Moral injury refers to the psychological, social and spiritual impact of events or acts that a person performs, witnesses or fails to prevent, which conflict with one’s own deeply held moral beliefs and values.

Moral injury is a specific type of psychological injury that reflects an enduring impact on an individual’s self-image and worldview.

Although research and clinical communities are in the early stages of understanding what moral injury is, how best to treat it and potentially how to prevent it, evidence suggests that that moral injuries are common among members of the Canadian Armed Forces (CAF) and people who work in public safety, including members of the Royal Canadian Mounted Police (RCMP).

Family members of people who have served can also feel distress while trying to support their loved one in the aftermath of moral injury. In addition, Family members can also experience their own moral injury.

To support Veterans and Family members, the Atlas Institute is actively engaged in research about moral injury and developing resources for Veterans and Family members.

WHAT CAN MORAL INJURY FEEL LIKE?

When a moral injury occurs, the range of outcomes is broad and can include:

• Feelings of guilt, shame, anger, sadness, anxiety and disgust
• Intrapersonal outcomes such as lowered self-esteem, high self-criticism, self-destructive behaviours, and feelings of being bad, damaged, unworthy or weak
• Interpersonal outcomes such as loss of faith in people, avoidance of intimacy and lack of trust in authority figures
• Existential and spiritual outcomes such as loss of faith in previous religious beliefs and no longer believing in a just world

While moral injuries are strongly linked to military service members due to the conditions of deployments and likelihood of being exposed to events that can lead to moral injury, moral injuries are not limited to serving personnel and Veterans.

Researchers also recognize that moral injury may resonate with those who work in high-pressure environments such as health care. In particular, front-line health-care workers have faced moral stress from making critical decisions, often with limited resources.

Moral injury can also impact professions such as:

• Social workers
• Journalists
• Lawyers, judges, jurors and others in the legal field
• Aid workers
• Veterinarians

Watch this video on moral injury from the King’s Centre for Military Health Research:

CAUSES

There are three identified primary causes of moral injury:

• An act of commission: When someone does something they should not have done or that strongly goes against their own moral code.
• An act of omission: When someone should have done something but did not.
• Betrayal: When someone feels betrayed by others, particularly by a higher authority who either acted, failed to act or compelled an individual to act in a way that goes against their moral code.

Moral injuries typically result from events that fall into one of those three categories. These could be traumatic or morally challenging circumstances with vulnerable people or populations, events where a person is unprepared for the emotional consequences of their role, or a lack of social support.

IMPACT AND TREATMENT

The effects and impacts of moral injury vary for everyone.

Some people feel no lasting effect. Others will recover in the short term. Others will find that the lingering effects of their actions — or inaction — only become more intense over time and develop into a mental health crisis.

Research shows that people suffering from a moral injury are vulnerable to other mental health challenges, including posttraumatic stress disorder (PTSD), depression and suicidal thoughts.

Moral injuries also act as barriers that stand in the way of recovery. Those suffering a moral injury often avoid seeking treatment and refuse to discuss their injury with their support team or medical providers because they feel shame, anger or guilt, or even because they fear legal consequences from their actions.

While there is no single, defined treatment for moral injury, it is vital that anyone suffering from it discuss their feelings with a mental health professional. Treatment and therapy can begin to help make sense of a person’s feelings and actions, which is an important first step towards healing.

RESOURCES

The following resources on moral injury are designed to help Veteran, Veteran Family and public safety personnel deepen their understanding about moral injury. They also offer tools and strategies that can be used by individuals or Family member that have been impacted by moral injury, and organizational leaders who want to identify moral injury and respond appropriately.

A GUIDE TO MORAL INJURY FOR VETERANS AND FAMILIES

This resource can help Veterans and Veteran Family members understand what moral injury is, how it is different from PTSD and what you can do if you think you are experiencing moral injury.

EXPERIENCES OF MORAL INJURY IN CANADIAN PUBLIC SAFETY PERSONNEL

Information and resources related to research on moral injury in public safety personnel, including case studies that illustrate how moral injury can manifest within different personnel roles.

MORAL INJURY TOOLKIT

This toolkit helps organizations understand and address moral injury. It offers videos, tools, templates and tips to identify existing prevention and intervention measures and make necessary improvements.

RESEARCH

Find out more about research at Atlas on the topic of moral injury and see related outputs.

WEBINAR: THE ASSESSMENT AND MEASUREMENT OF MORAL INJURY AND MORAL DISTRESS

This webinar brought together a panel of experts and people with lived experience for a conversation about the importance of recognizing moral distress and moral injury, shared highlights of existing research on the quality of measurement tools for moral injury and moral distress, and provided leading recommendations related to the application of these tools in research, clinical and community settings.

LOVING A BROKEN SOUL: THE LIVED EXPERIENCE PERSPECTIVE ON THE IMPLICATIONS OF VETERANS’ MORAL INJURIES FOR FAMILIES

Veteran Family members may be impacted by a loved one’s moral injury and even experience moral injury themselves. However, research on the implications of moral injury for Family members remains uncharted territory. Read this article on the lived experience of Family members whose loved one is affected by moral injury in the Journal of Military, Veteran and Family Health.

RACIAL INEQUITIES AND MORAL DISTRESS: A SUPPLEMENT TO MORAL STRESS AMONGST HEALTH CARE WORKERS DURING COVID-19 — A GUIDE TO MORAL INJURY

Learn more about how lived experiences of racism and discrimination can collide with the moral stress of working in health care and put racialized health care workers at an increased risk of experiencing moral distress and moral injury.

CANADIAN MORAL INJURY RESEARCH COMMUNITY OF PRACTICE

The Atlas Institute is the convenor of the Canadian Moral Injury Research Community of Practice (MI CoP), which aims to promote knowledge-sharing and collaboration on moral injury and its impact on active and former members of the CAF and RCMP and their Families, health care workers and public safety personnel.