Published on September 14th, 2017 | from CAMH

Behind the Uniform: When struck by moral injury

By Dr. Katy Kamkar, Clinical Psychologist at CAMH, Director at Badge of Life Canada and Medical Practitioner at the Invictus Games

When moral injury hits, it hits hard and can have a long lasting emotional and psychological impact.

In my work with Police/first responders and veterans, I felt that more awareness and attention should be brought to the concept of moral injury and the devastating pain and suffering it brings to a human being.

Although it is a concept that originated among military veterans, it is also very much present among Police and First Responders. It was first defined by Psychiatrist Jonathan Shay as the psychological, social and physiological results of a betrayal of “what’s right”.

Moral injury is a loss injury; a disruption in our trust that occurs within our moral values and beliefs. Any events, action or inaction transgressing our moral/ethical beliefs, expectations and standards can set the stage for moral injury.

Some examples leading to moral injury include:

  • Unintentional errors leading to injury or death
  • Witnessing and/or failing to prevent harm or death
  • Transgression of peers, leaders or organizations that betrayed our moral/ethical beliefs or expectations

A large number of military personnel continue to experience deployment-related mental health problems, with moral injury playing a large proportion. Its repercussions can be very serious, and studies have shown that combat-related guilt is a contributing factor to suicides in the military. I also see moral injury playing a significant role within my work with police and first responders.

For many of them, the moral injury was never identified and only the diagnosis of Posttraumatic Stress Disorder (PTSD) was treated. Sometimes moral injury contributes more to the pain, suffering and disability than the trauma exposure itself. Thus, recognizing signs of moral injury and opening up the dialogue and receiving treatment can further help prognosis and treatment outcome, level of functioning and quality of life and well-being.

Examples of emotional, cognitive and behavioural symptoms of moral injury include:

  • Feeling anxious and afraid
  • Feeling demoralized
  • Feeling guilty
  • Feeling ashamed
  • Feeling “haunted” by decisions, actions or inactions that have been made
  • Anger in particular following betrayal
  • Feelings of worthlessness, helplessness and powerlessness
  • Sense of loss of identify and role
  • Questioning our sense of self and a loss of trust in oneself and in others
  • Persistent self-blame or blaming others
  • Negative beliefs about self such as “I am weak”, “I am evil”; self-deprecation; self-condemnation
  • Increased posttraumatic stress symptoms including distressing intrusive memories, nightmares and avoidance
  • Self-isolation, avoidance and withdrawal from others
  • Relationship problems
  • Reduced empathy or wanting to interact with others
  • Impairment in social, personal and occupational functioning
  • Increase in substance use
  • Suicidal ideation

If you feel you are suffering from moral injury and from some of the symptoms above, please seek social support and professional help. You are far from being alone. Seeking quality social support is very important, and peer support is also helpful. Having a peer to talk to helps to alleviate feelings of loneliness or isolation, helps us regain connection and feel we are understood, can help us better cope with the suffering and make it easier to reach for further help.

We need to provide further attention and focus to moral injury by opening the dialogue and communication, furthering our research and education and treatment on moral injury, and in turn helping resiliency and recovery.



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4 Responses to Behind the Uniform: When struck by moral injury

  1. Bruce Lacillade M.A. says:

    Thanks Katy for posting this article addressing moral injury/inner conflict. As as a combat veteran and retired from a fire service career I have a personal relationship with miral injury.
    Further, as a pastoral care provider I have a professional relationship with it as well.
    Many people struggle silently with this and are afraid to share it in this secular, everything is relative world. We need to step up and deal with moral issues.

  2. D.R. says:

    I can attest that in my own experience of PTSD as a former social worker, drug officer, forensic specialist , and finally lawyer (prosecutions) the moral injury component is in many respects the most lasting, resilient and devastating one. Three decades of anger and pain are not easily shed. It generates some of the most challenging sources of cynasism, rage, negative view points, and resistance to trusting others, and is the foundation of much of the isolation I experience in the recovery journey thus far. It is a tremendously deep pit to try to crawl out of and rebuild some kind of trusting, balanced and compassionate relationship with the world. I would encourage anyone who works in any occupation that demands an intensive element of service to others, to exposure to violence and its physical and emotional impact directly or indirectly , particularly where there is some expectation from self or others, that it is your responsibility to the control the outcome of events , to be wary and cognizant of the toll it takes, to not ignore it, and seek assistance and relief. I was “raised” in the era when this simply not done and paid a dear price for it. It’s a long long road back, but I am grateful to be on it.

  3. D.R. says:

    The only other observation / comment I would make with respect to examining moral injury concerns the need to look at role of the “system” that each of the occupations work within, and how, at least in my experience or perception, there has been what feels like an increasing “moral” ambiguity within them as they get bigger, more political, more bureaucratic, and micro managed , : about the role itself, the support due to its participants, the mission statement versus expedience, the focus on “policy” often in contradiction to duty, managerial focus on results, statistics, data, not the human element, and a list I suspect others could add to greatly. I have found myself and in talking to others that at least some of the sense of betrayal spoken of , lies in this more generic systematic domain, when simply doing the job they way you are told, ordered , or expected to becomes the very source of the betrayal.

  4. Harry Zeit MD says:

    Dr. Kamcar, thank you for blogging on this important issue. When I bring it up with colleagues, it always leaves a major impact. It is definitely worth reading Johnathan Shay’s profoundly important and disturbing paper.
    Thank you also D.R. for describing the core of institutional betrayal so eloquently.
    Working as an American board-certified emergency physician for over twenty years, I become familiar with moral injury before I had it articulated it to me. I certainly understand its impact much better now.
    I believe that moral injury now occurs at a high level in all areas of health care, especially in the area of mental health care. In many cases, morally injured clinicians are trying their best to heal morally injured clients, while the administrators and systems that have created the moral injury remain unchallenged.
    Our military and first responders have given a great deal and have paid huge costs in terms of PTSD and often broken bodies and broken minds.
    They deserve institutions to support them – institutions are accountable and ethical, and who openly acknowledge the cost of betrayal trauma. They deserve institutions that can be up front when they lack the resources needed to help out, and institutions devoted to the genuine well-being (rather than offering euphemisms that mimic well-ness) of their staff.

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