Moral Trauma, Also Known as "Soul Wounds"

*From Michele’s upcoming book, Writing the Wrongs: A Guided Journal for Healing Moral Injury (New Harbinger, 2024)

Moral Injury

In the last three decades, the study of moral adversity has seen increasing attention. While there is still no consensus definition, it is generally agreed that moral injury, happens when a person’s core moral foundations are violated in high stakes situations. This violation recasts the way people see themselves, others, and the world and causes changes in behavior that signal a loss of trust, connection, self-worth, and meaning.

Violations can happen from actions a person took (such as killing another person, whether it was intentional, unintentional, or unavoidable); actions a person witnessed (like torture or abuse); actions a person was forced to do against their will or better judgment (like abandoning or injuring someone or lying, cheating, or falsifying information because a higher-up commanded you too); and actions that a person couldn’t take to prevent a bad situation from happening.

People with moral injury often feel a range of emotions like shame, guilt, anger, disgust, contempt, resentment, despair, grief, remorse, worthlessness, hopelessness, helplessness, powerlessness, alienation, self-loathing, and hate. Sometimes, after a while, people stop feeling anything at all.

Depending on the type of violation, people often lose trust in themselves, others, God, and/or the world. They see themselves as bad, evil, weak, a monster, or unworthy — or they see others that way. They feel like the world no longer makes sense or is unsafe and unfamiliar. They often lose faith and have trouble forgiving, having compassion, or relating to others.

People with moral injury often have relationship challenges; they avoid intimacy, self-isolate, and lash out at the littlest provocation. Because the “story” of moral injury is often too painful to share — they think others couldn’t understand, wouldn’t understand, or would judge — people will “swallow the awful” and live in self-segregating silence. It’s not uncommon for people with moral injury to try to hide their pain with alcohol or drugs, or by engaging in risky and self-sabotaging behavior. Suicidal thoughts are also not uncommon.

 

Moral Distress

Moral distress, related to moral injury, is a term coined in 1984 by philosopher Andrew Jameton to describe the suffering nurses experienced when institutional or systemic barriers prevent them from acting with integrity, particularly when it comes to fundamental moral principles and ethical responsibilities. At times, actions deemed to be ethical are different than the ones a person would naturally choose if otherwise available.

In the wake of the COVID-19 pandemic and the social, political, and economic unrest that simultaneously emerged, the concept has broadened to include other professions, such as medical professionals generally, social service providers, teachers, law enforcement, the military, emergency service providers, lawyers, journalists, and politicians. In our day-to-day lives, this type of suffering can take a serious toll on beliefs, relationships, and affiliations.

Powerlessness, particularly, is at the heart of moral distress. It is the feeling that a person has had to, or must seriously, compromise themselves or something they hold dear due to external forces seemingly beyond their control. It is also the sense that others don’t grasp a moral significance or moral imperative that is clear to a person. Moral distress is what results from repeatedly not having their values respected, either individually or collectively.

People with moral distress often feel muzzled, restricted, devalued, unheard, or dismissed. They easily become fueled by anger, disgust, fear, and frustration. Over time, these emotions can fill a person with anxiety, depletion, or depression. A sense of being fragmented can set in, leaving them to question who they or others are at their core and what the world is, generally, like moral injury. Research by Dr. Cynda Houlton Ruston at Johns Hopkins University also shows that moral distress has long-term consequences, such as burnout, exhaustion, numbness, disconnection, and diminished moral sensitivity (also called “compassion fatigue”).

The damaging effects of moral distress aren’t limited to the affected actors. For instance, in health care, patients can also be negatively impacted, due to changes in a providers’ actions or attitudes toward care; similarly in law enforcement, social service settings, education, among others. In our day-to-day lives, this type of calcification can take a serious toll on beliefs, relationships, and affiliations. In its extreme form, it can result in “otherizing.”