Moral Injury
The Current State of Understanding About Moral Injury
Moral challenges occur when either one acts in a way that conflicts with one’s deeply held values or one witnesses or is a victim of others’ moral failures. The term moral injury (MI) was first used by Jonathon Shay (1995) to describe struggles service members face when betrayed by leaders in combat. Litz et al. (2009) more recently defined MI as the long-term psychological, biological, spiritual, behavioral, or social impact of potentially morally injurious events (PMIEs), which undermine beliefs about the goodness and trustworthiness of oneself, others, or the world. MI is characterized by frequent, intense, and impairing emotions and related social behaviors and beliefs, that vary by the type of PMIE (Litz, 2020). As will be described below, MI can be distinguished from moral frustration, which is a more transitory reaction to a moral challenge, or moral stress, which is an acute reaction to a moral stressor. Every painful, horrifying, or tragic experience entails a potential loss of something that is important to us. If something is extremely frightening, we may lose our sense of safety. If our home is damaged, we lose a sense of safety, comfort, and the resources we need to do the things that support us. If we lose somebody we love, we lose a source of support and comfort. Different losses may arise from exposure to PMIEs. When we do things that hurt others, we can lose the sense that we are good and valued, and our connection to various communities.
When we are victimized by others' behavior, we can lose our sense of the goodness of people or institutions. MI involves feelings and behavior that arise from these losses. We become ashamed or angry, blaming or unforgiving. This can lead to a variety of other experiences which can reinforce injurious beliefs. For example, we may quickly reject others out of distrust, leading to loneliness, isolation, and loss of belongingness. Although the concept of MI has become popular, academic consensus around the definitions or assessment of MI are lacking. As a result, researchers often use different terminology and many measures have validity problems. Our collective challenge is to define and reliably assess the MI syndrome, to develop treatments for Veterans who have MI-related functional impairment, and to use a standard measure of MI to evaluate effectiveness. Until we know the prevalence of clinically significant MI and have a gold standard outcome measure of MI, it is impossible to demonstrate efficacy.
Research Priorities for Moral Injury include:
- Consensus definition of MI as an outcome
- A gold standard clinical assessment measure of MI
- An operational definition of MI caseness
- Established prevalence of exposure to different types of PMIEs and MI as an outcome
- Evidence that MI has incremental clinical and explanatory validity over PTSD or depression
- Information about risk and resilience in response to exposure to PMIEs, maintaining factors, and the clinical care needs of Veterans with MI
Distinguishing Exposure to Potentially Morally Injurious Events versus Moral Injury as an Outcome
There is an important distinction between a PMIE and MI. A PMIE is a life event that might be such a severe moral transgression that it could be injurious. But exposure to a PMIE is a necessary but insufficient determinant of outcome. Some individuals will come to terms with a PMIE and recover. Event exposure shifts to MI when there is evidence of lasting impact and impairment. Historically PMIEs have been mislabeled as “moral injuries,” which confuses exposure and outcome (Frankfurt & Frazier, 2016). Litz et al. (2009) defined PMIEs as events in which a person perpetrates, fails to prevent, bears witness to, learns about, or is a direct victim of acts that violate deeply held moral beliefs and expectations. A PMIE can occur when an individual: (1) does or fails to do something – deliberately or by mistake, or (2) is exposed directly or indirectly to others’ transgressions (Currier et al., 2017; Jordan et al; 2017; Nash et al., 2013). PMIEs may include direct victimization, high-stakes betrayals (e.g., being sexually assaulted by an officer) or bearing witness to inhumanity. 24 to 40% of Veterans report exposure to events that violated their core moral and ethical beliefs, most notably personal acts of commission or omission, bearing witness to inhumanity, and high-stakes betrayal by leaders (Jordan et al., 2017; Wisco et al., 2017). Although both types of PMIEs may lead to common outcomes, self-related MI is associated with shame and other feelings, beliefs, and behaviors that affect self-esteem, while other-related MI is associated with anger, resentment, and blaming others and being unforgiving. In terms of clinical care and research, the assessment tasks are to determine whether an event is a PMIE, to assess overall MI, as well symptoms that are unique to self- vs. other-related PMIEs.
The Biological Foundations of Moral Injury
Social networks were critical to the earliest humans. Hunter-gatherers developed a system to recognize family and help or compete with others accordingly. Those early connections developed over time into the expectation of what is known as reciprocal altruism, which forms the basis of morality. Reciprocal altruism is the “golden rule,” or the belief “that if I do good by others, others’ will do good by me.” Morality can be thought of as a set of rules around these beliefs that helps humans to live together. We are hard-wired to take care of, as well as expect cooperation and help from, our kin-group (“us”) versus an outgroup (“them”). Neurotransmitters, or brain chemicals, such as dopamine and oxytocin help to make in-group cooperation is rewarding. People are also empathic with, and can mirror the emotions of, shared in-group members. By contrast, and arguably at the heart of MI, people in “us” groups tend to be apathetic towards, shun, and dehumanize people in a “them” group. Behaviors that create and maintain the experience of an “us” create comfort and safety. Behaviors that disrupt the in-group lead to fear and stress. This occurs in part through activation of the amygdala, a brain region associated with fear and threat, and insula, a brain region associated with maintaining basic functions for survival.
Loss of in-group social standing is associated with poor recovery from stress and associated biological and cognitive changes such as higher basal levels of metabolic steroids, higher blood pressure, poor immune functioning, and executive cognitive dysfunction (e.g., poor decision-making). Similarly, cues from others reinforce “us” behavior. Reactions to violators of social group norms include disgust (regulated through the insula), which in turn leads to social rejection. These reactions help people develop knowledge of moral norms and what happens when social rules are violated. Rules and expectancies are further learned through family, cultural norms and faith traditions. Self-related MI occurs when the person believes or gets feedback that they “can no longer be one of ‘us’” (Sapolsky, 2017, p. 502). Social exclusion is aversive and hurtful. If people do not feel like a valued member of a group, they are at risk for severe biological and functional problems (Cacioppo et al., 2011). Different emotions are designed to signal different events (e.g., via facial muscles) and motivate goal-directed action. Moral emotions are responses to feeling a part of “us” or “them” within one’s social group. The two moral emotions that are relevant to MI are anger, which usually focuses outward, and shame, which is focused on oneself.
Shame can be understood as the opposite of pride. Pride is experienced when individuals perceive the self as good and contributing positively and competently to the in-group’s success. Shame is triggered when an individual does something that violates social norms, with the resulting experience of being flawed and lesser-than. Shame is often accompanied by feeling the need to hide and hiding behaviors. Social rejection and shame are associated with increases in stress hormones (e.g., cortisol) and proinflammatory cytokines, which may lead to dysphoria, anhedonia, and “sickness behaviors,” such as low motivation, lethargy, fatigue, malaise, and social withdrawal (see Kemeny, Gruenwald, & Dickerson, 2004). By contrast, anger stems from experiences of unfairness and injustice and involves a motivation to attack, humiliate, and find retribution (i.e., get back at the violator). When the insult is not addressable—that is, when restitution is not possible–there can be brain circuity dysregulation. The betrayal of “us” expectations can also lead to disruptions in moral information-processing and emotion regulation. These experiences affect the capacity for social connections to be rewarding and the capacity to value others.
Next: The differences between Moral Injury and PTSD
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