MORAL INJURY

The term moral injury has recently begun to circulate in the literature on psychological trauma. It has been used in two related, but distinct, senses; differing mainly in the "who" of moral agency. Moral injury is present when there has been (a) a betrayal of "what's right"; (b) either by a person in legitimate authority (my definition), or by one's self-"I did it" (Litz, Maguen, Nash, et al.); (c) in a high stakes situation. Both forms of moral injury impair the capacity for trust and elevate despair, suicidality, and interpersonal violence. They deteriorate character. Clinical challenges in working with moral injury include coping with [1] being made witness to atrocities and depravity through repeated exposure to trauma narratives, [2] characteristic assignment of survivor's transference roles to clinicians, and [3] the clinicians' countertransference emotions and judgments of self and others. A trustworthy clinical community and, particularly, a well-functioning clinical team provide protection for clinicians and are a major factor in successful outcomes with morally injured combat veterans.