The emotional toll of moral injury

Most people have a moral compass or ethical code that guides them in determining right from wrong. It’s tied to our values and beliefs and can influence our behavior. When a person does something that goes against their moral compass, it’s called a moral injury. It typically happens in traumatic or highly stressful situations where a person perpetrates, witnesses, or fails to prevent harm. 

Moral injury may not leave physical scars. But, without support, it can create lasting psychological, behavioral, social, and sometimes spiritual challenges. Learning more about moral injury can help you recognize it, take steps to prevent it, and know when to ask for help.

Who’s most at risk of moral injury

Anyone can experience moral injury. However, it’s more common among certain groups. Research shows that about 2 in 3 of armed forces members and veterans, healthcare workers, first responders, educators, journalists, and child protection service employees will face a potentially morally injurious event. 

These groups may be at greater risk because of the nature of their work. They’re often in dangerous or high-stakes scenarios where they’re more likely to encounter harm. They may also choose values-aligned careers where they hope to make a difference. But they may find themselves without enough resources or unable to have a positive impact due to systemic limitations. For example:

• A teacher knows that one of his students is falling asleep in class because she’s staying up late to watch her baby brother while her mother works. She’s a bright kid, but she’s at risk of not graduating because she’s so far behind. The teacher has tried to find resources to support his student, but there are no accessible options due to budget cuts.

• When a police officer arrives at the scene of a domestic disturbance, it’s clear that the family is in distress. This isn’t the first time the officer has responded to this location, but the victim is unwilling to press charges. The officer knows that it’s likely that the children will continue to witness violence in the home and may become victims as well.

• While deployed overseas, a soldier receives orders to conduct a raid, knowing there will likely be civilian casualties. She enlisted to help make the world a safer place but knows she can’t go against orders. Years later, she can’t shake the feeling that she may have made things worse.

• A journalist is documenting animals in the wild for a new TV show. He sees an injured bear cub that was left behind and is at risk of being prey. Even though he wants to help, he knows he can’t intervene. He feels his morals are being tested and experiences challenges with the decision to leave the cub.

Recognizing symptoms of moral injury

If you’ve been exposed to traumatic or stressful events where you had to make decisions that were against your values, and you’re experiencing any of the following, you may be experiencing moral injury.

• You frequently feel angry, disgusted, ashamed, or guilty.

• You can’t forgive yourself for what happened, and/or you feel the need to punish yourself.

• You’ve ended a relationship because you feel you’re no longer worthy of love.

• You’ve stopped taking care of yourself because you feel like you don’t deserve it. 

• You haven’t asked for help because you’re too ashamed to talk about what happened.

These symptoms might start to appear days after an incident. But they might not manifest until years after the traumatic event. Moral injury can also occur with post-traumatic stress disorder (PTSD) and may make PTSD symptoms worse. People experiencing both moral injury and PTSD are at greater risk of impaired functioning, severe depression, and suicide.*

*If you or a loved one is experiencing suicidal thoughts or thoughts about harming themself or others, please call or text 988 on any phone for the Suicide & Crisis lifeline, contact a local crisis line, or head to the emergency room immediately. Any of these resources will ensure that the person in crisis receives support right away. For more information on getting help, go to 988lifeline.org

If experiencing a life-threatening emergency or you need immediate help, please call 911. 

The effects of carrying moral injury

Some people experience temporary moral injury that resolves on its own in time. But for others, the effects can be long-lasting. Without adequate support, moral injury can lead to:

• Negative self-worth (like thinking you’re a failure or a terrible person)

• Loss of trust in people and institutions

• Increased risks of mental health concerns 

• Existential crisis or questioning the purpose of life

• Social withdrawal and isolation

• Harmful coping mechanisms like unhealthy substance use

• Damaged relationships with loved ones

• Trouble functioning at work and potential unemployment

Support for people with moral injury

Moral injury isn’t an official diagnosis, but that doesn’t mean it can’t be managed. If you’re facing challenges with moral injury, one of the best things you can do is ask for help. This can be hard to do — especially if you’re feeling shame or guilt. But know that there are trauma-informed mental health professionals who can offer judgment-free support. While therapy can’t change the past, it can help you heal from moral injury and build hope for the future. Some of the most effective treatments for moral injury include:

• Adaptive disclosure therapy (ADT): This brief approach was specifically designed to address the effects of trauma in military personnel.

• Cognitive behavioral therapy (CBT): CBT is frequently used to treat PTSD and can be modified to address moral difficulties and promote self-forgiveness.

• Acceptance and commitment therapy (ACT): This form of care can help people focus on the present and live a values-based life.

• Prolonged exposure therapy (PE): As a subset of CBT, PE can help people gradually engage with triggers with their therapist’s support to change their emotional response to traumatic memories or events.

Clinician’s take

Healing begins when you can see your pain as a sign of your values rather than proof of failure. Recognizing that your moral sensitivity reflects compassion and integrity can help you move toward self-forgiveness, reconnection, and renewed purpose.

Ashley Ayala, LMFT

Clinical reviewer