Behind the Uniform: When struck by moral injury

RackMaster

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An excellent read. It's Canadian and the resources listed are Canadian but the article is relevant to many of us.

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.


Resources

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

Behind the Uniform: When struck by moral injury
 

Marauder06

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Interesting article. I admit to being skeptical, though. The article says:

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

The first two pre-suppose that unintentional deaths, or even intentional ones, are de facto "morally injurious." Moreover, the term "injury" is problematic. An injury is a wound, or some type of harm. To me this seems like a setup to get more people on the "disabled" rolls. I think there is probably a better and more accurate term out there than "moral injury."
 
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RackMaster

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There's a lot of use of injury up here. We typically don't use PTSD as a blanket description, since there's so many different flavours and combinations of mental health diagnosis. We use Operational Stress Injury to encompass everything. I think the intention is to cut back on comparing diagnosis and that it can be healed.
 

Marauder06

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How about just "operational stress" or "emotional distress?" Is there some benefit to calling it an "injury?"
 

Andoni

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Moral injury, PTS and TBI is the trifecta of Satan's asshole, imo. I found a therapist who works directly from St. Augustine's writing to treat moral injury.

She's 65, loves Krav Maga and previously affiliated with SWCS. She has my ear.

My takeaway is that "Privation of good" and "exposure to evil, not abuse" are two recurring topics and required elements in moral injury.

She is clear that "privation of good" and "exposure to evil, not abuse" doesn't apply to people who are true psychopaths or sociopaths-- but absolutely applies to the vast majority of war fighters and first responders, because the occupations require emotional paralysis in order to operate.

My take is that moral injury creates an injury of the soul, which can leave what feels and appears to an empty hole, afterwards. Augustine says that it's not empty, in the hole in your soul, it's just pitch black. Exposure to evil is the shade, and the sun is a person's soul.

When the sun is obscured from view, it's still there. When a non-sociopath is exposed to evil, it creates a hole that isn't empty, but it feel like it. The hole is dark for the same reason the ground is dark by a tree in the hot sun. The sun is still there, but tree obscures it, and there's a shadow, so it's dark and cool.

A lot of this is way over my head, honestly. I have zero interest in philosophy. But seeing the "moral injury therapist woman" isn't making anything worse, so that is of value to me.
 

RackMaster

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Moral injury, PTS and TBI is the trifecta of Satan's asshole, imo. I found a therapist who works directly from St. Augustine's writing to treat moral injury.

She's 65, loves Krav Maga and previously affiliated with SWCS. She has my ear.

My takeaway is that "Privation of good" and "exposure to evil, not abuse" are two recurring topics and required elements in moral injury.

She is clear that "privation of good" and "exposure to evil, not abuse" doesn't apply to people who are true psychopaths or sociopaths-- but absolutely applies to the vast majority of war fighters and first responders, because the occupations require emotional paralysis in order to operate.

My take is that moral injury creates an injury of the soul, which can leave what feels and appears to an empty hole, afterwards. Augustine says that it's not empty, in the hole in your soul, it's just pitch black. Exposure to evil is the shade, and the sun is a person's soul.

When the sun is obscured from view, it's still there. When a non-sociopath is exposed to evil, it creates a hole that isn't empty, but it feel like it. The hole is dark for the same reason the ground is dark by a tree in the hot sun. The sun is still there, but tree obscures it, and there's a shadow, so it's dark and cool.

A lot of this is way over my head, honestly. I have zero interest in philosophy. But seeing the "moral injury therapist woman" isn't making anything worse, so that is of value to me.

Very well put.
 

Serenity

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I think 'moral injury' sounds like a good term, but I was diasappointed with the article. It felt like it lacked depth over something that needs to be carefully defined, and is instead a catch all that could cover anything. So interesting concept but fluffy for me. As a civilian, I didn't get much from it tbh. I was hoping for more... :(
 
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