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Moral Injury

What It Is and How To Recover

Dr. James D. Guy
President & Cofounder, Headington Institute


The coronavirus (which causes the disease officially named COVID-19) has been declared a public health emergency by the World Health Organization (WHO), which often brings feelings of uncertainty, fear, anxiety and worry to many of us and to our families.  It can also lead to changes in mood and behavior.  Some may experience a need to “do something” but you don’t know what to do.  Others may feel a low mood and feel sad or hopeless.


Moral Injury

A couple of years ago, I spoke privately with a highly admired administrator in a large humanitarian aid organization.  Let’s call him Pete.  Over dinner, I asked how he felt about his long, successful career.  Rather than mention his triumphs, he began to cry quietly while he shared an experience nearly thirty-five years in the past.  As a relief worker in Africa, while touring a region ravaged by genocide, he had to decide which villages would get food and which would likely starve.  There simply was not enough for everyone.  The face of one particular child he encountered, who would not be receiving food in time to save her life, was imprinted on his soul.  He still has nightmares about that moment.  Despite all he accomplished since, he feels tortured by the decisions he made that day – some got fed, others did not.  My friend will carry this wound forever.

At the Institute, we regularly speak with aid workers and emergency responders who experience personal traumatic events like serious accidents, assaults, or injuries.  Others are vicariously traumatized by what they see or hear while doing their work.  In both cases, brain function and/or structure can be altered in a way that produces significant emotional distress such as anxiety, depression, anger, and suspicion.  But, neither phenomenon adequately explains what happened to Pete.

Recently, there has been growing recognition of a related but different kind of emotional pain referred to as moral injury.  Clinicians and researchers are finding evidence of what can best be described as “wounds to the soul.”  They result from violations of deeply held beliefs about what is right.  Decisions like the ones Pete disclosed, when one must choose among “bad” options, may force people to act contrary to their beliefs.  Frankly, I’ve yet to meet anyone not troubled by the need to pick the “lesser of two evils.”  When the stakes are high, such choices can haunt you forever.

Over the years, I’ve found that moral injury can result from a variety of additional causes: inability to stop others from committing atrocities; carrying out management directives that violate personal values; witnessing random suffering caused by natural disasters; tolerating overwhelming injustice.  These experiences leave lasting scars of guilt on the psyche/souls of those who feel responsible but unable to stop “evil” from occurring.  In addition, most of us live with the shame of knowing we made wrong choices that hurt others – errors of judgment or mistakes due to moral weakness.  Here, too, there may be lasting moral injury.

The experience of moral injury may cause feelings of personal regret, guilt, shame, or failure.  There may also be growing anxiety, depression, anger, or suspicion similar to that experienced by other trauma victims.  A loss of faith in God, suspicion of others’ motives, lack of self-confidence, and a growing fearfulness or hopelessness may accompany these emotions.  While not yet recognized as a clinically diagnosable condition, moral injury appears to me to be a very real experience.

Recent research on veterans returning from Iraq and Afghanistan provides convincing evidence of the significant and lasting impact of moral injury on the lives of those forced to commit or witness actions of violence inherent in warfare.  Few veterans are unaffected by these experiences.  Most are left with deeply seated conflicts regarding what was right and wrong, good and evil, necessary and unnecessary.

Military veterans are not the only ones left morally injured after a deployment.  Ironically, individuals who rescue victims of humanitarian disasters and local emergencies often face the same “no win” situations.  Like Pete, they may need to make decisions that hurt or kill others.  They may be unable to accomplish sufficient “good” in particularly “bad” situations to leave them at peace.  They may witness things that no human being should ever see.  Whether or not they are at fault, the resultant moral injury can leave lasting wounds that few understand or disclose to others.

While I recognize the need to tread carefully when using terms like “good and evil” and “right and wrong,” there seems to be a sense of human morality that transcends religious, socioeconomic, and political worldviews.  Added to this are personal beliefs and experiences that shape who we are and what we stand for.  When this tapestry of meaning and purpose is violated, lasting moral pain and injury may result.


How to Recover from a Moral Injury

After fifteen years of working closely with humanitarian aid and emergency response personnel, we’ve heard them describe numerous tragic experiences that violated people’s sense of decency, safety, and order.  Many were left with a worldview that no longer seemed viable or relevant.  In an effort to ward off despair, they sought ways to recover from this moral injury.

