Moral Injury and How Coaching Can Help
What is Moral Injury?
Moral Injury (MI) is intense emotional and psychological distress resulting from a person's actions, or failure to act, which violate an individual’s moral or ethical code. It clashes with who one believed oneself to be, one's identity as a moral being, and betrays one's expectations of oneself (Dr Matt Gray, 2024).
Put simply, it's when something you did (or couldn’t do) felt contrary to your morals (King’s Centre for Military Health Research (KCMHR), King’s College London, 2020).
Often MI results from situations where harm was unavoidable or accidental. For instance, military personnel who are involved in conflict where civilians are killed or injured, or where atrocities are committed. Or healthcare workers with limited resources such as on Covid wards, who had to choose which patients would receive lifesaving treatments or not. And Drivers who cause injury or death whilst being reckless, texting, or driving under the influence.
In organisations, people may feel complicit in management decisions that disadvantage innocent people on grounds of gender, race, orientation, etc. Such actions go against their moral code, and they don't speak out for fear of reprisals.
Three Causes
What are the effects of Moral Injury?
Shame, Guilt, Worthlessness and Anger - and the effects go beyond these for some people.
The effects can be debilitating. Those affected may use words like "a stain on my soul" and feel they don't deserve to live. Effects range on a spectrum from Recoverable "if only" Regrets to Moral Injury with significant persistent symptoms, functional impairment and ultimately to Significant Psychological Disorders including Depression, PTSD, and suicidal ideation.
Professions Affected by MI include:
Risk factors include:
Treatment
MI creates a barrier to recovery because feelings of shame, guilt, worthlessness, self-loathing and anger often lead people to become isolated as they don’t want to talk about what happened (KCMHR, 2020).
Guilt may be an adaptive response to causing harm and has a societal function. However MI is maladaptive as it overwhelms the person's ability to cope and recover, and often the harm caused was unavoidable or accidental.
Currently there is no clearly defined treatment for Moral Injury and some psychotherapies are contraindicated as they may worsen the condition.
The Goal
The most effective treatment is currently thought to be helping people make sense of what’s happened to them (KCMHR, 2000). Coaches and therapists are well positioned to do this work.
I want to help the client to realign to their personal core values by firstly exploring their values with the client. This approach allows clients to discover and reclaim their core values (Dr Eboni Webb, 2024).
Assessment:
I ask questions to assess the nature of the threat to a person's core values. Using my skills, I ask myself objectively 'how serious is the impact of this action/inaction?' (Dr Matt Gray, NICABM, 2024). This is important to assess whether coaching can help or whether the client has PTSD from a physical threat and needs to be worked with using a trauma-informed lens and therapeutic treatment (IFS, DBR, Sensorimotor).
We pay attention and enquire to understand the client's expressions of guilt and whether there has been a change in self perception ie. from 'good person' to 'bad person'.
As well as exploring the client's core values, I enquire into the client's understanding of morality, and who and what they consider to be their responsibilities and moral obligations. This may extend to a deeper understanding of the impact of their company's and even their community's sense of morality. We develop a language to express something that may have been culturally absorbed without being explicitly named and create a shared understanding. In this process we are starting to build awareness and skills to mitigate isolation, aloneness and suffering and to invite connection, presence, empathy and compassion.
If these steps are not taken, people may experience burn out, psychological impairments and leave their roles or even leave their healthcare/military etc profession altogether.
IFS therapy can help to facilitate a client to reconnect with their higher Self and address the parts of them that feel Shame, Guilt, Anger, Worthlessness and Disgust. IFS helps clients turn towards elements that can heal trauma and self-hatred such as connection, trust, relationship, attachment, identity. It can also be helpful to integrate mindfulness, teach self-compassion, and work with clients on the visceral body feelings of self disgust (Dr William Nash, NICABM, 2024).
IFS work often shows that client's protective parts want to retain Guilt feelings, to indicate that they are still a moral person. I help the client to honour and respect this protective part, in both IFS coaching and therapy. We work to find the part in the body, and allow it to fully describe its feelings, and possibly associations from the past. If trauma memories arise, we process these using IFS, DBR (Deep Brain Reorienting), and Sensorimotor processing.
Success is achieved when the client re-enegages with who they "used to be" and activates the behaviours, emotions and thinking of the past. They re-engage in activities and with family and friends and reclaim themself as a moral person.
Amends
Often it is not possible to directly repair the harm done, especially in military conflict situations. And it is not possible to undo the act or effects. However, clients can make amends in meaningful ways, for example by volunteering, contributing or donating. This explicitly addresses the damage done through what Dr Matt Gray calls "the balance sheet of life".
