EASY-TO-UNDERSTAND SUMMARY: MORAL INJURY
What is Moral Injury?
“Moral Injury” is a type of mental health injury that can arise after being forced to do something that contradicts one’s own moral code, or witnessing someone else act in such a way and failing (or being unable) to stop it. Examples of this could be a soldier following orders to do something during wartime that they would never consider doing outside of war (e.g., torture, killing someone, sexual assault), or an employee feeling unsupported or betrayed by their institution (e.g., a police officer feeling their mental health struggles are being disregarded).
A recently relevant example of moral injury could take place during the COVID-19 pandemic, when a healthcare provider might have only one ventilator but two patients who need it, and they must choose which patient gets the life-saving treatment. Their choice may mean that the other patient dies. These are often impossible situations with no satisfactory options, and moral injury can be the result. We’re exploring this important topic in a couple of our ongoing studies. Stay tuned for the results of those studies, below.
What does research show about how military service is associated with moral injury, guilt and shame?
Nazarov A, Jetly R, McNeely H, Kiang M, Lanius R, McKinnon MC. (2015). Role of morality in the experience of guilt and shame within the armed forces. Acta Psychiatr Scand , 132: 4–19.
For this paper, we were interested in better understanding how military operations affect the mental health of its personnel. This article offers a summary of the existing research (as of 2015), investigating how personal morals might be connected to experiences of guilt and shame, and consequently, to overall mental health in military personnel – and more specifically, to moral injury. Within the context of war, certain (previously unthinkable) actions might seem necessary for the greater good.
Review of the research suggests that experiencing a moral injury during military service is associated with symptoms of guilt and shame, and that these particular symptoms play a significant role in the development of mental health issues, such as PTSD and Major Depressive Disorder. Interestingly, these associations remained the same regardless of how much combat the individual had seen.
This suggests that it is very important for us to recognize moral injury (and its relation to guilt and shame) as a significant source of psychological trauma, in addition to the more traditional fear-based events, such as combat. This understanding will help us develop more effective treatments, and ideally, help us identify potential ways to prevent such significant mental health consequences.
What changes happen in the brain when someone recalls the memory of a moral injury?
Lloyd CS, Nicholson AA, Densmore M, Théberge J, Neufeld RWJ, Jetly R, McKinnon MC, & Lanius RA. (2021). Shame on the brain: Neural correlates of moral injury event recall in posttraumatic stress disorder. Depress Anxiety, Jun 38(6):596-605. doi: 10.1002/da.23128.
Military members and public safety personnel (or “PSP” – e.g., police officers, corrections officers) are often faced with situations that challenge their own ethics and morals. Finding ways to handle this type of challenge while maintaining their own sense of right and wrong can help them feel purposeful and accomplished on the job. On the other hand, acting in a way that contradicts their personal and moral beliefs, or witnessing a trusted college violate these beliefs can result in a type of mental health injury referred to as a “moral injury” (MI).
MI tends to involve a number of distressing emotions such as shame, guilt and rage. As noted in previous sections, an example of this type of situation could be if a soldier were ordered to complete a task that conflicted with their personal morals (e.g., torture). MI has been linked to the development of PTSD in military members, and knowing there was very little research on the effects of moral injury on the brain, we wanted to explore this further.
To do this, we recruited participants who would fit into one of two categories, either, 1) adults with PTSD from the Canadian Air Force or other PSP groups, or 2) adults from the civilian population who had been exposed to a moral injury but had no history of PTSD or any other mental health disorder (our “control” group). Our hypothesis (i.e., assumption, or guess) was that recalling memories of a moral injury would affect the brain differently in these two groups.
To test our hypothesis, participants were asked to write a description of two personal memories: 1) an emotionally neutral event (e.g., a trip to the grocery store), and 2) an event that involved a moral injury. Then, on a second day, our participants were asked to complete an fMRI scan (functional Magnetic Resonance Imaging). An fMRI scan takes many images of the brain while someone is completing a mental task – these images reveal which brain areas are being used for the task.
In this study, our participants read the descriptions of of their memories, one sentence at a time, while the fMRI was taking images of their brain – first their neutral memory, and later, their MI memory. After exposure to each sentence of their memories, participants were asked to rate the extent of any shame they were experiencing in the moment. This allowed us to investigate how both types of memories, including any related shame, affected the brain activity of our participants in our 2 research groups.
Indeed, we found that brain activity during memories of moral injury looked different in our participants with PTSD than it did for those without. In the PTSD group, more activity was seen in brain areas involved in hyperarousal (e.g., being highly aware of surroundings, being easily startled), and in areas that help interpret “gut reactions” (e.g., feeling “knots” in the stomach/sick feelings that may tell us we feel uncomfortable with our actions). The PTSD group also showed more activity in brain areas involved in responding defensively to threats (e.g., engaging in self-protection), and areas used for cognitive regulation of emotions (e.g., using logic/reasoning to try to reduce distress).
