Roots of Moral Injury: Exploring Sources and Triggers

Unlock the mysteries of moral injury with Dr. Daniel Roberts as we journey into a realm often overshadowed by PTSD. What truly sets moral injury apart from other psychological wounds? This episode promises to enrich your understanding by delving into the intricate layers of moral injury, exploring its roots in experiences of betrayal, trauma, and ethical conflict. Through heartfelt stories and reflections, we aim to shed light on how moral injury manifests in various communities, including women veterans, racial minorities, and those facing sexual identity discrimination, emphasizing the vital need for recognition and tailored care.

As we navigate the tapestry of moral injury, you’ll hear how resource scarcity, discrimination, and toxic environments can erode one’s moral fabric, leaving deep wounds of guilt and responsibility. Dr. Roberts shares the transformative power of storytelling and forgiveness as pathways to healing, illustrating their significance in identifying and comprehending moral injury. This conversation brings to the forefront the widespread impact of moral injury across industries and highlights the urgent need for awareness and resources to support recovery. Tune in for an insightful exploration that not only defines moral injury but also calls for a compassionate response to its challenges.

Chapters

• 0:35 Understanding Moral Injury and Sources
• 22:21 Understanding Sources of Moral Injury

Transcript

Speaker 1: 0:35

Welcome to this episode of Moral Injury Support Network podcast. I'm Dr Daniel Roberts, president and CEO of Moral Injury Support Network for Service Women Incorporated. Today's podcast is called Roots of Moral Injury Exploring Sources and Triggers, and I want to talk about briefly, definitions of moral injury. We always sort of cover that in our episode, just because if this is the first episode you're listening to, you may not be super familiar with the term moral injury, so we'll get into that a little bit. So we'll get into that a little bit. But then I want to talk about sources of moral injury, how moral injury can happen for people and there's a variety of different ways. We're finding out through research about how moral injury can happen and we'll discuss We'll get into that a good bit today and then we'll do some triggers of moral injury, how different situations and how they can trigger people and really you know, result in that those deep wounds that we call moral injury. And then I'll share a little bit of personal reflection as well as some stories of people that I've worked with who have, who are suffering from moral injury and get into that. So I hope you I'm excited that you're listening to this podcast A lot of information I think it'll be really helpful to you. We have lots of other podcasts on our station too. Last month's podcast I recorded what's called Unseen Wounds Understanding Moral Injury. So that can give you some fundamental concepts about moral injury. If you haven't heard that episode, so let's get into it.

Speaker 1: 2:54

So moral injury has been defined a number of different ways. So moral injury has been defined a number of different ways and it's not a term that is completely. It's not like a term like PTSD, that has been really well defined in the research and has, you know, a very strong, agreed upon definition with very specific criteria of how, um, of what, how someone qualifies, if you will, to to have PTSD, and it's in the DSM and it's, you know, very well defined. Of course there. Course there's still debate about PTSD, for sure. But moral injury is even much it means and how to best define it, how to capture all the possible aspects of moral injury. It's certainly not in the DSM.

Speaker 1: 4:08

Now one of the projects I'm taking on, and Moral Injury Support Network for Service Women is taking on, is to get moral injury in the DSM. We're really looking hard at that. I think it'll take if we're able to accomplish that. I think it'll take two to three, four, maybe even five years to get that done. We'll see, because there's a lot of research that still needs to happen about moral injury. As far as I'm aware, we have moral injury instruments that can determine if someone has moral injury, but you know we don't have symptomatology instruments to really determine to what degree they're suffering from it and how to diagnose it, that sort of thing. So there's a lot of major gaps in the research and that's something you should know up front.

Speaker 1: 5:13

But let's think about how different researchers have defined it. Jonathan Shea defines it as a betrayal of what's right by someone who holds legitimate authority, like in the military, a military leader, for instance, in a high-stakes situation that all says it's perpetrating, failing to prevent, bearing witness to or learning about acts that transgress deeply held moral beliefs and expectations. Dr Nash says it's literal harm to a person or a community as a direct result of betrayals of moral trust in high-stakes situations, trails of moral trust in high-stakes situations and in the medical field, other fields are starting to look at what the term burnout and looking at how what used to be just called burnout we now may need to consider moral injury in that, and that includes places like the law field, medical field and so on. So the way I define moral injury is it's when something traumatic happens to someone, something traumatic that someone participates in, they're a witness to or even heard about. Because we've had folks, they've heard about a very traumatic situation that violates someone's deeply held moral beliefs. So it's got to be deeply held moral beliefs. So it's got to be deeply held moral beliefs. So something very tragic happens to someone, or the person could morally injure themselves by doing something to someone, or they could observe some very traumatic, devastating sort of thing, or even just hear about something very tragic that also violates their deeply held moral beliefs. So we have trauma, violation of deeply held moral beliefs. That's when moral injury can happen. Beliefs that's when moral injury can happen, and we'll get into some more specific examples about that and how you know to help illustrate that better.

