types of traumatic
stress injury
Here we unpack the various types of moral injury. Each type has a distinct character or emotional tone which, along with threat and traumatic loss, represent different pathways to traumatic stress injury.
Traditional perspectives on trauma
To understand moral injury, we need to understand it in the context of trauma and Post Traumatic Stress Disorder (PTSD). In broadest terms, trauma is something that affects our sense of the world being safe. PTSD is a reaction to trauma where the brain and body prioritise safety and survival at the expense of other priorities like pleasure, social connection and learning. These reactions to extreme stress are natural and are typically experienced by most people in the context of life threat. They usually subside when the traumatic event passes, but with PTSD, the survival response gets "locked on."
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There are several theories about why some people develop a lasting injury like PTSD after trauma and we don't need to go into those here, other than to say that something derails the brain's usual processing of experiences and that the intensity of the event, one's reactions and the degree of social support all contribute.
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Mental health and diagnostic systems have traditionally adopted a fairly narrow view of what constitutes traumatic stress. PTSD was first formalised as a diagnosis in 1980. At that time it was categorised as an anxiety disorder and thought to be an entirely fear-based injury caused by experiencing or witnessing threat to one's physical integrity. It was associated with intense feelings of fear, helplessness, powerlessness or loss of control.
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This established a paradigm of neglecting a whole spectrum of traumatic experience that was not fear-based at all. In fact, the latest research demonstrates that other experiences can cause symptoms similar to PTSD and that exposure to potentially morally injurious events (PMIEs) is significantly associated with PTSD, along with depression and suicidality.
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In this context, moral injury is a type of traumatic stress injury and one cause of PTSD, as well as a separate injury in it's own right.
​Examples of threat-based traumatic stressors include:
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Accidents
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Natural disasters
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Physical and sexual violence
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Armed combat, peacekeeping and law enforcement operations
For those experiencing severe trauma-related distress, it is generally more helpful to think in terms of a range of traumatic stress injuries.
types of moral injury
Descriptions of moral injury have tended to settle into two types. The first derives from the experiences of Vietnam-era veterans documented by psychiatrist Jonathan Shay and focuses on experiences of moral betrayal. The second put forward by Brett Litz and colleagues derives largely from experiences of veterans of the wars in Iraq and Afghanistan and focuses on moral transgressions. While these are dominant themes in our clinical work, we have also seen a range of other experiences that are not fully accounted for in the predominant models. A more granular model that speaks to the full range of moral wounding that can be experienced is outlined below.
Moral Pollution
We are neurobiologically wired in a way that allows us to recreate the physical and emotional experiences of others in our own bodies. This gives us the capacity for empathy and compassion but is also a means by which we can be psychologically wounded by proxy. We can be deeply affected by witnessing human vulnerability, suffering, devastation, gore and emotional anguish.
This concept is more commonly referred to as vicarious traumatisation (being exposed to trauma suffered by others) and there is a broad literature on it's impact in certain populations. It is included here because there is growing recognition of vicarious traumatisation as a common and powerful pathway to moral distress and traumatic stress injury. Vicarious trauma can lead to moral injury when one is left with a sense of helplessness, responsibility or culpability about the harm or suffering of others.
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The term moral pollution is used here to convey the lived experience of vicarious traumatisation: the way that horrifying experiences can contaminate one's being like a toxic substance. Sometimes bearing witness to intense trauma suffered by others can hit with such an explosive force that it lodges in one's own psyche like a kind of "emotional shrapnel."
Moral pollution invokes feelings of horror and disgust and can leave one feeling tainted long after traumatic events have passed. Concerns that this toxicity might somehow spill into loved ones can have a significant impact on relationships and quality of life.
Moral Betrayal
When Jonathan Shay first introduced the concept of moral injury in his 1994 book Archilles in Vietnam: Combat Trauma and the Undoing of Character, he described it as
"A betrayal of what's right by someone who holds legitimate authority in a high stakes situation."
Shay conveyed the profound experience of being let down by those who were supposed to "be there" when it mattered. Betrayal can be an absence of needed support and resources that undermines one's capacity to stay safe or do the right thing and is most corrosive when it occurs at a time when the support is crucially needed.
