What is a moral injury — and how can it be treated?

TVO.org speaks with researcher Ruth Lanius about the psychological toll of the pandemic and why she’s investigating treatments for moral injuries in health-care workers
By Josh Sherman - Published on Nov 04, 2021
Ruth Lanius is an associate scientist at the Lawson Health Research Institute. (Courtesy of Western University)



While interviewing a Vietnam War vet a decade or so ago for a book she was working on, Ruth Lanius had an epiphany that would influence her research for years to come.

“I had noticed that my patients had incredible difficulties making eye contact, and I asked this veteran, ‘What’s it like for you to make eye contact?’” recalls Lanius, a psychiatry professor at Western University. “He said to me, ‘I cannot look anyone in the eye for fear that they will see the stain on my soul.’ And I thought, Wow. Trauma is not just about fear; it goes much deeper. And this is an area we really need to focus on.”

The experience helped spark her interest in what is known as moral injury, a little-understood phenomenon affecting the brain. With COVID-19 having overwhelmed Ontario hospitals at points during the pandemic, Lanius has turned her attention to how moral injuries could be affecting health-care workers. It’s the subject of the new study she’s leading from Western and Lawson Health Research Institute, where she is an associate scientist.

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“Health-care workers have suffered significantly during the pandemic, and they really deserve to have some way of healing and some hope,” says Lanius, who continues to recruit volunteers. “Anybody who’s interested is welcome to email my research coordinator.” The study, which will involve about 60 participants, launched in October and is expected to last between 12 and 18 months.

TVO.org speaks with Lanius about what causes moral injuries, how they manifest, and what might make for an effective treatment.

TVO.org: So, first off, for people who aren’t familiar with the term: What is a moral injury?

Ruth Lanius: The moral injury can occur when somebody experiences an event that really conflicts with a person’s moral values or standards.

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TVO.org: That sounds as if it could be different for everybody, depending on their morals.

Lanius: Absolutely. There are three main categories in terms of moral injury. One is if you witness something, if you saw someone do something or fail to do something. So, for example, if you’re a soldier, and you watched one of your buddies being killed, and you couldn’t do anything about it, because that would have endangered your troops. And when we think about this in the context of the COVID-19 pandemic and health-care workers, it would’ve been, for example, witnessing a patient in a lot of distress or a family member in a lot of distress because you couldn’t provide the care or you watched them not be able to get the care they needed.

TVO.org: So the first category is witnessing. What’s the next?

Lanius: The second category you would call the perpetrator category — that you did something that you really feel morally conflicted about. So, in the war situation, this may be that you had to kill a civilian to keep your troops safe. And in the COVID-19 pandemic scenario, this may have involved actually providing life-saving care that was very burdensome on the patient and that resulted in a lot of suffering without there being much hope — or really any hope — of the individual surviving. We hear a lot of these stories now from health-care workers, especially in the ICU, where I think family members weren’t ready to lose their loved ones, and so they insisted that care continue to be given. And the health-care workers then had to administer this care, which is often very, very painful and torturous for the patient, and they really suffered as a result of that.

TVO.org: That’s witnessing and perpetrating — what’s the third category of moral injury.

Lanius: The betrayal — so, feeling betrayed. We see a lot of this in the COVID-19 pandemic where, for example, health-care workers really felt betrayed by the system that they worked in. And the feelings of betrayal have changed a little bit over the course of the pandemic. At first, they felt that they were thrown to the wolves because we didn’t have enough PPE. And then, later on, as we moved into waves two and three, they felt very betrayed because often there was a horrendous demand for workers, and they had to do the job of 10 people where they can really only do the job of one. They felt betrayed by the lack of staff — and the lack of support.

TVO.org: When did you first hear the term moral injury, and where does it originate from?

Lanius: I first heard about it several years ago; at the time I was reading work by Bill Nash. And I don’t want to say this is where it originated from, but Bill Nash was certainly one of the first individuals who wrote about moral injury in the context of war.

TVO.org: And is that where the earliest research on moral injury comes from?

Lanius: Yes. It originated in the war situation, and, of course, I think we really need to be aware of the struggles of our soldiers when they come back and some of the things they were engaged in because they had no choice and how they often feel like it’s eating them up alive inside. And now, of course, some of these concepts apply directly to the COVID-19 pandemic. 

TVO.org: What are the symptoms of a moral injury, and how do they range in severity?

Lanius: There’s a whole range. I think we can say some people have moral distress. Some people have moral injury, and obviously moral injury is a more severe phenomenon of moral distress and would likely be associated with a greater decrease in functioning.

I just want to interject something here for a second that I think is important: often our health-care workers just feel that they’re burnt out, right? And I think when we talk about moral injury, for some of them a lightbulb goes on, and they go, “Oh, that’s what it is,” and if that’s what they experience, it makes a lot of sense to them.

What do people experience? I think you can really divide the symptoms into two levels. One is a thinking level — at the thinking level, or at the cognitive level — and that’s where you often feel, when you have moral injury, “I’m bad. I’ve done something bad. I should’ve done this, or I should’ve done that,” so you blame yourself (so a lot of self-blame).