Speaker 1: 7:57

Why is it important to understand moral injury? Well, people have found that there are people that have been morally injured but they didn't have a name for it. They hadn't heard of moral injury. They have found that just by being able to name it, being able to say what you have is a moral injury and the reason why you're having such a hard time recovering from it is that it's not just whereas PTSD tends to be about chemical reaction physiology, moral injury is something deeper, it's spiritual, it goes to the core and heart of what someone is, that it can be.

Speaker 1: 8:55

People with moral injury can respond to treatments PTSD treatments but not always. They don't always respond to it because it is a different thing. And so when you understand if you're a care provider, and you understand about moral injury, then when you have a person who presents to you, who is struggling with anxiety, depression, a loss of self, a sense of a loss of self from some traumatic experience experience and just taking medicine is not helping doing you know and you're able to, after hearing their story, what they went through. You're able to help them identify, you're able to identify it as moral injury and you're able to help them identify it. And you're able to help them identify it, then you can start working towards helping them, caring for them and working on that healing at the moral, spiritual level. And I think it's really important to point out that moral injury is actually someone becoming morally injured means they're normal and that this is moral injury, is a normal response to an incredibly tragic, immoral situation. So somebody's morally injured. There's nothing wrong with them. They are a person with morals that were violated. But we want to help them heal and recover and be able to interpret what they experienced through a lens that can help them recover from the trauma that they experienced. So that's why it's important to know what moral injury and and how it can affect people.

Speaker 1: 11:09

So Dr Harold Koenig says that moral injury has both psychological and spiritual dimensions. As a spiritual problem, people experience guilt, shame, spiritual crisis. Why did God allow this to happen? Is there really a God If he would allow this kind of thing to happen? Does it exist? Or it may not even be that it may be. A person still believes in God. They still, but they're just. They're just. They feel so disconnected from God. They just feel they can't. Either they're angry with God or, you know, they just feeling dead spiritually, if you will.

Speaker 1: 12:04

Now, as a psychological problem, it can result in emotional dysregulation, depression, anxiety, suicidal ideations and a whole host of other symptoms. It is not the same as PTSD, but it's very closely related in that people with PTSD experience those kind of things Anxiety, depression, emotional dysregulation, for sure, sleeplessness. There's a lot of, you know, similarities, but the big difference between moral injury and PTSD is that moral injury includes those moral concerns and it includes betrayal, loss of trust, difficulty forgiving, loss of meaning, loss of identity, self-condemnation, religious struggles, loss of religious faith. All those things can be included in somebody who has moral injury, and PTSD does not necessarily include those symptoms. But it is also true that somebody can both have PTSD and moral injury, so they can coexist, no question about it.

Speaker 1: 13:34

So what are some of the sources of moral injury? What are some of the things that experiences or events that could promote or cause moral injury in somebody? So let's talk about that. The first one is you could, a person could, be faced with decision-making dilemmas that are basically lose-lose type situations, right? One example might be. One example might be a doctor having to choose between who lives and who dies, not because of a lack of resources about that during COVID but it's sort of a lose-lose situation of you know, both people can't live. No matter what decision I make, one of the people is going to die, and this could have been prevented by A, b, c or D, right?

Speaker 1: 15:00

So just that sense of helplessness in a very tough decision that results in some tragic consequence. That could be a potential source of moral injury, and then the consequences of actions taken right? So if you, the doctor, has to make one decision or the other, then the doctor has to live with her decision and, you know, maybe questioning for a long time, did she make the right decision? You know, was it right? I'm not a medical doctor but I'm sure medical doctors get training and education about these kind of decisions. But it's different to think about it in a classroom environment versus do it for real. So you have the action versus inaction kind of. You have the action versus inaction kind of conundrum that can face someone.

Speaker 1: 16:16

That can be a potential source of moral injury, feeling responsible for others, and again it kind of goes back to that decision. But it's also about a sense of hyper-responsibility, being responsible, being in a position where you're responsible for the life and death of other people, like military leaders we talked about doctors making those decisions that you know if you're a military leader, you're a commander and you have to send people to war, then you have to live. You know, and you may be in situations, decision-making situations, where you know people are going to die and you're responsible for that. As a, as a combat soldier. You could, uh, you know, you know that you are responsible, you could be in a situation where you know you're the responsible for the death of people, and it's it's one thing to be responsible for the death of um other combat soldiers, the enemy in uniform soldiers have less of a less potential or less experience of moral injury with that sort of thing. Uh, because it's sort of they're trained to do that. Um, they are being attacked, if you will, by the enemy and so people don't have as much of a tend to have as much of an issue with that sort of thing.

