As of April 2024
Judith Borren*
Within the nature of humanitarian work, it is almost implied that humanitarian workers encounter and witness human distress and trauma more often than others. They can face inherent dilemmas of providing aid in complex and often volatile environments. These circumstances can lead to moral injuries. Moral Injury (MI), in short, is the psychological damage to one’s conscience or moral beliefs, values, and worldview. This can occur when someone witnesses, or is involved with an event that clashes with one’s moral beliefs or ethical code. [1] Moral Injury is often linked to military service, but it can affect others as well. MI can occur with many first responders, including humanitarian workers.
Jonathan Shay has been researching MI since the 1990s, primarily in relation to American war veterans who fought in Vietnam. He coined the term, but moral injuries are not new.[2] It is actually believed that it can be traced back to the Trojan War.[3] Shay states that there are two ways in which MI can be present; There has been a betrayal of “what is right” by either a person in authority or by the person itself, usually in a “high stakes situation”.[4] While the main research focus of MI is usually found in relation to the military (veterans), this article will focus mainly on Moral Injury in the humanitarian sector.
Multiple studies have shown that the work humanitarians do have a lot of stressors. One of the main stressors for humanitarian workers in high-risk environments is being confronted with morally challenging situations.[5] An example of a morally challenging situation is shown by a study from 2008.[6] Aid workers have reported a ‘deep sense of unease’ when they did work that went against their core values, like having to face particularly challenging triaging work. Also following policies that they viewed as being discriminatory or unjust, or choosing their own safety over that of others could be regarded as Potentially Moral Injurious Events (PMIE).[7] PMIE’s are defined as fear-based traumatic events, that can threaten lives, safety, or integrity. Recently it has become clearer that PMIE can have real psychological consequences for first responders.[8]
The main symptoms following moral injuries are strong feelings of shame, guilt, anger, betrayal, and anxiety. Other things that can arise after witnessing potentially morally injurious events, can be suicidal thoughts, hypervigilance, nightmares, substance abuse, self-harm, social withdrawal, fear of being misunderstood, loss of faith or other beliefs, and trust issues.[9] Witnessing PMIE can thus lead to moral injuries, which again can lead to other mental health disorders such as depression, PTSD, and suicidal thoughts. However, MIs can occur along a spectrum. Some people are affected differently than others. Some people don’t seem to be affected much after experiencing a PMIE, while others experience short-term distress, with no substantial lasting impact. Finally, some can develop more formal mental health disorders.[10]
There are three ways in which MI can occur. 1) When an individual has done something, they should not have done. 2) When an individual should have done something but did not. 3) A feeling of betrayal, often from a higher-ranking authority, usually a person of trust.[11] There are certain situations that make moral injuries more likely. These are events involving vulnerable people, like children or injured people. Those are contexts in which humanitarian workers are often found in, thus they are at higher risk of witnessing PMIEs. Furthermore, emotionally unprepared personnel, the lack of social support, and the experience of highly traumatic events have a high likeability of causing moral injury. A moral injury does not necessarily have to involve a life-threatening situation.[12]However, PMIEs are events that can threaten one’s deeply held beliefs and trust.[13]
Unfortunately, people with MI often carry feelings of shame, anger, and guilt with them. This could cause them to be more reluctant towards psychological help and talk about their problems. They may be concerned by what others think of them and worry about judgment. The reluctance to talk about their injury could act as a barrier to recovery, and even lead to other mental health issues.[14]
Moral injury itself is not considered to be a mental illness.[15] It can be viewed as an injury to one’s moral compass or belief system. With help or treatment, this wound can heal. However, untreated, and for people with a high-risk factor of becoming morally injured, this injury can lead to other mental illnesses. Research has shown that morally injured people are more vulnerable to developing other mental health disorders like PTSD and depression, as well as spiritual struggles, substance abuse, suicidal thoughts, and anger problems.[16] However, PMIE can also cause people to question their life objectives and cause positive psychological changes for the person who experiences them. People can develop new ideas of what is important in life and prioritize social relations and develop a sense of personal strength.[17]
According to multiple research done, MI should be seen as an important public health concern.[18] Treatment for MI-related ill health is still not highly developed or available. Currently, there is no clearly defined way to treat MI. Clinicians find it difficult to support people suffering from it or to offer treatment. Currently, the most effective way is to help people make sense of what happened to them.[19] Treatment that focuses on self-forgiveness, self-compassion, and acceptance holds the most promise of being effective in treating MI.[20] It is very important when faced with a moral injury, that you seek (professional) help. To heal, you need support and to acknowledge the risks that can come with moral injuries.
Three tips given by mental health expert Eva Skinner-Regel:[21]
- You should allow yourself to feel unsettled and recognize the work that needs to be done.
- Acknowledge the impact of your valuable work and contributions to the humanitarian field.
- Remember that, despite the incident, you have made a positive difference.
