Defining Moral Injury

Moral injury results from a betrayal of trust, disrupting one’s beliefs and moral compass. It comprises persistent psychological and emotional distress, moral confusion, spiritual anguish, social alienation, and distrust for institutions.

Probably comes closest to definition I use, to wit:

What is moral injury? We at the Moral Injury Institute define moral injury as witnessing (whether in person, through reporting, or some other means) something that causes a crisis of conscience due to a violation of one’s deeply held moral, religious, or ethical beliefs such that one psychically suffers in a materially adverse way.

Note that both are in alignment with Dr. Jonathan Shay’s groundbreaking work on moral injury. The Shay Moral Injury Center continues to offer counseling for veterans.

Unfortunately the VA has, in the words of Dr. Roger Brooke has pathologized its definition. It has systematically stripped all nods to the very real psycho-spiritual components. This has denuded what separates moral injury from PTSD. Their definition is:

In traumatic or unusually stressful circumstances, people may perpetrate, fail to prevent, or witness events that contradict deeply held moral beliefs and expectations (1). When someone does something that goes against their beliefs this is often referred to as an act of commission and when they fail to do something in line with their beliefs that is often referred to as an act of omission.

Do you see how their definition a) strips any spiritual component out and b) not so subtly, shifts the blame to the witnessing subject ? This, in my opinion is to a) avoid any religious component from therapy and b) to smash the square peg in the round hole of quote “evidence based outcomes.” This avoids any questions about the morality of war, discussion of squishy subjects like religion or ethics, and delving into where the individual’s ethics come from .

The definition you start with drives everything. If you start from retraumatizing the patient, like VA does, no wonder they have poor longitudinal outcomes. Desensitization might work for PTSD, but it isn’t effective for moral injury.

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