What doesn't help so much?
Clients usually know objectively whether what happened was or wasn't their fault (thoughts), however it is the visceral feelings and emotions that cause the symptoms to persist and worsen.
Self-blame may be appropriate and it's not helpful to minimise or dismiss self-blame. Therefore research shows that CBT Restructuring is not helpful as egregious actions do not lend themselves to reframing. CBT interventions need to be adapted, and third wave approaches such as ACT (Acceptance and Commitment Therapy) can be helpful (Evans, W.R., 2020).
Suggesting self care and setting limits on client's efforts may be counterproductive as clients can't turn away from their responsibilities and this can set them up to feel like they are failing.
Where cognitions are distorted it may not help to engage CBT tools too quickly as it may invalidate the client's feelings and harm the relationship (Gray, Matt J. et al, 2015).
Finally, exposure based approaches can be counterproductive as they may reinforce and make negative self thinking more salient. Any such treatment needs to be adapted, for instance by slowly introducing Cognitive Restructuring, Socratic Questioning and Reappraisal processes.
Resources
King’s Centre for Military Health Research (KCMHR), King’s College London https://kcmhr.org/moral-injury/
French, L., Hanna, P., & Huckle, C. (2022). “If I die, they do not care”: U.K. National Health Service staff experiences of betrayal-based moral injury during COVID-19.Psychological Trauma: Theory, Research, Practice, and Policy, 14(3), 516–521. https://doi.org/10.1037/tra0001134
Combat Stress https://combatstress.org.uk/about-us/news/guide-to-moral-injury
Gray, Matt J. et al, 'Adaptive Disclosure: a New Treatment for Military Trauma, Loss and Moral Injury' (Guildford Press, 2015)
Evans, Wyatt R., 'The Moral Injury Workbook: Acceptance and Commitment Therapy Skills for Moving Beyond Shame, Anger and Trauma to Reclaim your Values' (New Harbinger, 2020)
Dr William Nash, 'Recognising and Treating Moral Injury', 2023 https://www.youtube.com/watch?v=7hOnv0HANTQ
Moral Injury (MI) is intense emotional and psychological distress resulting from a person's actions, or failure to act, which violate an individual’s moral or ethical code. It clashes with who one believed oneself to be, one's identity as a moral being, and betrays one's expectations of oneself (Dr Matt Gray, 2024).
Put simply, it's when something you did (or couldn’t do) felt contrary to your morals (King’s Centre for Military Health Research (KCMHR), King’s College London, 2020).
Often MI results from situations where harm was unavoidable or accidental. For instance, military personnel who are involved in conflict where civilians are killed or injured, or where atrocities are committed. Or healthcare workers with limited resources such as on Covid wards, who had to choose which patients would receive lifesaving treatments or not. And Drivers who cause injury or death whilst being reckless, texting, or driving under the influence.
In organisations, people may feel complicit in management decisions that disadvantage innocent people on grounds of gender, race, orientation, etc. Such actions go against their moral code, and they don't speak out for fear of reprisals.
Three Causes
- Acts of Commission – doing something one should not have done
- Acts of Omission – not doing something one should have done
- Betrayal – by others, possibly someone in authority
What are the effects of Moral Injury?
Shame, Guilt, Worthlessness and Anger - and the effects go beyond these for some people.
The effects can be debilitating. Those affected may use words like "a stain on my soul" and feel they don't deserve to live. Effects range on a spectrum from Recoverable "if only" Regrets to Moral Injury with significant persistent symptoms, functional impairment and ultimately to Significant Psychological Disorders including Depression, PTSD, and suicidal ideation.
Professions Affected by MI include:
- Military Personnel
- Social Workers
- Healthcare Workers
- Vets
- Aid Workers
- Media Professionals
- Educators
Risk factors include:
- Vulnerable people
- Emotionally unprepared people
- Those lacking in Social Support
- Those in multiple simultaneous highly-demanding situations
Treatment
MI creates a barrier to recovery because feelings of shame, guilt, worthlessness, self-loathing and anger often lead people to become isolated as they don’t want to talk about what happened (KCMHR, 2020).
Guilt may be an adaptive response to causing harm and has a societal function. However MI is maladaptive as it overwhelms the person's ability to cope and recover, and often the harm caused was unavoidable or accidental.
Currently there is no clearly defined treatment for Moral Injury and some psychotherapies are contraindicated as they may worsen the condition.
The Goal
The most effective treatment is currently thought to be helping people make sense of what’s happened to them (KCMHR, 2000). Coaches and therapists are well positioned to do this work.