Speaker 1: 18:01

It's a collateral damage that's often the result of um of combat, the women, children that die often as a result of things that happen in war. And we see this all the time. We've seen this in the Israeli conflict. We see this all the time. We've seen this in the Israeli conflict, we've seen it in the many years the US has been in Afghanistan and Iraq. You know there's all these rules of war and it's often intelligence that's not accurate.

Speaker 1: 18:50

And my friend talks about as an airborne ranger. He talks about how he struggles with mortal injury because they ended up killing a lot of civilians, lot of civilians, even though they didn't mean to. They were told that, you know, the buildings that they were attacking had basically nobody but bad guys in them, and so they went into those buildings throwing grenades, shooting everything you know, just destructively, because they weren't picking and choosing targets, only to find out that there were women and children in there and they did, you know, end up taking the lives of a lot of them. And so he really suffered from moral injury as a result of that and in ways, it wasn't his fault because he was doing what he was ordered to do, wasn't his fault because he was doing what he was ordered to do. But at the same time, you know it's still it was him and his fellow rangers that pulled the trigger, that threw the grenades, etc.

Speaker 1: 19:59

Another source of moral injury can be feeling helpless in an institution, system or organization that is making bad decisions or decisions that are harming people and yet not being able to do anything about it. Um a a one woman I interviewed, you know she was, as a master sergeant, in charge of the SHARP program Sexual Harassment and Assault Response Program for her unit, and she really wanted to help, especially the women, because those were most, you know, survivors were women. She really wanted to help them by making sure the system worked for them, but the commander was not supportive. He was publicly supportive but in reality he wasn't really following the program or supporting it like it was supposed to be executed. So she felt totally helpless and she knew that women were suffering in the system but she was unable to do anything about it, and so she felt a lot of responsibility for that, a lot of shame for that and guilt and a lot of anger about a system that promises to take care of people but doesn't so that lack of control, feeling helpless in a system or organization. And then there's witnessing atrocities. That can also be a potentially moral injury experience, and I talked about the Airborne Ranger, but other women talked about just what they saw overseas and, again, not being able to do anything about it, seeing the indigenous people in horrific situations, being abused, being attacked, not having the resources they need food, medicine, et cetera and just being deployed there but not being prohibited from helping or not having the resources to help.

Speaker 1: 22:21

One woman I know suffered for years and years and years. She was in charge of the medical program in a faraway country years ago. We were trying to help with medical supplies and so on, setting up, you know, helping refugees and so on, but she was never really given the resources she needed and so she had to stand by and watch many of the folks that she was supposed to be helping die and she carried that burden for many, many years. Then she has gotten some help and we see that help, support, can make a difference to someone and can help someone recover, because the person that helped her was able to help her see that wasn't her fault. So those are some potential sources of moral injury.

Speaker 1: 23:30

What we see a lot of times with women veterans. Moral injury happens in the context of sexual assault, gender harassment, toxic leadership environments, blaming women for everything wrong in the world, making them feel like they don't belong. All those sort of things are very common experiences to women veterans, and so that's sources of moral injury for them can often be really based on their gender. No-transcript. One of the things that we haven't talked about yet but there's definitely an issue for many people is racial issues and sexual identity issues. Minority groups, either racial, ethnically minority groups, have life, liberty and the pursuit of happiness for everyone, yet many people still feel that they are discriminated against and prevented from really finding that life, liberty and happiness, either due to the color of their skin, due to their sexual identity, due to other factors that are beyond their control, or that they were born with and yet feel that discrimination, even violence, against them. And one woman, a friend of mine. She talks about how, uh, she's a black woman and she worries about her son, what kind of world he's going to grow up to. She really worries about his safety because of of violence that continues to happen to racial minorities.

