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Tuesday, February 7, 2017
The Moral Injury Definition
The Moral Injury Definition
Moral injury refers to the lasting psychological, spiritual and social impact of one’s own or others’ actions that transgress deeply held moral beliefs and expectations (see Litz et al., 2009; Shay, 1994). Shay (1994), for instance, suggests that a caregiver’s betrayal of the moral order through physical or sexual abuse or neglect impacts the character of the vulnerable child through a disruption of a sense of safety, trustworthiness, reliability and competence within the family. In Brandon’s case, he was not only the victim of abuse by the adults responsible for his protection, he witnessed and failed to protect his younger siblings from abuse, and he perpetrated a moral transgression against his beloved grandfather.
Moral injury is a relatively new term. The experience, however, has been described since ancient times, as when Homer wrote of Achilles’ experiences of social withdrawal, indignity, violent rage and severing of emotional bonds as the result of Agamemnon’s violations of commonly understood social and moral values in the Illiad nearly 3,000 years ago. The use of the term moral injury began when psychiatrists providing services to Vietnam combat veterans began to recognize that many were suffering from a type of persistent distress that was not being captured by the DSM diagnosis of PTSD (Gray et al., 2012; Shay, 2014), or resolved by interventions for PTSD (Gray et al., 2012; Litz et al., 2009; Nieuwsma et al., 2015). By definition, PTSD involves a traumatic threat to one’s own or loved one’s physical safety and results in symptoms of anxiety (American Psychiatric Association, 2013).
In contrast, moral injury occurs when a high stakes event contradicts one’s deeply held moral framework. In other words, when there is a troubling mismatch between the individual’s core moral beliefs and the event (Boudreau, 2011; Dombo, Gray, & Early, 2013; Meagher, 2014). This mismatch leads to a “breakdown in global meaning” (Currier, Holland, Rojas-Flores, Herrera, & Foy, 2015a, p. 26) or “threat to the integrity of one’s internal moral schema” (Dombo et al., 2013, p.200). It is this lack of meaning, not threat to physical safety (Currier, Holland, & Mallot, 2015c), that contributes to individuals’ guilt, shame, rage, depression, (Dombo, et al., 2013; Kopacz, Simons, & Chitapong, 2015; Litz et al., 2009; Shay, 1994) and loss of confidence in their own or others’ “motivation or capacity to behave in a just and ethical manner” (Drescher et al., 2011, p. 9).
Moral Injury & Child Welfare
Somewhat surprisingly, moral injury has received very limited attention in the social work literature (but see Dombo et al., 2013). Yet the impact of moral injury may play a significant role in increasing the vulnerability of a wide range of the profession’s clients as well as its practitioners. Some parents involved with the child welfare system may experience moral injury due to harm they (or others) inflicted on their children while they were under the influence of substances or experiencing mental health issues. They also may have experienced moral injury from their own experiences of child maltreatment or intimate partner violence, or due to their failure to provide basic necessities to their children as a result of poverty. Children like Brandon also may present with moral injury, for example, due to the violation of trust while experiencing abuse or neglect, actions they take for survival, and exposure to parents’ violence or violation of other social norms. Parents, children and child welfare professionals all may experience harm within social systems they are expected to, and which are charged with, providing assistance to struggling families.
Addressing Moral Injury
The literature on moral injury has only been emerging over the past 10-15 years, thus information about how to address moral injury is limited. However, the following interventions and strategies show promise:
Acceptance & Commitment Therapy (Nieuwsma et al., 2015)
Adaptive Disclosure (Gray et al., 2012)
Prolonged Exposure Therapy (Paul et al., 2014)
Pastoral care (Moyo, 2015)
Current research suggests that moral injuries can heal via therapeutic inventions which provide for meaning-making, self-forgiveness, acceptance, and a recommitment to personal values (Currier et al., 2015a, Currier et al., 2015b, Ferrajao & Oliveria, 2016; 2015; Gray et al., 2012).