I want to help the client to realign to their personal core values by firstly exploring their values with the client. This approach allows clients to discover and reclaim their core values (Dr Eboni Webb, 2024).
Assessment:
I ask questions to assess the nature of the threat to a person's core values. Using my skills, I ask myself objectively 'how serious is the impact of this action/inaction?' (Dr Matt Gray, NICABM, 2024). This is important to assess whether coaching can help or whether the client has PTSD from a physical threat and needs to be worked with using a trauma-informed lens and therapeutic treatment (IFS, DBR, Sensorimotor).
We pay attention and enquire to understand the client's expressions of guilt and whether there has been a change in self perception ie. from 'good person' to 'bad person'.
As well as exploring the client's core values, I enquire into the client's understanding of morality, and who and what they consider to be their responsibilities and moral obligations. This may extend to a deeper understanding of the impact of their company's and even their community's sense of morality. We develop a language to express something that may have been culturally absorbed without being explicitly named and create a shared understanding. In this process we are starting to build awareness and skills to mitigate isolation, aloneness and suffering and to invite connection, presence, empathy and compassion.
If these steps are not taken, people may experience burn out, psychological impairments and leave their roles or even leave their healthcare/military etc profession altogether.
IFS therapy can help to facilitate a client to reconnect with their higher Self and address the parts of them that feel Shame, Guilt, Anger, Worthlessness and Disgust. IFS helps clients turn towards elements that can heal trauma and self-hatred such as connection, trust, relationship, attachment, identity. It can also be helpful to integrate mindfulness, teach self-compassion, and work with clients on the visceral body feelings of self disgust (Dr William Nash, NICABM, 2024).
IFS work often shows that client's protective parts want to retain Guilt feelings, to indicate that they are still a moral person. I help the client to honour and respect this protective part, in both IFS coaching and therapy. We work to find the part in the body, and allow it to fully describe its feelings, and possibly associations from the past. If trauma memories arise, we process these using IFS, DBR (Deep Brain Reorienting), and Sensorimotor processing.
Success is achieved when the client re-enegages with who they "used to be" and activates the behaviours, emotions and thinking of the past. They re-engage in activities and with family and friends and reclaim themself as a moral person.
Amends
Often it is not possible to directly repair the harm done, especially in military conflict situations. And it is not possible to undo the act or effects. However, clients can make amends in meaningful ways, for example by volunteering, contributing or donating. This explicitly addresses the damage done through what Dr Matt Gray calls "the balance sheet of life".
What doesn't help so much?
Clients usually know objectively whether what happened was or wasn't their fault (thoughts), however it is the visceral feelings and emotions that cause the symptoms to persist and worsen.
Self-blame may be appropriate and it's not helpful to minimise or dismiss self-blame. Therefore research shows that CBT Restructuring is not helpful as egregious actions do not lend themselves to reframing. CBT interventions need to be adapted, and third wave approaches such as ACT (Acceptance and Commitment Therapy) can be helpful (Evans, W.R., 2020).
Suggesting self care and setting limits on client's efforts may be counterproductive as clients can't turn away from their responsibilities and this can set them up to feel like they are failing.
Where cognitions are distorted it may not help to engage CBT tools too quickly as it may invalidate the client's feelings and harm the relationship (Gray, Matt J. et al, 2015).
Finally, exposure based approaches can be counterproductive as they may reinforce and make negative self thinking more salient. Any such treatment needs to be adapted, for instance by slowly introducing Cognitive Restructuring, Socratic Questioning and Reappraisal processes.
Resources
King’s Centre for Military Health Research (KCMHR), King’s College London https://kcmhr.org/moral-injury/
French, L., Hanna, P., & Huckle, C. (2022). “If I die, they do not care”: U.K. National Health Service staff experiences of betrayal-based moral injury during COVID-19.Psychological Trauma: Theory, Research, Practice, and Policy, 14(3), 516–521. https://doi.org/10.1037/tra0001134
Combat Stress https://combatstress.org.uk/about-us/news/guide-to-moral-injury
Gray, Matt J. et al, 'Adaptive Disclosure: a New Treatment for Military Trauma, Loss and Moral Injury' (Guildford Press, 2015)
Evans, Wyatt R., 'The Moral Injury Workbook: Acceptance and Commitment Therapy Skills for Moving Beyond Shame, Anger and Trauma to Reclaim your Values' (New Harbinger, 2020)
Dr William Nash, 'Recognising and Treating Moral Injury', 2023 https://www.youtube.com/watch?v=7hOnv0HANTQ