in instances of betrayal that enable survivors to maintain their relationship with the person who broke their trust by blaming themselves for the things that happened rather than holding the other person responsible. This can constitute and intensify moral injury.
How Can Moral Injury Impact Family Systems?
Moral injury is common among family members who have experienced family trauma, especially betrayal trauma. It may occur after a sequence of deceptive sexual behaviours and the web of deception that rocks the family system. It may be experienced by partners and children, as the people they depend on emotionally or existentially act in ways that violate their principles.
When a family member, or multiple family members, experience moral injury, the impact is felt throughout the family system. Overwhelming feelings of anger and shame in parents affect parent-child relationships, often preventing them from meeting their children’s emotional needs. This can contribute to insecure attachment relationships where young people are unable to learn and develop effective emotional and social skills.
Individuals who experience moral injury often report family breakdown and a tense, volatile home environment that develops from maladaptive coping mechanisms, such as social withdrawal or destructive behaviours.
A growing body of literature suggests that moral injury may also be transmitted between family members, moving from parents to children. Because they both identify with and emulate their parents, children exposed to their parents’ feelings of guilt, shame, or hopelessness may take on these emotions themselves.
How Can Families Recover from Moral Injury?
When family systems have been shaped by moral injury, recovery needs to take place at both an individual and a structural level. This means supporting family members with individual therapeutic approaches, as well as family therapies and interventions.
Parents and adolescents who have experienced moral injury may benefit from a range of therapies. These therapies tend to focus on addressing feelings of guilt, shame, and betrayal, rather than simply the processing of traumatic memories (which is central to the treatment of PTSD). However, PTSD treatments may also be helpful. Some treatment approaches include:
- Acceptance and commitment therapy, a compassion-focused therapy that incorporates mindfulness techniques
- Adaptive disclosure therapy, a novel therapy especially designed for moral injury
- Cognitive-processing therapy, a form of CBT that helps process traumatic memories
- Spirituality-based therapies, which strengthen spirituality as a coping resource against feelings of shame or guilt
Some interventions have also been developed for children whose parents may have experienced moral injury, to support and strengthen parent-child relationships and child well-being. For example, therapeutic storybooks can help children understand a parent’s experience in an age-appropriate way, and explore why certain things have happened in their family. This can help maintain parent-child connections and prevent the transmission of feelings such as guilt and shame from parents to children.
Aside from individual therapies and interventions, families impacted by moral injury often require support in restructuring dynamics and rebuilding relationships. Family trauma and consequent moral injury and PTSD can rock the family system, impacting boundaries and family roles. Family therapy and other interventions can help families find new ways of relating, develop parenting skills, and create safe and nurturing environments for young people.
The Wave Clinic: Specialist Mental Health Support for Young People and Families
At the Wave Clinic, we offer specialist mental health support for families who have experienced family trauma. We offer parenting and family intensives that combine the lessons of months of outpatient therapy into a few days or weeks. Our programs include two or three-week intensives focusing on deceptive sexual behaviours and infidelity, and three to five-day intensives to help bring parents of young people with mental health concerns back into their parenting role.
Our family interventions combine exceptional therapeutic approaches with enriching experiences, supporting families to rescript dynamics by creating new memories together.
Fiona Yassin is DSTT (Deceptive Sexuality and Trauma Treatment) trained by Dr Minwalla, applying the most specialised, up-to-date medical theory and practice to every family’s program.
If you’re interested in learning more about our programs, get in touch today.
