As the world enters the second calendar year of the coronavirus disease-19 (COVID-19) pandemic, the United States (U.S.) faces another ongoing national issue – racism, marginalization and oppression of Black, Indigenous and People of Color (BIPOC). While the pandemic is brand new, the issue of oppression is older than the country. Although incomparable, they share similar psychological sequelae including depression, anxiety, substance misuse and posttraumatic stress (e.g., Salari et al., 2020; Williams, Printz, & DeLapp, 2018).
Another such shared outcome may be moral injury, which refers to the biopsychosocial-spiritual suffering that stems from events or situations that violate deeply held moral beliefs or values (Farnsworth et al., 2017; Litz et al., 2009; Shay, 2014). Some researchers have bifurcated potentially morally injurious events into perpetration-based and betrayal-based (e.g., Bryan et al., 2016). Freyd and colleagues (2007) described betrayal trauma as occurring, “when the people or institutions on which a person depends for survival violate that person in a significant way” (p. 297). Health care providers and others on the front line of the COVID-19 response may experience the actions, inactions and decisions of leaders and systems as betrayal, thwarting their ability to keep their oath, provide care and potentially save lives. Similarly, BIPOC may experience the (in)actions and decisions of leaders and systems as betrayal, failing to protect and serve these communities and provide justice for transgressions. At the intersection of these issues, the disproportionate rates of COVID-19 among BIPOC (AMP, 2020) is further evidence of the systemic failures to reduce inequities woven into the fabric of our country’s institutions.
As COVID-19 began to overwhelm health care systems and providers across the world, moral injury quickly entered into discussions with particular attention to the moral pain of health care workers. Being placed in ethically challenging situations, moral distress in health care workers can manifest as guilt, anger, disgust, and thoughts about systemic and leadership failures (e.g., Hossain & Clatty, 2020; Litam & Balkin, 2020). In addition to personal anguish, betrayal of providers’ moral values by health care leaders and systems may lead to professional fallout including low morale, burnout and compassion fatigue (Nash, 2020). In moments like this, the moral values that guide those in the business of caring render them vulnerable to the pain of values betrayed. It is, therefore, incumbent upon professionals in the field of traumatic stress studies to continue broadening and deepening the understanding of and response to moral injury in health care and other helping professions.
During 2020, the longstanding systemic oppression of BIPOC in the U.S. came increasingly to the forefront of sociopolitical conversations propelled by public attention to relentless demonstrations of police violence and an election year. Although the effects of racism on both BIPOC and communities of color have long been documented (e.g., Comas-Díaz, Hall, & Neville, 2019; Paradis et al., 2015), action to seriously change this pattern of institutional betrayal has yet to be taken. In an essay published by The Shay Moral Injury Center, the Reverend Traci Blackmon describes how the centuries of enduring systemic racism leads to moral injury. She says:
“When authorities betray what is right, when those who are supposed to defend and protect citizens, kill our children instead. When those who are responsible for the common welfare work to reassert white supremacy, they betray us. Such betrayal is acute when we are betrayed by those who claim to care—people who benefit from oppression and do nothing to stop it. When I used to speak about the cost of inaction, or complicity in oppression, I would say our humanity was at risk... Moral injury is damage to our very souls…”
The betrayal experienced by BIPOC in the U.S. crosses all domains of morally injurious events. It is implicit and explicit. It is action and inaction. It is at every level of society, from health care access and recognition of legitimate pain to food justice and basic safety in one’s neighborhood. It is also in our very own field: the legitimacy and fallout of racial trauma has yet to be fully recognized within the current diagnostic model (Williams, Metzger, Leins, & DeLapp, 2018), with many BIPOC experiences of racial trauma falling outside the scope of a Criterion A event per DSM-5. We must not perpetuate the moral transgressions against BIPOC by disregarding these lived experiences. To do so risks deepening the moral suffering of communities of color and, simultaneously, risks violation of the moral values of the field of traumatic stress. Racial trauma is the culmination of numerous discriminatory or oppressive experiences (Carter, 2007; Williams et al., 2018). It is common and consistent and, as Rev. Blackmon says, is soul damaging. Significant room for improvement remains in the reigning definition of trauma and posttraumatic stress, but a history of racism, colonization and white supremacy hinders progress. The scope of morally injurious events and the characterization of moral injury are still under development. Construct definitions should, therefore, actively and decisively address this inequity and explicitly acknowledge the moral fallout of institutional betrayal. Intervention development, too, will be more just if done so with understanding of racial trauma and its potential for inducing moral injury in BIPOC.