Social and systemic structures like procedures, codes of conduct, chains of command, ethics and a clear purpose can act as a container for traumatic stress. But when these fail, such as when another agenda or objective is held above the one that morally matters, this betrayal of values is experienced as a type of abandonment.
Moral betrayal ruptures social bonds that bring cohesion, order and meaning to the world. When we can't trust the systems, structures and people around us, the world feels eminently more threatening and we face it alone. "A world in which trust is lost is a dangerous world," (Steel and Hilbrink, 2015).
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Moral betrayal most often leaves those who experience it with feelings of outrage, anger and embitterment. Research is beginning to show how moral pain and chronic embitterment can maintain PTSD symptoms. A distinct diagnosis known as Post Traumatic Embitterment Disorder has been proposed in the trauma literature and recent studies have demonstrated it's close relationship with moral injury and, to a lesser extent, PTSD.
Injustice
Justice can be something that we don't really notice until it is violated. It has been often overlooked in the trauma literature but there is convincing evidence that it can both cause and maintain psychological distress. On the surface, injustice may seem similar to moral betrayal because it can stem from systemic failures, but it can also involve more targeted and deliberate violations of human rights, compounded by lack of access to a means of addressing those violations (restorative justice).
Injustice involves experiences of discrimination, indignity, disrespect and marginalisation that can feel intensely disempowering and deeply personal; like an attack on one's (or indeed, someone else's) person based on either very specific characteristics or arbitrary status.
Injustice injuries are incredibly isolating because it is difficult to convey the hurt that comes from being portrayed or treated as something you are not, somehow less human or less deserving of respect and dignity, or sometimes just invisible. It is also hard to explain the smouldering embitterment or explosive anger that ensues. Like being in a dream where one is unable to speak, rendered silent and invisible to those around you; only the dream is your reality. People with injustice injuries often become preoccupied with justice (or revenge) and acutely sensitive to even small examples of injustice in daily life.
Moral Compromise
In all of the above types of moral injury, the agent of harm is external to the individual. Moral compromise brings the agency of injury within the sphere of one's behaviour and is generally caused by actions (or inaction) that violates important values. Brett Litz and colleagues (Litz et al., 2009) describe this as
"Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations."
Moral compromise relates to experiences of moral transgression: acts of both commission and omission. One can feel morally compromised by one's own or another's actions. Either way, it is experienced as personal corruption caused by actions or outcomes that directly conflict with one's intentions or deeply held values. These can be accidental, such as in a motor vehicle accident resulting from poor choices or reckless behaviour. Or they can be intentional, resulting from a momentary loss of control or a more sustained disconnection from one's moral compass.
Whatever the circumstances, the wound is caused by one's sense of moral culpability. Being the agent of harm - where serious injury is connected to one's actions - can be experienced viscerally like in moral pollution. But with moral compromise comes a deep sense of what Judith Sherman (2014) called "lost goodness." This simple phrase conveys the sense of lost virtue, honour and standing, leaving one feeling permanently stained.
Moral compromise - and its associated feelings of guilt and shame - can be isolating because of one's expectations about others' reactions to the perceived transgression.
Moral Degradation
Under certain circumstances, humans have the capacity to behave in ways that breach conventions of acceptable behaviour. The term moral degradation indicates an erosion of one's moral compass to the point where one's sense of right and wrong becomes corrupted, distorted or even inverted.
Moral degradation refers to behaviour that develops in one context but can cause shock, horror and moral distress when reflected on in a different context. This can occur in situations involving crisis, survival, disaster, complex operational dynamics or exhaustion and burnout, where other priorities are held above those of usual moral standards, resulting in cruel, uncaring and degrading behaviour.
Corruption of one's moral compass can develop through a process of numbing in response to prolonged exposure to threat, traumatic loss, injustice and human rights violations. It is a reaction to injury or harm caused to others, but it is also an injury to oneself: a corruption of one's values and ethical codes. However, to be injured, one has to become aware of this degradation: where numb uncaring gives way to horror at the realisation of one's actions - sometimes triggered by the reactions of others - resulting in guilt and shame.
