Why Young People Are Struggling: Moral Injury

Consider this brief thought experiment: 

Person 1: “I need you to help me.” 

Person 2: “I don’t know if I can … I am not sure … I will try.” 

Person 1: “Please, I’m desperate!” 

Person 2: Inwardly: “There is nothing that can be done. I have informed everyone on my team, I have filled out the appropriate paperwork, I have reached out to colleagues—but I am powerless to affect a real, meaningful solution, if there even is one.” 

Is this a conversation between a doctor and a patient? Perhaps a teacher and a parent of a special needs child? Maybe it is between an employer and employee. Next question: Is this relatable? Do you find yourself recalling a variation of this conversation? 

We all deal with stressful situations. We all deal with feelings of disappointment, of failure, of hopelessness. Some people will have stronger resilience or better coping strategies. But there is no doubt that part of the human condition is dealing with difficult things. Most of us experience, at some point in our lives, a kind of existential hopelessness—and many feel like we now live in an era where it’s more common than ever. 

Whether this is an opinion, or a fact, does not matter. Kids talk about it. Parents coming into schools talk about it. Sit in an emergency room for hours waiting to see a doctor and listen to the frustration and fear people express. Statistically, it is true that advances in medicine save more lives. Statistically, it is true that global health and wealth is steadily improving, child mortalities are declining, more people survive natural disasters, and we devote humanities research time to better understand the rights and freedoms of people.¹ Statistically, it is true that we have learned a lot about student learning styles and a whole field of research explores better ways to teach. But none of this stops people from feeling what they feel, and as such, it is important to bring a new term into the conversation: Moral Injury (MI). 

There is no way out, and no way to attain success, or the situation has no solution or no end.

Defence Research and Development Canada (DRDC), in collaboration with Canada’s defense, security, and public safety communities, defined Moral Injury as “The lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”²

In working on our preliminary research for Defence Research and Development Canada,³ we found that some individuals are more at risk of developing moral injuries for the following reasons: 

1. They have skills that allow them to make critical decisions.
2. They feel a personal sense of responsibility toward humanity and may risk their lives for others.
3. They make critical decisions on a regular basis and are successful most of the time. In other words, they have come to expect that their knowledge, experiences, and decisions will lead to a desired outcome that is both necessary and correct.

Moral injuries happen: 

1. When a person is faced with an impossible situation. This is defined as a situation that will always lead to a critical loss. There is no way out, and no way to attain success, or the situation has no solution or no end.
2. When a person does not have a choice but to decide.
3. When a person is in a learned helplessness situation: they are damned if they make one decision, and damned if they make another decision.

An example that has, in some form or another, been used repeatedly to illustrate Moral Injury is the situation that came to light in the early days of the COVID pandemic, where two patients are in respiratory distress and there is only one ventilator. In what universe would any doctor or nurse ever fully recover from knowing that one person was essentially sacrificed to save another? 

We can find other examples: Imagine facing a child holding a firearm, where it is likely that either that child or someone else will be harmed. This event has sadly been reported in schools. In the classroom, many of my colleagues and I have countless times had a child disclose worrisome information that is both a cry for help but also implies a fear of retaliation for talking about it (which is why a teacher is often told rather than a parent). Due diligence requires reporting it to a higher authority, but there is also the knowledge that nothing is likely to be done about it, except to break trust with the child and possibly make matters worse for the child. While it is true that a number of children’s welfare organizations exist throughout North America, they are often overworked and underfunded. These organizations may investigate, but often kids will refuse to disclose any more information, which stalls the investigation. Sometimes the nature of the problem, such as verbal abuse or sexual harassment, is hard to prove. Variations of the “Good Samaritan” law exist throughout the world to protect people who help others in emergencies from liability, but they don’t protect the Good Samaritan’s psychological well-being. 

Finally, think of all the moral lessons we give to kids that contain mixed messages. We say sometimes it is important to turn the other cheek, to walk away from conflict. But we also say you should support your peers by standing together against bullying, racism, or sexism. We say, “stand up for what you believe,” but we also teach the importance of free speech and the right for others to have differing opinions. Of course, as adults, we know these are not mutually exclusive. But they do require nuanced understanding, and sadly, there are times when ideals clash with reality. The person who spoke up may have very well been defending an ideal—one that is morally right even. To not defend the ideal is a betrayal of self. But if, in defending that ideal, others have experienced real harm, the question remains whether it would have been better to walk away. 

In my experiences in the classroom, I see that young people face impossible choices, and are not immune from what appears to be moral injury. Students have been told for years that they will bear the burden of climate change. They have a sense that the school recycling program is not a sufficient solution. They may want to actually feel as if they can do more and wish to learn more meaningful content, only to be hit with excuses such as, “This isn’t in the curriculum,” or “We don’t have time or resources.” Young people begin to feel guilty for not doing more to address the problem, and in time, they may seek to avoid the situations that provoke feelings of guilt. This is just a deceptive bit of cognitive dissonance, because avoidance does not really make the problem go away. Kids with high levels of social anxiety also show a similar struggle with guilt for not being a “normal” participant in the classroom. And then there are the kids that have experienced traumatic events that were not their fault, but nevertheless, they feel guilt and shame. While academic challenges can lead to behavioral challenges—that’s textbook and even predictable—you can plan for it. However, a child with a moral injury is often a different story. Once we add disturbing news of war, climate change, and natural disasters, the influences of social media, partisanship views, and a generalized sense of existential crisis to their plate, can we really be surprised that so many young people are in a dark place? 

