Pūtahi Hauora
Defence Health HubMoral Challenges
Taupatupatu Tikanga
When our core values are challenged it is important to identify and understand our reactions, and how this impacts the way we think and feel.
What is a moral injury?
Our moral compass comprises a set of core values which help us to understand and identify the actions and behaviours in life we find just and unjust. They guide us through life, shaping our behaviours, actions and emotions. It is common for us to face moral dilemmas. We can second guess ourselves or feel uneasy about our decisions, but the likelihood of harm is usually minimal. These scenarios don’t have a lasting impact on our guiding compass.
There are two types of moral conflicts we can experience. The first is when we do something inconsistent with our morals, or fail to do something we believe we should have done. The second is when we are exposed either directly or indirectly to someone else committing an act which we consider to be a betrayal of our own moral code.
The lasting impacts on our moral compass lie on a continuum. While moral conflicts involve a breakdown of our moral values and beliefs, their potential for resulting in harm greatly depends on how severe the experience is for us. When a moral injury occurs, it has the potential to negatively impact our self-image and world view.
The history of moral injury
Examples of moral injuries
- At the low end of the continuum, we all have experiences where we witness behaviours of others we deem to be wrong. Our emotional response to these behaviours is most likely that of frustration, or a degree of contempt for the person, but these feelings are also most likely short-lived.
- Another example could be an unintentional error on the part of a healthcare professional, which results in serious consequences.
- In a military context, a moral injury may arise when a soldier has been forced to act against their entrenched moral values and beliefs.
- A soldier failing to intervene to protect civilians, even though they feel that they should, because doing so would have been a breach of orders or rules of engagement.
- Killing or harming others or ordering others to do so.
- Medics unable to care for all wounded.
What can make us more vulnerable to a moral injury?
- Loss of life of people we perceive as vulnerable.
- Lack of support from leadership, our whānau and wider community.
- Exposure to additional trauma.
- The nature of the potential moral stressor—people may be less likely to disclose or discuss their difficulties due to shame they associate with the moral injury, or due to potential legal or social consequences.
Impacts of moral injury
When we, or someone we care about, experience a moral injury, the impacts can be broad across Te Whare Tapa Whā:
- Feelings of guilt, shame, anger, worry or disgust in ourselves or towards someone else
- Self-condemnation or self-punishment
- Feelings of worthlessness or powerlessness
- Low self-esteem, high self-criticism, feelings of unworthiness
- People may become withdrawn, avoidant, reduction in empathy
- People may engage in self-sabotaging behaviours
- Loneliness
- Interpersonal impacts may include a loss of faith in people, avoidance of intimacy, a lack of trust in others and in the self
- An inability to forgive
- Questioning of our spiritual connections: a loss of faith , lack of belief in a ‘just’ world, disconnection from our identity, loss of a sense of purpose or motivation.
The impacts of a moral injury extend beyond that of individual impacts, and can significantly impact our interactions and the trust we place in others. One of the most helpful means of addressing moral injury is to share the experience with trusted others and get their perspective and support.
What can we do about it?
Much of the research around moral injury has been done with military personnel. This is because the battlefield can put people in a position where they are exposed to situations and experiences that can be morally ambiguous and are often shrouded in the fog of war.
Although we cannot always avoid an event which results in a moral injury, there are ways we can manage and recover. It’s important to remember that while we can experience psychological distress from a moral stressor, these challenges we face also present opportunities for personal growth. This includes an improvement in resilience, increased esteem as well as compassion and engagement with others.
Overcoming Moral injuries
If you’ve experienced a moral injury, a core part of making progress is making sense of what has happened to you.
Here are some steps you can take to begin the recovery process:
- Acknowledge the moral dilemma or injury exists.
- Commit to actively working through the moral conflict you are struggling with to find a resolution. You can drown things out with noise for a time, but moral injury will not be resolved through avoidance.
- Recognise that your behaviour at a point in time does not define who you are.
- Confide in someone you trust to help you work through this.
- Acknowledge what your values are and accept the conflict within the situation.
- Seek meaning. It’s important when experiencing a morally injurious event. Reflect on the purpose behind the situation or event. Those who do not are at a greater risk of depression, Post-Traumatic Stress Disorder
- If you feel you are experiencing, or are at risk of experiencing any of these, seek help.
Helping someone else
It can be difficult for those around us to share when they have experienced a morally injurious event due to feelings of guilt or shame. Create an environment for your peers and loved ones which enables people to work through their moral dilemmas.
Trust in leadership is a crucial part of working through morally injurious events. Create an open dialogue with those around you and explaining the rationale for the decisions made can aid in mitigating the sense of betrayal or disconnection a person can experience from their moral compass by understanding potential outcomes of alternative decisions.
Getting help
It’s important that where you feel you are experiencing distress from a moral injury that you seek help, either psychological or spiritual, when you need to. There is effective treatment and support available.
The two most used forms of therapy are Prolonged Exposure, which provides the opportunity to emotionally process the events, make sense of trauma and reconnect with the values you find important. The second is Cognitive Processing Therapy (CPT), which encourages you to work through beliefs which tend to underlie our feelings of guilt, shame and betrayal including “I should have done this differently." CPT also addresses beliefs about the self, including "I cannot forgive myself, I am worthless" and works to rebuild trust. These treatments can be accessed by talking to your medical provider.
If you are wondering whether or not you need support for a moral injury, it is highly likely you do. Reach out to your local social support network:
- Chaplains
- Marae
- Social workers
- NZDF4U
- Defence Health Centre (DHC) for military or your local GP/Doctor
- NZDF psychologists