Moral injury: the effect on mental health and implications for treatment

Moral injury is understood to be the strong cognitive and emotional response that can occur following events that violate a person’s moral or ethical code. Potentially morally injurious events include a person’s own or other people’s acts of omission or commission, or betrayal by a trusted person in a high-stakes situation. For example, health-care staff working during the COVID-19 pandemic might experience moral injury because they perceive that they received inadequate protective equipment, or when their workload is such that they deliver care of a standard that falls well below what they would usually consider to be good enough. Unlike post-traumatic stress disorder, which can occur following threat-based trauma, potentially morally injurious events do not necessarily involve a threat to life. Rather, morally injurious events threaten one’s deeply held beliefs and trust. Moral injury is not considered a mental illness. However, an individual’s experiences of potentially morally injurious events can cause profound feelings of shame and guilt, and alterations in cognitions and beliefs (eg, “I am a failure”, “colleagues don’t care about me”), as well as maladaptive coping responses (eg, substance misuse, social withdrawal, or self-destructive acts). It is these challenged beliefs and altered appraisals that are thought to lead to the development of mental health problems, with a 2018 meta-analysis finding that exposure to potentially morally injurious events was significantly associated with post-traumatic stress disorder, depression, and suicidality. Although exposure to potentially morally injurious events, and the moral injuries that followed, were initially examined in military personnel in combat settings, moral injury is not limited by occupation. Studies increasingly show many professionals are exposed to potentially morally injurious events and the risk of moral injury, including journalists, police, and veterinarians, as well as military personnel. In the context of the COVID-19 pandemic, moral injury has been found to be one of the greatest challenges reported by UK National Health Service frontline health-care staff and is significantly associated with post-traumatic stress disorder and depression. Moral injury was also reported to be a key cause of distress for journalists during their coverage of the 2015 migrant crisis. Nonetheless, moral injury remains a difficult concept to measure objectively because existing tools often have methodological problems or are not validated for use in non-military populations. Beyond the reported associations between potentially morally injurious events and mental health outcomes, studies have begun to examine what moral injury can mean for the person affected and how this type of experience can affect their daily functioning. Studies, largely from the USA, highlight how people with moral injury can undergo an existential crisis as a result of their experience. Other studies show how moral injury can adversely affect the person’s familial and occupational functioning, with many affected individuals reporting familial breakdown and unemployment due to their distress related to potentially morally injurious events and maladaptive coping responses. Taken together, the international literature indicates that moral injury might be an important public health concern. Yet, no validated treatment for moral injury currently exists. Treating patients whose mental health problems are caused by moral injuries can be challenging for clinicians. Firstly, exposure-based approaches could be unhelpful or even harmful in cases of moral injury if inadequate attention is paid to emotional processing of feelings of shame and guilt. Secondly, many commonly used evidence-based treatments for trauma-related mental health problems (eg, trauma-focused cognitive behavioural therapy) often involve cognitive restructuring of a patient’s erroneous, pathological, or distorted appraisals and their replacement with new and more adaptive appraisals of the self or the event. Such methods might not be effective or appropriate when treating patients whose shame and guilt arise from commission of transgressive acts of perpetration, rather than from erroneous appraisals. For example, with a prison officer who seriously injured a detainee with undue force, it might be futile at best, or increase the likelihood of future perpetration at worst, for a clinician to challenge their accurate appraisals of wrongdoing. Lancet Psychiatry 2021