Moral injury

Moral injury refers to an injury to an individual's moral conscience resulting from an act of perceived moral transgression which produces profound emotional shame. The concept of moral injury emphasizes the psychological, cultural, and spiritual aspects of trauma. Distinct from pathology, moral injury is a normal human response to an abnormal event. The concept is currently used in literature about the mental health of military veterans who have witnessed or perpetrated an act in combat that transgressed their deeply held moral beliefs. Moral injury can also be experienced by to those who have been transgressed against. For example, when one goes to war thinking that the purpose of the war is to eradicate weapons of mass destruction, but finds that not to be case, the warrior can experience moral injury. Those who have seen and experienced death, mayhem, destruction, and violence have had their worldviews shattered - the sanctity of life, safety, love, health, peace, etc. - can suffer moral injury as well.

Brett Litz and colleagues can be credited for major developments in the psychological perspective on moral injury. They define moral injury as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Litz and colleagues focus on the cognitive, behavioral, and emotional aspects of moral injury in a preliminary conceptual model. This model posits that cognitive dissonance occurs after a perceived moral transgression resulting in stable internal global attributions of blame, followed by the experience of shame, guilt, or anxiety, causing the individual to withdraw from others. The result is increased risk of suicide due to demoralization, self-harming, and self-handicapping behaviors.

Psychological risk factors that make an individual more prone to moral injury includes neuroticism and shame-proneness. Protective factors includes self-esteem, forgiving supports, and belief in the just-world hypothesis.

The concept of moral injury was introduced by clinical psychiatrist Jonathan Shay, and the cultural perspective on moral injury has been developed in his work. He defines moral injury as stemming from the “betrayal of ‘what’s right’ in a high-stakes situation by someone who holds power.” The process of recovery, according to Shay, should consist of “purification” through the "communalization of trauma." Shay places special importance on communication through artistic means of expression. Moral injury can only be absolved when “the trauma survivor… [is] permitted and empowered to voice his or her experience….” For this to occur, there needs to be openness on the part of civilians to hear the veterans’ experiences without prejudice. Fully coming “home” means integration into a culture where one is accepted, valued and respected, has a sense of place, purpose, and social support.

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