Moral injury is a relatively recent term used to describe the suffering that arises from situations where high stake decisions involving life or death situations and/or situations that have resulted in severe injury clash with a person’s sense of morality. It has developed as an idea over the last twenty years as a consequence of work in Post-Traumatic Stress Disorder-PTSD. Over the last year, it has been seen as particularly relevant with the experience of NHS staff in responding to the pandemic.

The pain involved in a moral injury is the consequence of the dilemma between what is termed the ‘morality of the mind’ and the 'morality of the heart’. The work of Evans et al. in their The Moral Injury Workbook offers us some insights into how we work in this area.

Understanding the distinction between these two moralities is essential in recognising where the pain comes from. The morality of the mind can be expressed as the morality that we have learned throughout our lives, our families, our work, and our culture. The morality of the heart is different. It is experienced emotionally. It may even be hard to express in words, being experienced purely on a gut level.

When the stakes are not high, these two moralities work together, and there is no problem. In cases of moral injury where the stakes are higher, there is often a conflict. For example, In the instance of Complex Trauma, there might be a conflict between the morality of the mind which may involve respect for authority, versus the morality of the heart, when the abuser is the authority figure.

Richard was physically abused by his father from the ages of 5 to 10. He felt anger when he remembered the experience and anxiety when he had flashbacks. However, he felt powerless because of the morals within his family, which talked about respecting elders.

The morality of the heart is where painful emotions are experienced. In many situations, the pressure may be on the morality of the mind, and the need to make cool-headed objective judgements is not easy. We cannot ignore emotional pain. Any pain is a signal. Painful emotions are signals to act. If we feel anxious, we want to escape. If we feel angry, we want to attack. If we feel guilty, we want to make reparations. However, coping with emotions is hard.

Using ACT to tolerate and move forwards

For much of the time, life problems exist in our environments. Our cars won't start, our computers crash, the central heating doesn't work. These are not tricky problems as they exist ‘outside’ of us. Complex thoughts and emotions are different. They are ‘inside’ in our heads, and we cannot fix them in the same way we might fix our computer.

However, the ways we try to fix them through suppression makes the problem worse. In the infamous episode of Fawlty Towers with the Germans, Basil tries to suppress his emotions and feelings. The harder to tries to do this, the stronger they become. The emotional pain of moral injury cannot be dealt with by trying to push the emotion away.

Evans et al. point towards the usefulness of Acceptance and Commitment Therapy- ACT in working with the emotional pain of moral injury. The Acceptance part of ACT is about cultivating a willingness to ‘feel and think’ what we are ‘thinking and feeling’. In issues of moral injury where something terrible occurred, this is less about saying the event was ‘ok’ and more about tolerating the memory of the emotion.

This is because the suppression of thoughts and feelings about the event turns the original pain into something worse. ACT teaches us to defuse our emotions not by stopping thoughts and feelings but by taking ‘two steps back’ from them. In combination with mindfulness, diffusion enhances the ability to stand back and, in doing so, manage the emotion.

The saying from Buddhism about ‘pain being inevitable’ and ‘suffering being optional’ is highly important. These techniques are not easy because experiencing pain can never be easy, but it is better than suffering. ACT is also about looking forwards as well as backwards. By coming to terms with what happened, we can begin to use the idea of values in ACT to start to move forward with our lives.

Want to read more? Buy Michael's books ‘A Practical Guide to Working with Depression: A cognitive behavioural approach for mental health workers’ and ‘Working with Compassion’.