Moral Injury and Systemic Betrayal in the United States

As the world enters the second calendar year of the coronavirus (COVID-19, or Coronavirus Disease, 2019) pandemic, the United States 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, both are instances of collective trauma and 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).

Moral injury is not a new construct. It has long been talked about by great thinkers and writers such as Plato and Homer. However, within the past approximately ~15 years, the term moral injury has resurged as a focus within the field of clinical psychology and psychiatry. At the current moment, there is no consensus on a definition, and in fact, great controversy and resistance exists to even acknowledge moral injury as a traumatic stress response. Some researchers have bifurcated 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).

Healthcare providers and other COVID-19 frontline workers 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 amongst 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 healthcare systems and providers across the world, moral injury quickly entered into discussions, with particular mainstream attention to the moral pain of healthcare workers. Being placed in ethically challenging situations, moral distress in healthcare 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 healthcare leaders and systems may lead to professional fallout including low morale, burnout, and compassion fatigue (Nash, 2020).

During 2020, the longstanding systemic oppression of BIPOC in the U.S. became increasingly at 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) including the effect of witnessing police violence (Bor et al., 2018), 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 healthcare access and recognition of legitimate pain to food justice and basic safety in one’s neighborhood. It is also in my own field of traumatic stress research: 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 what counts as legitimate trauma per DSM-5. 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.

The current psychiatric model and DSM delegitimize both racial traumas and morally injurious events, which exemplifies the Euro-centric and colonial roots of these frameworks. The medicalization of traumatic stress consequently removes culture, morals, and values; but nothing is ever a blank state, and if fact, that belief is just another example of colonial mindset. Rather than providing an avenue for equitable healing, this approach represents a fear of confronting that all of our suffering is interconnected and legitimate.

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.

The false assumption of moral neutrality has caused significant damage and it is time to confront the “moral” nature of moral injury and discrimination, and trauma in general. Even in our approaches to healing, the mental health field places high value on the role of the individual as the source of the problem and solution rather than the collective or society.

In other words, it’s an individual’s “problem” and it’s on them to do the work to “heal themselves.”

This conceptualization counters the centuries of evidence from a multitude of fields ranging from social psychology to quantum physics that shows our interconnectedness. Similar to the importance of White people educating themselves on their privilege and the historical and current implications of that privilege, can we also collectively acknowledge and take responsibility for the traumas that happen and their moral roots? Can we carry our share of the weight by confronting the social responsibility we have for each other? Can we address inequities by expanding our conceptualizations and approaches to include the moral fallout of traumatic stress and institutional betrayal?

The ineffable truth of our interconnectedness and interdependence on each other for safety and wellbeing is ready to be acknowledged. The question is whether we, as society including mental health researchers and professionals, are brave enough to face it.