Moral Injury | Carepatron

What is moral injury?

Moral injury describes the lasting psychological, social, and spiritual impact of events that challenge a person's deeply held moral beliefs and values. It's a complex issue that can affect anyone who experiences situations that violate their sense of right and wrong, particularly in high-stakes scenarios (Shay, 2014).

Moral injury can arise from various potentially morally injurious experiences (PMIEs), such as participating in or witnessing acts of violence, abuse, or atrocities, being betrayed by legitimate authority figures, or failing to prevent harm due to inaction (Jinkerson, 2016). Yet, it is not just a military phenomenon; healthcare workers, law enforcement officers, and anyone who faces ethical dilemmas in high-stakes situations can experience moral injury.

Examples of potentially morally injurious events

Moral injury can occur when someone experiences moral injury (directly commits an act), witnesses morally injurious events (observes another's transgression), or fails to prevent morally injurious events (when inaction feels wrong). These events can be single, impactful, or smaller transgressions that accumulate over time.

1. Military context

Military personnel may experience moral injury due to situations that violate their moral beliefs or ethical code. These include participating in or witnessing acts of violence against civilians, including killing or harming non-combatants. Engaging in or observing actions that harm innocent civilians can be deeply distressing and morally dangerous.

Being unable to prevent the death or serious injury of a fellow service member or civilian. Failing to protect lives, particularly those under one's care or responsibility, can lead to moral injury, especially among military veterans.

Furthermore, witnessing or being involved in acts that violate the rules of engagement or laws of armed conflict. Participating in or observing actions disregarding established regulations and laws of warfare can be morally injurious.

2. Healthcare settings

Healthcare workers may also experience moral injury due to situations challenging their ethical principles or commitment to quality care.  This type of occupational moral injury includes providing inadequate or substandard care due to resource constraints or systemic issues. Being forced to provide suboptimal care due to factors beyond one's control can be morally injurious.

Failing to provide adequate relief or comfort to patients due to restrictive policies can violate caregivers' moral principles.

This can also involve making decisions about allocating scarce resources (e.g., during a pandemic) that conflict with one's moral values. Rationing limited resources in a way that contradicts one's moral beliefs can lead to moral injury.

3. High-stakes situations

Moral injury can also occur in other high-stakes situations where individuals face ethical or moral challenges. This can happen when law enforcement officers use excessive force or witness brutality. Using excessive or unjustified force or observing such acts can be morally injurious for law enforcement personnel.

This can also be evident among first responders who cannot save lives due to circumstances beyond their control. Failing to rescue or save lives despite one's best efforts can be morally injurious for first responders.

Moral injury also happens when aid workers are being prevented from providing humanitarian assistance, especially to refugees and migrants, due to political or security concerns. Being unable to provide aid or relief due to external factors can violate aid workers' moral principles.

Is moral injury the same as post-traumatic stress disorder?

Unlike physical injuries, which leave visible marks, moral injuries inflict deep psychological wounds, challenging one's sense of right and wrong and causing profound emotional distress. Moral injury and post-traumatic stress disorder (PTSD) are both severe mental health conditions that can arise from exposure to traumatic events. However, they are distinct experiences with some key differences.

PTSD, captured in the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association (2013), results from witnessing or experiencing traumatic events, leading to symptoms like flashbacks, avoidance behaviors, and hyperarousal.

While moral injury and PTSD can co-occur, they are distinct constructs with different underlying mechanisms and symptom presentations. Individuals with moral injury may experience profound feelings of guilt, shame, anger, and self-condemnation, which are not necessarily present in PTSD and related mental health outcomes (Griffin et al., 2019).

It's important to note that moral injury is not currently recognized among mental health diagnoses in the DSM. However, researchers and clinicians have advocated for its recognition as a unique condition, given its distinct etiology, manifestations, and potential implications for treatment (Pai & Vella, 2023).

Moral injury vs. moral distress

Moral injury is the psychological distress resulting from actions, or the lack thereof, violating one's moral or ethical code. Unlike physical injuries, which harm the body, people who suffer moral injury are affected by clashing their reality with deeply held moral beliefs.

Moral distress, on the other hand, refers to the disruption and negative feelings experienced when individuals cannot act according to their moral beliefs or values. This can be due to external constraints or institutional barriers. This is often associated with healthcare settings, where healthcare professionals may feel powerless to provide the care they believe is ethically appropriate due to limited resources, organizational policies, or hierarchical structures.