Speaker 1: 26:15

So that also, those sorts of things are definitely moral, injurious experiences, mysterious experiences, and you know, again, we just go back to the definition of moral injury, of traumatic experience that violates some of the deeply held moral beliefs and now you're talking about can happen to anyone, anywhere, in any scenario, in every industry, even though you know research is really focused on most research has focused on military. There's a good bit of research that's going on about the medical field, some in the law field, but you could basically take just about any, any industry and look at the look at issues within that industry that are happening to people, that are immoral and people feel abused. One more example when you think about whistleblowers, people that identify in organizations things that are wrong, illegal, unethical, and then the retaliation that those people often experience could lead about moral injury instruments you know surveys that can be taken to help identify someone has moral injury, and we're not going to cover those in this episode, but they are out there and they can be used. But one thing you can do and I suggest you do anyway, even if you have access to the survey instrument is just really getting the person to tell their story and as you listen to their story you can identify these things triggers, moral injury experiences in their stories, thinking about and looking for themes related to decision-making dilemmas, ethical implications, feeling helpless, disempowered in situations. Them talking about how they've harmed others or how they've seen harm in others or how they've felt helpless to help others who are being harmed. You can look for things like resource scarcity, scarcity, a violation of ethics, clashing values with societal norms or forms of discrimination. So that's what you're really looking for in those stories and if you're hearing those things, then you're probably dealing with somebody who has moral injury and needs some help sorting through the soul wound they've experienced because of whatever events have transpired.

Speaker 1: 30:18

And in probably most cases, what you'll hear are survivor stories like this happened to me, but in some cases you may be hearing perpetration stories of this is what I did, perpetration stories of this is what I did, and a lot of times people people who were actually disempowered in this situation still feel responsible for what happened and they may be saying I should have it's. Another common thing to hear is I should have done this, I should have done that, and it may not really be true that they had a lot of control in that situation. They might have felt they did or should have, but they didn't. They might have felt they did or should have, but they didn't. And commonly you hear that with sexual assault type situations where I should have known not to drink with that person, I should have, you know, not trusted them. I should have been able to do something while it was happening to me, but I was just frozen. And so they're taking responsibility for things that were really outside of their control or they didn't have the information they needed to do it. Like the Airborne Ranger friend I was telling you about, they killed a lot of innocent people, but it wasn't because they wanted to. It was because they were given bad information. They were given bad information. So now, looking back, you have to factor that in to how much guilt or how much blame someone should take for themselves. And even if they are fully to blame or nobody's ever fully to blame, 100% to blame there's always other factors that are playing in. But even if they have some blame to take, well then that's what forgiveness is for, and everybody has to be able to come to a place where they can feel they can be forgiven.

Speaker 1: 32:26

Okay, so I hope this podcast has been really useful to you. We've talked about the concept of moral injury, how it's currently being defined, and then its difference between moral injury and PTSD and the importance of understanding moral injury, and then we've talked about some potential sources and triggers for moral injury from a whole bunch of different directions, and throughout that I've tried to weave in some personal stories of people I know or people that I've helped or worked with or conducted research with, about how they experienced moral injury, and so we. So I encourage you to look at last month's episode. In November. We'll I'm going to, each month, continue to do another episode, digging deeper and deeper into moral injury for you and helping to really, you know, understand it on a on an even deeper level. The great news about having it as a recorded podcast. You can go back through and listen again and again and each time you listen to these podcasts you'll find something, find some new information. So the next podcast scheduled for January is about the effects of moral injury. We'll get into how people really, how it changed their lives and how difficult you know we're talking about a really deep wound that has like PTSD, has a lot of effects, both in a person's body, their mind, their soul, and it can affect their relationships, other people. The tentacles of moral injury and its effects are many and they can be far-reaching. So we'll talk about that next time.

Speaker 1: 34:36

If you're struggling with moral injury you'd like to get some help, I suggest you reach out to Moral Injury Support Network for Service Women Incorporated, especially if you're a service woman. That's our specialty is working with them and you can reach us by calling 910-701-0306. You can find us on the website, misnsorg or you can email me at droberts at misnsorg. So if you're struggling with moral injury, we have a lot of partners. We have a lot of experience and knowledge in how to help you and you don't have to be a woman to reach out to us. You can be any kind of person, you don't have to be military, you don't have to be military, and we'll help you get the help you need. We will assist you. And so feel free to reach out to us.

Speaker 1: 35:40

If you're a chaplain or a psychologist, social worker, a counselor and you want to learn about moral injury, we have training programs. We have books that we publish, training programs, we have books that we publish, and so there's a lot of you know. We have information for you to help you. We're working on a moral injury fundamentals kind of guidebook. That's been out. We've published three other books you can get from Amazon. You can get from Amazon.

Speaker 1: 36:16

Um, I've been published in peer reviewed journals, uh, multiple times, and so have my partners. So a lot of help out there for you, information for you We'd be happy to share with you and uh, so until then, I hope you have a great, great day this is being recorded just as Christmas holidays are upon us. So, whether you call it Christmas or holidays, you know, I just want to wish you a happy holidays, a merry Christmas. I just want to wish you a happy holidays, a merry Christmas, that this time of year, hopefully this time of year will be bright and fun and joyful. I know it's also going to be very stressful, and so I hope that it's more joyful and helpful than stressful. So, uh, but anyway, until next time. Bye for now.