While moral degradation represents a dereliction of moral codes, the injury and associated pain - like the other forms of moral injury - represents a beginning. Facing, assimilating and learning from the pain can become a foundation of recovery: recovery of goodness, rehabilitation of one's moral compass, and social and emotional healing.
The injury and associated pain represents a beginning: facing, assimilating and learning from the pain becomes a foundation of recovery.
Traumatic and Symbolic Loss
Another cause of traumatic stress injury involves traumatic loss of life. While death has been core to our definition of trauma in diagnostic criteria for decades, the experience of loss involved in this type of stressor - particularly as it might arise with a stranger - has often been overlooked. Like moral injury, treating loss and associated grief or guilt reactions with interventions that target anxiety and threat-survival responses may miss the mark.
Traumatic loss can cause intense feelings of shock, grief, guilt and concerns for human vulnerability and dignity.
​Examples of traumatic loss include:
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Sudden, horrifying and violent loss of life
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Death of a vulnerable person (e.g. child, elderly)
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Personal connection or identification with the victim of an accident or crime (e.g. same age as own child)
There is a type of traumatic loss that arises surprisingly often amongst health and public safety personnel along with the military. This is where one has no direct personal connection to an individual but are deeply impacted because of a symbolic connection. The person can remind one of someone (a child or sibling), or be representative of vulnerability (elderly). We will refer to this type of loss experience here as "symbolic loss."
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There is a core theme in symbolic loss around dignity. This derives from an implicit sense of people's deservedness of dignity in death: involving basic respect for someone's remains and respect for the cultural norms and imagined wishes of both the individual and those that love them.
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These experiences can be deeply wounding but are hard to understand, let alone express. And there are no established norms for how to process such feelings. So people are often left with a prolonged sense of guilt and a keen imperative to remember - or more accurately, to not forget - the individual.
People suffering from traumatic or symbolic loss can find themselves stuck in a cycle of guilt and self-handicapping behaviour through a desire to honour the memory of the individual and may need specialist support in finding less self-restricting ways of doing this.
psychosocial pillars Related to trauma and recovery
The psychosocial context in which trauma occurs can be as important as the nature of the trauma itself. Derek Silove and colleagues (2013; 2017) have reinforced how responses to trauma are multidimensional; involving social, cultural and existential aspects along with the more commonly recognised biological and psychological ones.
The psychosocial pillars include:
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Safety and security
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Social bonds and networks
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Justice
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Roles and identity
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Existential meaning
These psychosocial structures represent an adaptational scaffolding upon which both individual and community wellbeing depends. They provide a container of cohesion and meaning that serves as a protective buffer and promotes resilience in situations involving prolonged stress, moral adversity and social upheaval. But like individual resilience, they can be eroded, creating vulnerability to sustained psychological harm. That is, when these pillars are strong, they help us be strong and stay well. When even one of them breaks down, it is through this breach in the container of cohesion and meaning that the trauma-related harms outlined earlier on this page can cause injury.
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These pillars may also help to explain "delayed onset PTSD" - where the injury does not emerge or affect wellbeing and functioning until sometimes many years after the traumatic stressor. For many, particularly those who have sustained cumulative exposure to potentially traumatic events but largely remained resilient, it is when the container itself gets damaged that they become flooded with overwhelming memories of past events.
Moral injury may be more corrosive to the pillars than threat or traumatic loss, because as highlighted above, threats to moral integrity can also impact on our sense of safety, our social bonds and sense of justice as well as our identity, roles and meaning.
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The model highlights the important role of the psychosocial environment not only in injury, but also in recovery. Interventions for PTSD and other forms of trauma related distress need to account for sources of threat to moral, judicial, spiritual and affiliative integrity as well as physical integrity. Horror, loss, indignity, injustice and betrayal need to be addressed in the environment that caused the injury (for example, workplace factors) and efforts need to be made to not perpetuate these factors in the recovery environment.
Sometimes one's only option is to disengage from a toxic environment. Alternatively, empowering oneself with information and support can help one to weather psychologically corrosive injury management systems. A foundational principle of trauma therapy is that in order to be effective, it needs to be conducted in an environment that is safe and free from the threats that caused the injury.
It is up to all of us who live and work in this trauma space to recognise and push for changes that reduce unnecessary or preventable harm and support wellness and recovery.