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The Trauma of Moral Injury

Trauma takes many forms. Some such as Post-Traumatic Stress Disorder (PTSD) have become common terms in recent years, but one kind of trauma that gets less publicity is Moral Injury.

Moral Injury, often misdiagnosed as general PTSD, stems from a person acting in a way that is discordant with his or her core values, thus leaving them with an acute identity crisis.

Imagine a doctor who is working in a hospital that is overwhelmed with dying COVID-19 patients. She has taken an oath to save lives but, due to a lack of equipment, she is forced to choose which patients will get ventilators and live and which patients will not, and therefore are likely to die.

Moral Injury here is a traumatic identity crisis brought on by a conflict between her core values (a desire to save lives) conflicting with her actions (denying care to some patients). Which is the doctor's true self; the life saver or the life denier? Can she still see herself as a good person? Is she still a person of honour, who always acts in accordance with her values? The doctor's inability to answer such painful questions can be profoundly traumatic. This is moral injury.

While the doctor in this example actively had to choose who to let die, Moral Injury can also affect people who have not made such direct choices but have, rather, failed to do something, or failed to do it well enough. A firefighter who cannot rescue everyone in a burning building would be one such example. He may ask himself why he managed to save some people and not others? Could he have acted differently to save more people? Could he have been quicker? Or communicated better? Or looked for survivors elsewhere? Or called in sniffer dogs sooner? Can he still see himself as a decent man? Again, his core values of being a good person (who rescues others) is in conflict with his actions (failing to rescue some people) and it is causing an acutely traumatic identity crisis.

Moral Injury is not restricted to hospital wards, burning buildings or battlefields. It can happen anywhere. People who endure domestic violence situations may not just be traumatized by the violence itself, but also by their own failure to stop it from happening - such as a family member who fails to stop an an abusive parent beating another family member. Here, again, the behaviour is discordant with the values.

Moral Injury is a specific kind of trauma and, psychotherapeutically, it needs be treated at an identity level. The therapist will work with the client to build, develop or strengthen their sense of identity and ensure that it is based on WHO they are, rather than on WHAT they have or have not done or HOW WELL or poorly they have done it. Only then will the client be able to reconcile the conflict between their values and the actions that truly horrific situations have imposed upon them.



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