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.