And then you have this whole second component that goes along with those feelings, which is a visceral component — so you feel this in your gut. You know, you often feel this gnawing sensation in your gut, and sometimes people also tell us, “I feel like this is eating me alive inside.” And, of course, when we think about treatment for this, we really have to think about both approaching the cognitive level but also the visceral level. And sometimes patients come to me after they’ve had some treatment, and they say to me, “You know, Ruth, I know this wasn’t my fault, and I know I did the best I could, but viscerally I still feel this gnawing sensation in my gut.”

TVO.org: You mention treatment. What does treatment for a moral injury look like?

Lanius: We’re so early on in the development of treatment, and we have some cognitive treatments that really work with those thoughts. Where we really need more intervention is at this visceral level, and we need brain-guided treatments. Because, for example, our group is now doing studies looking at what happens during moral injury — in the brain — and we’re really finding also that the brain changes really reflect both this thinking, or cognitive, level as well as this visceral level. Areas involved in the processing of visceral sensations are overactive when we recall a morally injurious event. I think our future work really needs to think about brain-guided treatments that can target some of these areas directly.

TVO.org: What could these brain-guided treatments and cognitive approaches involve?

Lanius: By brain-guided treatments, I use it more as a general term that we need to use our understanding of how the brain functions during the recall of morally injurious events to guide our treatments, so I mean that as a broad statement. But there are some specific treatments that target brain areas. One is called neurofeedback, where you can target certain brain networks or regions of the brain directly to help quiet those areas. And, of course, cognitive treatments we’re very familiar with, because that’s where we help people restructure their thoughts. So, really help them to understand on a thinking level, or a cognitive level, that “I did the best I could” or “This wasn’t my fault; I had to protect my troops.” What’s key in those treatments is that, after treatment, the thinking and the visceral sensations align. We don’t want somebody to have settled their thoughts, but the visceral component doesn’t align with that. 

TVO.org: I read that treatment is going to be part of your study. Can you explain how your study is going to work and what role treatment plays?

Lanius: In this study, we’re going to provide eight sessions of a treatment that targets some of those deep-brain areas involved directly with the processing of visceral sensations. Some pilot work has shown that, once we actually settle those visceral sensations, the thoughts settle as well. And, so, we’re going to offer people eight sessions of treatment, and we’re going to scan their brain before and after treatment. Then we will also follow them up to three months after the treatment to see how they do after the treatment has ended. (And this study is going to focus on health-care workers with post-traumatic stress and an experience of moral injury.)

TVO.org: Will the treatments involve using neurofeedback? 

Lanius: This is a study that will process a morally injurious event. Part of the response to a moral injury at first involves an orienting response to the event, and this response often involves tension in the neck and the face when we orient to that memory or to that event. And so we help individuals process that, and the next response after the orienting response that often occurs is that people, before they have an experience of intense emotion, often have what we call pre-affective shock, so this [gasp] response, and we help them process that. And this is often associated with tension in certain parts of the head and neck. And after that, we really focus on processing those visceral, intense sensations. We really want to go in at the foundation.

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TVO.org: When you say “help them process” these experiences — is this more of a talk-therapy approach? What does it involve?

Lanius: There’s some talking involved, but a lot of it is just focusing on the bodily sensations that arise and focusing on them until they resolve. Some talking — but a lot of it involves just noticing what happens to those sensations as we process them. And what we’ve seen in the treatment in the pilot work is that they subside if they’re processed appropriately. Does that make any sense to you?

TVO.org: Could you explain a bit more about what it means to “focus on those responses”?

Lanius: You sit there with the person who does that, and they just notice what happens in their body, and then they notice shifts. It’s not a static thing. When you orient to a memory and you experience all that tension, that tension takes a path. And often we see an increase in that tension, and then it’s like a wave — that tension slowly decreases. So the therapist sits with the person to really go through those natural paths of these tensions, these pre-affective shocks and those visceral sensations. If it’s done right, they occur in waves, and they intensify and then they go down, and, over time, the waves become much more shallow and in the best-case scenario disappear altogether.

It’s almost like cutting the pie into smaller pieces so people can tolerate it more.

TVO.org: And what do you ultimately hope to accomplish with your study?

Lanius: We hope to really accomplish progressing treatment of moral injury and disseminating this treatment and really increase our understanding and our treatment, because this is not just a significant problem in health-care workers. It’s also a big problem in our military personnel and our veterans and in the civilian population.

TVO.org: Your study is limited to health-care workers, and a two-year study that began in January 2020, also at Lawson, is looking at moral injuries in veterans. But are there any other fields of work or environments where moral injuries may be especially prevalent?

Lanius: In our public-safety personnel, they’re also very prevalent. And in the civilian population, people who have experienced sexual assault often also suffer from moral injury.

TVO.org: You mentioned PTSD earlier. How does moral injury relate to PTSD. Is it part of it?

Lanius: This is a great question, and it’s been a question that has been debated significantly. At this point, some people say, “It’s part of PTSD”; other people say, “It’s a separate phenomenon.”

We’re going to focus in the study on really looking  at more of the classic PTSD symptoms — the hyperarousal symptoms — and how they do after we focus specifically on treating symptoms more associated with moral injury, which is the self-blame and the visceral sensations.

TVO.org: Maybe it’s too early to know, but how do moral-injury recovery times vary?

Lanius: We don’t know yet. This is a very new area, and it’s just beginning to be studied, so these are all questions that we will need time to answer.

This interview has been condensed and edited for length and clarity.

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