When Jennifer S. Wortham was a teenager, her younger brother Patrick started acting out and getting in trouble at school.
Their stepfather had recently died and their mother was struggling. If anyone could help get Patrick back on track, she thought, it was the Catholic priest who had become a close family friend.
The priest was no longer living near their home in California, so that summer, she and her mother sent Patrick to stay with him in Texas.
At the time, Patrick begged not to go. More than a decade later, the family found out why. The priest had been molesting both Patrick and his younger brother, Michael, since they were about 10 years old.
The discovery “completely destroyed my family,” said Dr. Wortham, who is now a researcher at the Human Flourishing program at Harvard.
She suffered for years, feeling guilty and heartbroken over having unknowingly facilitated some of the abuse. “We never celebrated Christmas together ever again,” she said. “We couldn’t all be together.”
The experience led Dr. Wortham to study the topic of moral injury, or the deep distress that can emerge when you feel that your values have been violated, either by yourself or someone else.
The resulting feelings of powerlessness, guilt and shame can lead to mental health problems like anxiety, depression and even suicidal behavior.
“Why are you experiencing all these feelings? It’s because deep down, at your core, who you are is actually being challenged, threatened or violated,” said Dr. Tessy A. Thomas, a physician and bioethics researcher in Danville, Pa., who has studied moral distress among health care workers.
In other words, she said, it can feel as though your very integrity is at stake.
How do you recognize moral injury?
Egregious betrayals, like what Dr. Wortham and her family experienced, can create psychological distress — but so can “relatively small, everyday events,” said Dr. Connor Arquette, a plastic surgery resident at Stanford who has researched moral injury.
“These moments often make us feel uneasy, even if we can’t immediately articulate why,” he said. And over time, people may reach a breaking point.
Say that you value fairness, Dr. Arquette said, but your team at a large academic hospital has been instructed to go above and beyond for a particularly wealthy or well-connected patient. If other patients aren’t receiving the same level of attention, you may feel as though your morals are being compromised, he added.
“Moral distress,” a precursor to moral injury, was coined in the mid-1980s in reference to nurses who felt they were being obstructed from doing what was morally correct while on the job.
Later, in the ’90s, the psychiatrist Jonathan Shay created the term “moral injury” to refer to veterans who were psychologically harmed by carrying out orders that violated their beliefs, such as instructions to kill or harm civilians.
The term has been applied to other groups as well: Teachers, health care workers, government officials and public safety professionals may encounter mandates that threaten to compromise their values, witness morally repugnant behavior or become a victim of somebody else’s transgression.
In the last five years, there has been “an explosion of research” on moral injury, said Dr. Harold G. Koenig, Dr. Wortham’s mentor and a psychiatrist at Duke University who, with his team, created scales to measure these emotional wounds.
Dr. Wortham and her colleagues have proposed modifying the American Psychiatric Association’s D.S.M.-5, psychiatry’s classification of mental health conditions, to include the notion that moral problems could contribute to a mental health condition.
In December, after more than a year of review, the A.P.A. agreed. The change will appear in September.
The addition helps validate the term “moral injury,” Dr. Koenig said. Now, he added, more research can be done to further define it and examine its effects on mental health outcomes.
How do you handle moral injury?
There isn’t a quick fix to address moral injury. But taking action can be an important step in the healing process. Speaking up and asking for change is one option.
Dr. Wortham went so far as to meet with Pope Francis, who later spoke with a group of sexual abuse survivors, which included her brothers, and apologized for the failings of the church. She is working with a team of experts to develop a moral injury guide for those who counsel clergy abuse survivors and their families.
There might be situations where your hands are tied — at work, for example — that make you question whether this is the right environment for you, Dr. Arquette said.
When faced with moral injury, experts say that building moral resilience is crucial.
Dr. Thomas does this with a daily ritual: Every time she washes her hands she thinks about the challenges that others may be facing. Then she finds a way to make a simple gesture, like checking in with a colleague who is having a stressful day. These small acts of compassion help bolster one of her core values: integrity.
“I can’t change all those external things that are happening,” she said. “The only thing I can control in the moment is my attitude and my behavior.”