There is a need for more research into moral injury across the field of social work, and particularly in high-stakes, morally challenging contexts like child welfare. Social work researchers and practitioners may identify possibilities for future research on moral injury based on the level of their practice lens (micro-mezzo-macro) and specific areas of expertise. Social workers concerned with micro-level issues, for instance, may focus on issues of moral transgressions committed by parents while they are experiencing altered mental states due to substance abuse or mental illness. For example, if a mother left her two young children alone for days while she was on a meth binge, how does she integrate the reality of her transgressions, once she is in recovery, with her identity as mother and how does this viewpoint impact her ability to re-engage as a parent and help her children heal? Social workers concerned with macro-level issues, for instance, might focus on ways that the child welfare system, with its structures, processes, policies, and practices, results in moral transgressions against families, children, and professionals involved in the system. In such complex contexts, individuals may have overlapping experiences of perpetrator, victim and bystander of moral injury; there may be compounding influences of PTSD, medical illness, poverty and infrastructure problems; and family, community and culture may be shaped and distorted over time. The need is great for policy and organizational systems innovations that lead to more just and ethical systems, thereby decreasing the risk of moral injury.
Also, keep an eye out for our Twitter and Facebook posts over the next week, as we will share various resources pertaining to moral injury.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). Arlington, VA: American Psychiatric Publishing.
Boudreau, T. (2011). The morally injured. The Massachusetts Review, 52(3/4), 746-763.
Bowman, M. (1997). Individual differences in posttraumatic response: Problems with the adversity-distress connection. Mahway, NJ: Lawrence Erlbaum.
Buechner, B.D. (2014). Contextual mentoring of student veterans: A communication perspective. (Doctoral dissertation). Available from ProQuest Dissertations and Theses #3615729.
Currier, J. M., Holland, J. M., Rojas-Flores, L., Herrera, S., & Foy, D. (2015a) Morally injurious experiences and meaning in Salvadorian teachers exposed to violence. Psychological Trauma: Theory, Research, Practice, and Policy, 7(1), 24-33.
Currier, J.M., Holland, J.M., Drescher, K., & Foy, D. (2015b). Initial psychometric evaluation of the Moral Injury Questionnaire-Military Version. Clinical Psychology & Psychotherapy, 22(1), 54-63.
Currier, J.M., Holland, J.M., & Malott, J. (2015c). Moral injury, meaning making, and mental health in returning veterans. Journal of Clinical Psychology, 71(3), 229-240.
Dombo, E. A., Gray, C., & Early, B. P. (2013). The trauma of moral injury: Beyond the battlefield. Journal of Religion & Spirituality in Social Work: Social Thought, 32(3), 197-210.
Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schutz, K., & Litz, B. (2011). An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology, 20(10), 1-6.
Ferrajao, P.C. & Oliveira, R.A. (2016). Portuguese war veterans: Moral injury and factors related to recovery from PTSD. Qualitative Health Research, 26(2), 204-214.
Ferrajao, P.C. & Oliveira, R.A. (2015). From self-integration in personal schemas of morally experiences to self-awareness of mental states: A qualitative study among a sample of Portuguese war veterans. Traumatology, 21(1), 22-31.
Ferrajao, P.C. & Oliveira, R.A. (2014). Self-awareness of mental states, self-integration of personal schemas, perceived social support, posttraumatic and depression levels, and moral injury: A mixed-method study among Portuguese war veterans. Traumatology, 20(4), 277-285.
Gray, M.J., Schorr, Y., Nash, W., Lebowitz, L., Amidon, A., Lansing,A, Maglione, M., Lang, A.J., & Litz, B.T. (2012). Adaptive disclosure: An open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behavior Therapy, 43, 407-415.
Kopacz, M.S., Simons, K.V., Chitaphong, K. (2015). Moral injury: An emerging clinical construct with implications for social work education. Journal of Religion & Spirituality in Social Work: Social Thought, 34(3), 252-264.
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706.
Moyo, H. (2015). Pastoral care in the healing of moral injury: a case of the Zimbabwe National Liberation War veterans. HTS Teologiese Studies/Theological Studies, 71(2), 1-11.
Nieuwsma, J.A., Walser, R.D., Farnsworth, J.K., Drescher, K.D., Meador, K.G., & Nash, W.P. (2015). Possibilities within Acceptance and Commitment Therapy for approaching moral injury. Current Psychiatry Reviews, 11, 193-206.
Paul, L.A., Gros, D.F., Strachan, M., Worsham, G., Foa, E.B. & Acierno, R. (2014). Prolonged exposure for guilt and shame in a veteran of Operation Iraqi Freedom. American Journal of Psychotherapy, 68(3), 277-286.
Shay, J. (1994). Achilles in Vietnam: Combat trauma and the undoing of character. New York, NY: Scribner.
Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182-191.