By sharing in their journey, those experiencing moral injury have taught us a great deal about how to mend the soul.  Recognizing the sensitivity of this topic, I will do my best to respectfully summarize what others have found helpful.  Start here, and then find your own unique way to recover from moral injury, if that becomes necessary.

Despite individual differences, many who experienced moral injury followed a similar path to recovery by giving attention to the following:

  • The need for support: The feelings of grief, shame, regret, and fear that accompanied moral injury often led to a profound sense of isolation.  Finding others who understood and cared was vital to recovery.  This was typically accomplished by talking regularly with a loved one, mentor, or mental health professional.  Some found it helpful to join organized support groups, such as those offered to returning war veterans.  It was important to find likeminded people who provided encouragement, validation, reality testing, and unconditional love.  For many of our clients, reaching out to others led to meaningful connections that promoted recovery.  It may be the best place for you to begin, if you also suffer moral injury.
  • The need for a new perspective: After witnessing human suffering, particularly if unjustified or extreme, some found it helpful to view it as part of something larger than that particular moment.  They looked for a bigger meaning or purpose to it all by considering the event within a larger context.  Many sought input from organized religion, spiritual mentors, or the expressive arts (music, graphic art, literature, film).  All of these speak of the human experience in ways that helped troubled individuals find an expanded understanding of reality.  They describe the processes of confession, forgiveness, restitution, and recovery that promote healing after moral injury.  They provide meaningful examples of what is “right” and “good” in the midst of apparent randomness and chaos.  Allow them to anchor you in a bigger reality than the “here and now.”  These sources of input will help you resolve distortions about what happened and why, giving you a more realistic perspective on your personal responsibility and capacity to bring change.  For example, an experienced humanitarian aid worker recently told me that regularly reading historical novels provided the input she needed to understand her limited role in reducing suffering and injustice present over the millennia of human existence.  Find the best way to do this for yourself – it will help, if you suffer moral injury.
  • The need for a new plan: When responders found that their sense of safety, fairness, order, and goodness could no longer account for the violence, hatred, and random suffering they encountered, they revised their moral “road map.”  They changed their beliefs about how the universe works to allow for what they had recently witnessed.  By integrating the recent “bad” with the established “good,” they emerged with a more realistic worldview that mirrored their experience.  This enabled them to clarify their core values, live congruently, and make better decisions about work and personal life.  Through reflection, meditation, and prayer, they were able to take personal responsibility and make amends where appropriate, and extended forgiveness where necessary.  While their revised life plan led some to leave the field, most found new confidence and a stronger resolve to continue humanitarian and rescue work.  One responder told me that she had aligned more passionately on the side of the “good” once she understood just how bad things could get.  If you suffer moral injury, use it as an opportunity to talk and journal about how to revise your life plan in a way that brings peace and a new sense of direction and resolve.
  • The need for hope: I’ve talked at length with hundreds of aid workers and emergency responders over the past 15 years.  Despite repeated and even serious moral injury, I’ve watched them rise up afterwards like a phoenix and return to their work with greater resolve.  It took considerable effort and time, but they did it.  Having learned more about themselves and the world around them, they were determined to go on trying to save lives, reduce suffering, and promote recovery.  I’ve lost count of how many have told me, “If I try harder… if I don’t give up… if I find better ways to help, I can change things.”  This view seems based on a persistent belief that good triumphs over bad, even if only briefly.  This hope is strengthened when the needs for support, a new perspective, and a new plan have been adequately satisfied after moral injury.  There is once again reason to believe that personal efforts can make a difference in the lives of beneficiaries.  This completes the recovery from moral injury.  There is now sufficient reason to go on, to continue the good fight.

At the root of all helping work is a moral “vitality” and strength that fuels efforts to work on behalf of others.  You believe that you can make a difference in the lives of victims, and you believe that helping them is a noble, worthwhile work.

Should you experience moral injury that undermines this perspective and leads you to question your motivation and capacity to help, take these steps to promote your recovery:

  • Resolve distortions about what happened and why by talking with someone who was there or has experienced similar things.
  • By journaling, work towards a personal explanation of what and why and how
  • Reaffirm core values and live congruently
  • Intensely pursue what matters
  • Practice self-directed compassion – integrate personal failures with character strengths
  • Practice meditation, prayer, and reflection
  • Practice forgiveness
  • Make amends
  • Promote personal spiritual renewal and transformation

Feel free to ask us to assist you, as we’ve done for many others before you.


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