What is moral injury?

The concept of the moral injury originated in the work of the psychiatrist Johnathan Shay (1994, 2002, 2014) who treated armed service personnel traumatised by experiences where either they, or their leaders, violated their values. Potentially morally injurious experiences (PMIE’s) include perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations, which can result in psychological distress or moral injury (Litz et al. 2009).  Moral injury is often associated with strong moral emotions related to the event, including guilt, anger and disgust, and can also lead to negative thoughts about oneself or others, for example, “I am a terrible person,” and can lead to distress and psychological difficulties (Farnsworth et al, 2014).  Moral injury can impact upon work and social life.  It has been linked to increased difficulties coping with occupational stressors and difficulties with authority figures. 

What can we learn from research into this area?

Research into moral injury is still in its infancy, however a recent systematic review and meta-analysis found that moral injury is not unique to any particular profession (Williamson et al, 2018). I had not heard the term before I began listening to webinars about how COVID-19 is placing significant demand on key workers. Victoria Williamson, Dominic Murphy and Neil Greenberg from King’s College London have recently written an editorial in the latest edition of Occupational Medicine Journal ‘Front-line key workers, such as healthcare providers and emergency first responders but also other non-healthcare-related staff (e.g. social workers, prison staff), may be especially vulnerable to experiencing moral injuries during this time’.  It’s a compelling read and helpful to those of us that work with key workers and decision makers in a coaching capacity.

When might people experience moral injury?

In the editorial, the authors highlight that key workers are at increased risk of moral injury if:

• The life of a vulnerable person is lost.  
• When workers don’t feel supported or that leaders haven’t taken responsibility.  
• When staff are not prepared for the emotional consequences of the decisions they are making.
• If other traumatic events occur at the same time such as a personal bereavement.
• If they have a lack of social support.

The authors are equally keen to point out that exposure to PMIEs does not automatically result in moral injury. 

How can leaders, teams and individuals reduce the risk or impact of moral injury?

The authors highlight the following recommendations which may be beneficial for individuals and teams to consider:

• Be aware of the possibility of potentially morally injurious events and each other to develop psychological preparedness.
• Encourage team members to seek informal support from managers, colleagues, chaplains and other welfare providers.
• Advise team members to seek professional help at an early point, especially if they are having trouble functioning. 
• Leaders and managers need to check in with their teams at regular points to provide support and to signpost the team members and others to services if needed.
• Employers should not use debriefing techniques or psychological screening, but they should facilitate team cohesion as well as make informal as well as professional support available.
• Events need to be frankly discussed and efforts made to ensure that staff understand potential impact on their mental health, whilst ensuring the are also aware that psychological growth can also be expected as staff ‘do their best’ under challenging conditions.

It has been extremely helpful to understand a little more about how PMIE may impact key workers.  The practical recommendations outlined by Williamson et al are also particularly helpful and give some insight into the role of leaders and teams.  They also recognise that not all managers will feel comfortable in having ‘psychologically informed conversations’ with their staff, or possess such skills, and that it’s important that others are available to step into this role, to check in with staff on a regular basis. 

References

Farnsworth JK, Drescher KD, Nieuwsma JA, Walser RB, Currier JM. (2014).  The role of moral emotions in military trauma: implications for the study and treatment of moral injury. Rev Gen Psychol, 18(4). 

Litz, B.T., Stein, N., Delaney, E., Lebowitz, L., Nash, W.P., Silva, C. and Maguen, S. (2009) ‘Moral injury and moral repair in war veterans: A preliminary model and intervention strategy’, Clinical Psychology Review, 29(8), 695-706.

Shay, J. (1994) Achilles in Vietnam : combat trauma and the undoing of character, New York: Atheneum ; Oxford : Maxwell Macmillan International.
Shay, J. (2002) Odysseus in America : combat trauma and the trials of homecoming, New York: Scribner.
Shay, J. (2014) ‘Moral Injury’, Psychoanalytic Psychology, 31(2), 182-191.

Williamson, V., Stevelink, S., & Greenberg, N. (2018). Occupational moral injury and mental health: Systematic review and meta-analysis. The British Journal of Psychiatry, 212(6), 339-346. 

Williamson,V., Murphy, D., Greenberg, N. (2020). COVID-19 and experiences of moral injury in front-line key workers, Occupational Medicine [https://doi.org/10.1093/occmed/kqaa052]