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.
- Your organization’s Employee Assistance Program (EAP)
- CAMH Website
- Badge of Life Canada (BOLC)
- Walk the Talk: First Responder Peer Support
- Canadian Institute for Public Safety Research and Treatment
- Report of the Standing Committee on Public Safety and National Security
- Portico Network (Canada’s Mental Health and Addiction Network, powered by CAMH)
- Wounded Warriors Canada
- Connex Ontario (Information about mental health, problem gambling, drug and alcohol): 1-866-531-2600 24 hours a day, seven days a week.
- Telehealth Ontario at 1-866-797-0000