However, the treatment of morally injured people is highly personal and dependent on a person’s belief system. Mental health workers such as therapists, counselors, social workers, and clergy are often the people who are addressing the moral injury. Also, the importance of one’s community, relatives, or other personal support system should not be overlooked.[22] A substantial part of MI is the feeling of isolation and loneliness in carrying the burden of the witnessed event. However, when the people surrounding you are listening and sharing in your experience, outside a clinical setting, this can help break the silence and loneliness that a person is experiencing.[23] The acknowledgment and confrontation of moral injury can be done in settings such as religious dialogue, therapy, art, writing, discussion and talking circles, and spiritual gatherings, among others. [24]
In conclusion, despite moral injury often being related to the military, it can also impact other first responders, like humanitarian workers. When someone witnesses or is involved in an event that has an impact on one’s psychological, spiritual, and social well-being, this can cause moral injuries. Moral injury itself is not classified as a mental illness, but untreated it can potentially lead to a spectrum of other mental health disorders like PTSD and depression. Recognizing the significance and severity of addressing a moral injury is of the utmost importance for the individual’s well-being and the effectiveness of the humanitarian workers. Whether it is through understanding and listening to an individual, providing guidance towards professional help, or implementing support systems on the work floor, it is imperative to offer guidance to an individual in order to process and give meaning to their experiences. By doing this, we do not merely aid in the healing of those affected, but we also strengthen the resilience of the humanitarian aid workers community and support their valuable work.
*Judith Borren is a research fellow at HDFF.
[1] Syracuse University. n.d. “What Is Moral Injury – the Moral Injury Project – Syracuse University.” Moralinjuryproject.syr.edu. https://moralinjuryproject.syr.edu/about-moral-injury/.
[2] King’s College London. 2020. “The History of Moral Injury.” Www.youtube.com. October 9, 2020. https://www.youtube.com/watch?v=QX8_QkNUoy8.
[3] King’s College London. 2020. “The History of Moral Injury.” Www.youtube.com. October 9, 2020. https://www.youtube.com/watch?v=QX8_QkNUoy8.
[4] Shay, Jonahtan. 2014. “Moral Injury.” Psychoanalytic Psychology 31 (2): 182–91. https://doi.org/10.1037/a0036090.
[5] Dewar, Michelle, Alison Paradis, and Pascale Brillon. 2023. “Morally Injurious Events among Aid Workers: Examining the Indirect Effect of Negative Cognitions and Self-Care in Associations with Mental Health Indicators.” Frontiers in Psychology 14 (April). https://doi.org/10.3389/fpsyg.2023.1171629.
[6] Dewar, Michelle, Alison Paradis, and Pascale Brillon. 2023. “Morally Injurious Events among Aid Workers’’
[7] Dewar, Michelle, Alison Paradis, and Pascale Brillon. 2023. “Morally Injurious Events among Aid Workers’’
[8] Dewar, Michelle, Alison Paradis, and Pascale Brillon. 2023. “Morally Injurious Events among Aid Workers’’
[9] Dewar, Michelle, Alison Paradis, and Pascale Brillon. 2023. “Morally Injurious Events among Aid Workers’’
[10] King’s College London. 2020. “The History of Moral Injury.” Www.youtube.com. October 9, 2020. https://www.youtube.com/watch?v=QX8_QkNUoy8.
[11] Australian Government Department of Veteran Affairs. n.d. “Moral Injury.” Open Arms. Accessed April 17, 2024. https://www.openarms.gov.au/signs-symptoms/moral-injury
[12] Williamson, Victoria, Dominic Murphy, Andrea Phelps, David Forbes, and Neil Greenberg. 2021. “Moral Injury: The Effect on Mental Health and Implications for Treatment.” The Lancet Psychiatry 8 (6). https://doi.org/10.1016/s2215-0366(21)00113-9.
[13] Williamson, Victoria, Dominic Murphy, Andrea Phelps, David Forbes, and Neil Greenberg. 2021. “Moral Injury’’
[14]King’s College London. 2020. “The History of Moral Injury.” Www.youtube.com. October 9, 2020. https://www.youtube.com/watch?v=QX8_QkNUoy8.
[15] Williamson, Victoria, Dominic Murphy, Andrea Phelps, David Forbes, and Neil Greenberg. 2021. “Moral Injury’’
[16] Dewar, Michelle, Alison Paradis, and Pascale Brillon. 2023. “Morally Injurious Events among Aid Workers
[17] Dewar, Michelle, Alison Paradis, and Pascale Brillon. 2023. “Morally Injurious Events among Aid Workers
[18] Williamson, Victoria, Dominic Murphy, Andrea Phelps, David Forbes, and Neil Greenberg. 2021. “Moral Injury’’
[19] King’s College London. 2020. “The History of Moral Injury.”
[20] Williamson, Victoria, Dominic Murphy, Andrea Phelps, David Forbes, and Neil Greenberg. 2021. “Moral Injury’’
[21] Schneider, Robbie. 2023. “Disaster Relief Workers and First Responders. Navigating Moral Injury.” Www.linkedin.com. November 7, 2023. https://www.linkedin.com/pulse/disaster-relief-workers-first-responders-navigating-moral-t3nkf/.
[22] Syracuse University. n.d. “What Is Moral Injury – the Moral Injury Project – Syracuse University.”
[23] Syracuse University. n.d. “What Is Moral Injury – the Moral Injury Project – Syracuse University.”
[24] Syracuse University. n.d. “What Is Moral Injury – the Moral Injury Project – Syracuse University.”