The differences between our 2 study groups suggest that, when individuals with PTSD remember moral injuries, they may experience a surge of shame/blame-related “gut” sensations. This, in turn, may trigger reactions in the brain to help manage these uncomfortable feelings in the gut and the related emotions (e.g., telling oneself, “This is necessary for the safety of our country”, to trying to reduce the sick feeling in their gut and any shame). Members of our non-PTSD group did not demonstrate these reactions. These results are consistent with previous research, demonstrating the psychological impact of MI.
How is PTSD following a moral injury different from other forms of PTSD?
As noted in previous sections, moral injury can arise after someone acts (or is forced to act) in a way that contradicts their own moral beliefs, or from witnessing a trusted colleague violate these beliefs. A moral injury seems to be a unique type of psychological trauma. Although a morally injurious event can cause mental distress, PTSD, depression and suicidality, a moral injury seems to be different from other traumas, but how?
While most moral injury studies have been completed with military personnel, moral injury can occur in a variety of helping jobs that involve trauma, like health care workers during the COVID-19 pandemic. One example of potential moral injury was at the beginning of the pandemic, when health care workers had access to only a limited number of ventilators, forcing them to have to choose which patient to give it to (and who went without). Through no fault of their own, they would have been unable to provide the appropriate treatment to a person in need, which many experienced as a moral injury. In this study, we began trying to clarify how brain function may be different between “standard” PTSD and moral injury.
As discussed previously, a moral injury typically involves people in high-pressure situations acting in a way that contradicts their moral beliefs, failing (or being unable) to stop someone else from violating these beliefs, or feeling betrayed by their trusted leader, peer or institution. Moral injury tends to involve a number of distressing mental health outcomes, for example, PTSD, depression and suicidal thoughts. However, the similarities and differences in brain function/activity when comparing PTSD and moral injury are not well understood. Further, while most research on moral injury has been conducted with members of the military, moral injury can occur in a variety of jobs in which traumatic events are common. For example, research shows that moral injury can be a significant issue for health care workers, particularly during the COVID-19 pandemic. This study was intended to contribute to the moral injury research.
A moral injury occurs when a deeply held moral code has been violated, and it can lead to the development of symptoms of posttraumatic stress disorder (PTSD). However, we still know very little about how brain activity differs between moral injury and PTSD. Research suggests that the default mode network (DMN) - a brain network involved in memory, self-reflection and our sense of self—may function differently in people with PTSD who have experienced moral injury. However, studies often leave out deeper areas of the brain, including the brainstem, midbrain and cerebellum. This is a critical oversight because these regions also appear to function differently in PTSD and may underlie strong moral emotions such as shame, guilt and betrayal.
What was involved in the study?
Methods: We conducted an independent component analysis on data generated during script-driven memory recall of moral injury in participants with military- or law enforcement–related PTSD (n = 28), participants with civilian-related PTSD (n = 28) and healthy controls exposed to a potentially morally injurious event (n = 18).
During the brain scan, participants were guided through the memory of a morally injurious event. The researchers then examined how different areas of the brain communicated during this memory recall. In particular, they looked at the default mode network, or DMN, which is involved in autobiographical memory, self-reflection and our sense of who we are. They also looked at lower regions of the brain, including the midbrain, brainstem and cerebellum, which are often left out of studies of large-scale brain networks.
What did we discover and how does this impact treatment?
The study found that participants with civilian-related PTSD showed stronger communication between the DMN and a midbrain region called the periaqueductal grey, compared with people who had experienced a potentially morally injurious event but did not have PTSD. They also showed stronger communication between the DMN and part of the cerebellum. Participants with military- or law enforcement–related PTSD showed a similar pattern of stronger communication between the periaqueductal grey and the DMN, although this finding did not reach the study’s threshold for statistical significance.
The periaqueductal grey is involved in automatic survival responses and in the bodily experience of intense emotions. The DMN, in contrast, is involved in memory, self-reflection and identity. The stronger communication between these regions suggests that, in PTSD, memories and thoughts about the self may be influenced more strongly by lower-level survival and bodily systems.
This may help explain why recalling a morally injurious event can bring up such powerful feelings of shame, guilt and betrayal, as well as a physical urge to cringe, hide or withdraw. The findings suggest that moral injury may be represented not only in higher brain regions involved in thought and reflection, but also in deeper brain systems involved in survival responses and bodily sensations. In other words, moral wounds may be experienced at a very deep, embodied level.
These findings also have possible implications for treatment. Therapies that work mainly through thinking, reflection and changing beliefs may be helpful, but they may not fully address the lower-level brain and body responses involved in moral injury and PTSD. We suggest that bottom-up approaches, which begin with bodily sensations and lower brain systems, may be useful alongside top-down psychotherapy. Examples of bottom-up approaches that could be helpful that we discuss in the paper include sensorimotor psychotherapy, Deep Brain Reorienting (DBR), and neurofeedback.
More research is needed to clarify the differences between moral injury and PTSD, and to understand whether these brain patterns are also present when a person is not actively recalling the event. However, this study highlights the importance of including the midbrain, brainstem and cerebellum when trying to understand the effects of trauma and moral injury on the brain.