New evidence from the frontline of the COVID-19 pandemic suggests that healthcare workers and first responders also suffered extreme psychological, cognitive, and emotional responses, including guilt and shame.

Moral Injury is a term that was originally associated with warfare and conflict and sometimes used interchangeably with Post Traumatic Stress Disorder (PTSD). A 2019 brain imaging study published in the journal Neuropsychopharmacology,⁴ showed that individuals with PTSD had increased activity in the amygdala and decreased activity in the hippocampus and prefrontal cortex. This limbic system response can produce symptoms such as anxiety, flashbacks, and difficulty in remembering the traumatic event.⁵ Another study published in the JAMA Psychiatry⁶ in 2012 found that individuals with PTSD had structural changes in the hippocampus, responsible for memory formation and retrieval. Again, patients with PTSD had trouble remembering the events of the traumatic event itself. Lastly, a study published in the Journal of Traumatic Stress⁷ in 2020 found that individuals with PTSD have “alterations in the functional connectivity between the amygdala and the prefrontal cortex. These alterations in functional connectivity might contribute to the emotional regulation difficulties that are commonly seen in individuals with PTSD.” 

New evidence from the frontline of the COVID-19 pandemic suggests that healthcare workers and first responders also suffered extreme psychological, cognitive, and emotional responses, including guilt and shame. This state of anxiety and distress is often described as burnout. However, the cluster of features and symptoms of moral injury is not adequately captured by interventions and treatments associated with burnout. Nor is moral injury being well captured by existing diagnostic tools. Brain imaging fMRI studies of PTSD patients who presented with feelings of guilt and shame showed they experience a surge of blame-related processing of bodily sensations within salience network regions, including the right posterior insula and the dorsal anterior cingulate cortex, which in turn, prompt regulatory strategies at the level of the left dorsolateral prefrontal cortex aimed at increasing cognitive control and inhibiting emotional effect.⁸ But the participants in these studies presented with both PTSD and MI. So, while we know that MI involves a different set of neurological responses than PTSD, neither the full extent of moral injury nor treatment is fully understood. What is clear is that MI requires a different treatment protocol than PTSD. MI requires a focus on the selfhood of the person. Ultimately, it may be a matter of heart and soul, of existentialism, rather than clinical, behavioral, or neurobiological psychology. 

The psychological trauma associated with moral injuries can lead to insomnia, depression, physical and psychological pain, and maladaptive behaviors, including isolation from friends and family, self-medication with alcohol and drugs, etc. Again, while “these symptoms are often ascribed to operational stress injuries, notably PTSD, moral injuries produce ‘scars’ that are not well captured by these current conceptualizations.”⁹

A coalition of Australian Defence researchers¹⁰ distinguished PTSD and Moral Injury as follows: PTSD is marked by fear, anxiety, concerns for physical integrity and safety, hopelessness, and horror.¹¹ Conversely, the hallmarks of moral injury are guilt and shame, remorse, contempt, disgust, resentment, betrayal, grief, and regret.^12, 13, 14 In comparing the experiences of veterans upon returning home, the Australian team separated two types of experience. Veterans diagnosed with PTSD “cannot withdraw from a perpetual state of combat-readiness.”¹⁵ The traumatic memories and perceptions become triggers for PTSD episodes. Once back home, “the physical and emotional reaction to danger, or any sensed threat, is effectively short-circuited in the prefrontal cortex and amygdala where intense memories can affect self-control, reasoning, and decision making.”¹⁶

Moral Injury (MI) is an emotional wound—a betrayal of one’s own sense of what is right and wrong that leads to an existential dissonance

Moral injury, on the other hand, does not share symptoms of hyperarousal, paranoia, or suspicions with PTSD; rather, “veterans engage in self-torment, punishing themselves with constant self-recrimination.”^17, 18 And while PTSD and MI can be comorbid, the research on MI shows that a person does not have to have directly experienced an event as gruesome as warfare. MI is an emotional wound—a betrayal of one’s own sense of what is right and wrong that leads to an existential dissonance. And it is this existential dissonance that both military and nonmilitary people (for example, first responders, medical personnel, volunteers in crisis situations, journalists, educators, and clergy) are encountering in their daily lives. 

Having said all this, there may be a tendency to think that everyone, everywhere, is experiencing moral injury. Maybe. But we should be cautious not to medicalize every situation and thus distinguish between daily hardships and MI. “Burnout” and “overload” are sometimes referred to as microtraumas or “trauma with a small t” (in order to not minimize the deep struggles and horrific experiences of veterans with pTsd). These are real experiences, but they do not usually carry the sense of guilt and shame that defines moral injury. MI is a lasting condition that is soul crushing. The feelings of burnout from work, for example, often go away on vacation, or at home time, or even by changing jobs. MI stays with you, all the time, and robs you of any ability to see the world above the existential hole. The sense of hopelessness and meaninglessness cannot be cured by antidepressants. It is like the line from Scent of a Woman, where an angry Col. Frank Slade (Al Pacino) says “there is nothing like the sight of an amputated spirit. There is no prosthetic for that.” 

Realizing that people with MI are not just weak or lacking resilience and determination is an important first step. And while there is good work being done on distinguishing MI from PTSD for military personnel, there is a greater need to address this issue in the general public, and especially our youth.