This year’s coupling of the pandemic with continued systemic oppression in the U.S. has awoken its inhabitants, more than ever before, to the ineffable truth of our interconnectedness and interdependence on each other for safety and wellbeing. The mental health field has attempted not to impose values on others, and yet it is clear that justice and equity and, therefore, suffering are inextricable from morality. For front-line health care workers, BIPOC and all of humanity, it is our imperative as traumatic stress professionals to be brave by shedding light on all facets of trauma and its sequelae.
About This SIG
The Moral Injury Special Interest Group (SIG) aims to bring together individuals from across healing disciplines and beyond in order to provide a professional home for moral injury discourse and development. The SIG strives to facilitate dynamic conversations and collaborations that advance our understanding, assessment and healing of moral injury and related phenomenon. We are strongly committed to examining and recognizing how historical and contemporary traumas impact moral pain and moral injury within individuals and communities. The SIG believes in the importance of humility and works to include and bring together, rather than limit, a host of diverse perspectives. These primary objectives of the Moral Injury SIG are addressed in the following ways:
- Advocacy for the expansion of traumatic stress conceptualizations to include the developing landscape of moral injury
- Supporting collaborative exploration of moral injury among SIG members in order to foster multidisciplinary moral injury conceptualization, research, assessment and services
- Establishing and maintaining an active SIG listserv to facilitate direct and wide-spread sharing of relevant content of interest (e.g., publications, training opportunities, new topic areas within moral injury)
- Serving as an additional resource for ISTSS members with lived experiences of moral injury
The Moral Injury SIG is a personal and professional diverse group of students and professionals from across the globe. Members include leaders in the field of moral injury, providers working to facilitate moral healing, and many more curious and compassionate people looking to learn from this community. ISTSS members can visit the SIG’s webpage and read past newsletters.
How to Join This SIG
- Log in and go to your ISTSS member profile.
- Go to the SIG Choices tab and check the boxes next the SIGs you want to join.
- Scroll down and click “save.”
About the Authors
Amanda J. Khan, PhD, is a licensed clinical psychologist in California and current co-chair of the ISTSS Moral Injury SIG. Dr. Khan completed her clinical internship and MIRECC advanced postdoctoral research fellow in PTSD at the San Francisco VA and is completing an additional postdoctoral scholarship in the Department of Psychiatry at the University of California, San Diego. Dr. Khan’s program of research investigates the roles of trauma type, emotion regulation and inflammatory processes in the etiology and treatment of PTSD, moral injury and depression/suicide. Dr. Khan provides educational seminars on moral injury to trainees working in the VA as well as trainings on working with gender and sexual orientation-diverse people.
Wyatt R. Evans, PhD, ABPP, is a board-certified clinical psychologist in the VA North Texas Health Care System and in private practice in the Dallas-Fort Worth area. Dr. Evans is the founder of ISTSS’ Moral Injury SIG and served as co-chair of the SIG from its inception in 2018 through 2020. Dr. Evans currently supports DoD- and VA-funded research into the prevention and treatment of PTSD, moral injury and other stress reactions among military personnel. On the topic of moral injury, Dr. Evans has published on definitional distinctions, interventions, religious/spiritual struggles and associated outcomes. In 2020, Dr. Evans and colleagues published The Moral Injury Workbook: Acceptance and Commitment Therapy Skills for Moving Beyond Shame, Anger, and Trauma to Reclaim Your Values.
References
American Public Media Research Lab (2020). The color of coronavirus: COVID-19 deaths by race and ethnicity in the U.S. https://www.apmresearchlab.org/covid/deaths-by-race, accessed January 6, 2021.
Blackmon, T. (2017). Where Is God?: How Enduring Centuries of Racism Leads to Moral Injury. The Shay Moral Injury Center. Retrieved from https://www.voa.org/moral-injury-stories/where-is-god
Bor, J., Venkataramani, A., Williams, D. R., & Tsai, A. (2018). Police killings and their spillover effects on the mental health of black Americans: A population-based, quasi-experimental study. The Lancet, 392(10144), 302-310.
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