When we no longer believe in our essential goodness

In addition to PTSD, many CADIs experience a constellation of feelings and thoughts known as moral injury – the distress that comes from failing to live up to our moral standards, expectations or aspirations. Even though we did not intend harm, many of us perceive our actions as violating foundational moral tenets, such as “be kind,” “don’t hit,” or “do unto others as you would have them do unto you,” etc.

  This man’s blood is on my hands forever. Like a stain on me that I can never get rid of.
S., accidentally killed someone in a car crash
Everyone has told him and he knows there was nothing he could do and it’s not his fault, but he can’t sleep and he feels guilty about living life if she can’t. We were to go to the beach yesterday, but he didn’t go because he says if she can’t go to the beach why should I get to go.
D., whose spouse became a CADI
Since all of this I have a little voice inside me that reminds me that I don’t deserve anything.
H., in an car crash as a teenager that killed a passenger in her car

The psychiatrist Jonathan Shay describes moral injury as a betrayal of “what’s right.” Dr. Rita Brock, another expert in moral injury, describes it as “a normal response to moral failure that can happen to any human being with a conscience.”

Dr. Brock wrote that people that people with moral injury are “divided against themselves” as a result of “fail[ing] their best selves” and suffering “unprocessed grief and guilt.” In short, when we have moral injury we no longer believe that we are virtuous and deserving of respect or acceptance. We live with guilt, shame, grief, a lack of trust in ourselves and others, depression, a sense of powerlessness, and sometimes a loss of hope. Moral injury is also associated with self-destructive behaviors such as substance abuse, thoughts of suicide, and – very often – isolation or social withdrawal, something many CADIs describe. I associate moral injury with that sense of ourselves as outsiders, as disconnected from others.

Unlike PTSD, moral injury is not a formal diagnostic category used by doctors or clinicians. While it overlaps with PTSD, it is not the same. Because moral injury is a newer concept than PTSD, there is less research on effective treatments. My own work suggestions that there are three keys to resolving moral injury and regaining a sense of belonging and acceptance.

Accountability: This means owning the damage we have done, even though we did not set out to hurt anyone. This involves investing the effort to accurately assess our own degree of responsibility and culpability for what occurred. We cannot resolve or heal moral injury if we refuse to hold ourselves accountable – but it also is not useful to heap blame on ourselves for factors beyond our control.  

Compassion: We can accept kindness and understanding from others, and we can also extend these to ourselves. The suffering and distress you experience as a CADI are evidence of your own caring and humanity. You deserve compassion.

Community: The existing research on moral injury indicates that peer support is extremely important to resolving moral injury. We need to feel that we can be accepted and valued for who we are. But community also means giving back – making amends, making reparations, or doing our part to make the world a better place. I describe this further in the section on post-traumatic growth, but it’s equally important in this context.

These conditions have enabled many CADIs to resolve moral injury. We may always carry sorrow and guilt, but we do so with the knowledge that we are deserving of acceptance and respect from ourselves, others, and (for those who believe) God.