In a nutshell, moral injury focuses on violating core moral beliefs, while moral distress emphasizes the inability to act ethically due to external limitations. Moral injury can be more enduring and debilitating, whereas moral distress may be more situational and resolved once the ethical conflict is addressed.

What is a moral injury events scale?

The Moral Injury Events Scale (MIES) is a self-report measure designed to assess potentially morally injurious experiences (PMIEs) in military populations (Bryan et al., 2016). It is one of the few validated instruments specifically developed to measure exposure to events that may lead to moral injury.

The MIES consists of 9 items that describe different types of PMIEs, such as acts of betrayal, incidents involving harm to civilians, and experiences of disproportionate violence. Participants rate the frequency and perceived degree of violation associated with each event on a 6-point scale (Bryan et al., 2016).

Other treatments used in addressing Moral Injury

While cognitive processing therapy and psychotherapy are central to treating moral injury, other valuable approaches can be effective intervention strategies. These moral injury treatments can promote moral repair, rebuilding a sense of meaning, purpose, and connection after a moral violation.

Moral injury group therapy

Connecting with others who have experienced similar moral challenges and moral emotions can provide validation, reduce feelings of isolation, and foster a sense of shared purpose.

Adaptive disclosure

Encouraging individuals to share their experiences in a safe and supportive environment can be a powerful tool for processing moral injury. This can be done with a therapist, trusted friend, religious leader, or even through creative outlets like writing or art.

Spiritual support

For some individuals, religious faith or spiritual practices can provide a framework for finding meaning and forgiveness after a moral transgression. Encouraging exploration of spiritual beliefs, if relevant, can be a valuable complementary approach.

Meaning-making activities

Engaging in activities that contribute to a greater good or connect with one's values can help rebuild a sense of purpose and moral agency. This could involve volunteering, creative pursuits, or advocacy efforts.

Benefits of treating moral health injury

Moral injury condition is increasingly recognized within the healthcare discourse, particularly among those caring for military personnel, war veterans, and health care workers themselves. The benefits of effectively addressing moral injury are deep for the individuals directly experiencing it and the broader healthcare system and society. Here are some reasons why it's essential to treat moral injury:

• Reduced symptoms of mental illness: Moral injury often co-occurs with conditions like depression, anxiety, and PTSD. Treatment can significantly reduce psychological consequences such as PTSD symptoms, improving a person's overall quality of life.
• Enhanced moral functioning: Addressing moral injury can help individuals rebuild their capacity to deal with morally distressing situations and restore a sense of meaning and purpose. This can lead to healthier relationships, increased self-worth, and a stronger sense of moral agency.
• Improved social connectedness: Moral injury can lead to psychological trauma, isolation, and withdrawal. Treatment can help individuals reconnect with loved ones and build a supportive social network, fostering a sense of belonging and reducing loneliness.

Address moral injury symptoms with Carepatron as your mental health software

Addressing moral injury symptoms in healthcare settings requires an integrative approach that combines clinical insight with advanced technological solutions. Carepatron's mental health software offers a comprehensive platform that empowers healthcare professionals to effectively monitor, document, and manage the symptoms of moral injury among patients.

Our streamlined clinical documentation software capabilities extend beyond clinical notes. The platform supports a broad array of documentation, including assessments and therapy plans, making it easier to track patient progress over time.

Treating moral injury is an investment in the well-being of individuals, families, and communities. Make this process more efficient by choosing Carepatron as your partner. Cut down the administrative burden so you can focus on delivering care.

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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Pearson.

Bryan, C. J., Bryan, A. O., Anestis, M. D., Anestis, J. C., Green, B. A., Etienne, N., Morrow, C. E., & Ray-Sannerud, B. (2016). Measuring moral injury: Psychometric properties of the moral injury events scale in two military samples. Assessment, 23(5), 557–570. https://doi.org/10.1177/1073191115590855

Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz, M., Villierme, C., Walsh, J., & Maguen, S. (2019). Moral injury: An integrative review. Journal of Traumatic Stress, 32(3), 350–362. https://doi.org/10.1002/jts.22362

Jinkerson, J. D. (2016). Defining and assessing moral injury: A syndrome perspective. Traumatology, 22(2), 122–130. https://doi.org/10.1037/trm0000069

Pai, N. B., & Vella, S.-L. C. (2023). Moral injury: A contemporary perspective. Journal of Psychiatry Spectrum, 2(1), 22. https://doi.org/10.4103/jopsys.jopsys_53_22

Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182–191. https://doi.org/10.1037/a0036090