Listening to the Unseen Wounds of Moral Injury

Cher McGillivray, Ph.D.

Director (Academic) Global Listening Centre.
Assistant Professor at Bond University, Australia.
Licensed Clinical Psychologist with the Australian
Health Practitioners Regulation Agency.

Within human experience there is a potentially overlooked dimension of suffering that transcends visible scars and goes to the fabric of our moral integrity. Moral injury emerges when the fibres of our deeply held beliefs unravel, leaving behind wounds that remain hidden, unheard and, often, untreated. Traditionally associated with the harrowing transgressions of wartime military, moral injury permeates realms far beyond the battlefield.

Moral injury occurs when we transgress a deeply held belief or sense of who we are, or when we fail to prevent suffering to someone, or simply witness actions that betray a moral boundary (Shay, 1994). Experiencing intense human suffering and feeling powerless leads to a loss of faith in the good in the world, diminished hope in one’s future, and a lack of trust towards oneself. Rooted in pain, guilt, disgust, and regret, moral injury becomes an unseen wound that is suppressed and no longer listened to. It leads to post-traumatic stress disorder (PTSD), psychological distress, and shame.

Soldiers returning from war have often found themselves unable to speak of the horrors they witnessed or were forced to perpetrate. Yet having someone hear and acknowledge the suffering they experienced is, for many, a key aspect of healing. The same is true of those experiencing moral injury in the corridors of healthcare and justice, where relentless exposure to complex decisions amidst limited resources and moral ambiguity often presents itself as physician burnout or compassion fatigue (Pfeffer, 2022). Health practitioners have been found to suffer with higher levels of moral injury (69%), and medical practitioners have suicide rates at more than twice the general population each year (Litam & Balkin, 2021).

In families too, moral injury is often present; yet it can be unseen and unheard, as stories go untold due to shame and self-judgement. The latest findings released from the landmark Australian Child Maltreatment study have reported that 62.2% of Australians have experienced some form of child abuse (physical, sexual, emotional, neglect and exposure to domestic violence). Family members are the most common perpetrators of abuse, which occurs most often at the hand of a parent (Mathews et al., 2023).

Not all children who experience sexual abuse will develop PTSD; however, 30-50% will meet the criteria and many more will experience many of the symptoms. Non-offending parents will often experience vicarious trauma through hearing of their child’s trauma. This leads to PTSD and has shown to result in moral injury that maintains the PTSD by up to 47% (McGillivray, 2022). But even though we know that moral injury is facilitating PTSD above and beyond the traumatic event itself, it often remains untreated because medical care focuses predominately on visual symptoms of PTSD (Koenig, 2019), leaving a further generation silenced with moral injury.

Our ability to listen to these narratives that have long been suppressed is the most effective tool we can all offer to aid someone who has experienced a moral injury crisis. Just as a physician’s diagnosis is incomplete without attentive listening to a patient’s history, so too is the journey towards healing impeded without lending an ear to the stories of moral injury.

The Royal Commission into Institutional Responses (2017a) reported that most survivors of child sexual abuse took an average of 23.9 years to make a disclosure of the abuse (Reitsema & Grietens, 2016). But remaining silent is never the right thing to do. We know that silencing ourselves—never speaking about our fears, thoughts, or ruminations on the past—can lead to psychopathologies and diseases. Intergenerational silencing contributes to mental health issues, as do self-critical thoughts of contempt and judgement (Farnsworth et al., 2014), or placing blame on oneself and others (Litz et al., 2009).

There is also the lack of self-compassion, underpinned by shame, that hinders our ability to listen. Perhaps listening to ourselves and tending to our discomfort, addressing the seeming mess within, is based on a fear of failure; and yet, it is being willing to listen that holds the message for recovery. When we fear that we will fail, meaning to disappoint others (or disappoint ourselves), that is often linked with shame (McGregor & Elliot, 2005). One of my favourite quotes, from the true story of Coach Carter (2005), says, “What if our deepest fear is not that we are inadequate; [what if] our deepest fear is that [we] are powerful beyond measure?” If success is failure turned inside out, and fear of becoming our full potential is what is limiting our ability to listen, how can we learn to better listen to the still, small voice within? Listening is so close to love that it is almost indistinguishable—it is not part of love, but rather, it is the core of love, and essential for taking care of ourselves and others.

Trauma originates from the Greek word wound, and an unhealed wound of the past that keeps being activated and hurting in the present causes a further trauma. Trauma is not what happens to us, but what is stored within us, leaving the absence of an empathic witness (Levine & Mate, 2010). Psychopathology is composed of two Greek words meaning “soul”(psyche) and “mind” (logos)—a linguistic compound that suggests mental processes and wellbeing are somehow separated from the body. Yet the integration of the body and soul encompasses meanings such as humanity, self, mind, and passion.

When our thoughts are out of alignment with who we really are, when we are trying to please others or tell ourselves things our body/brain do not believe such as, “I am a terrible person because I did not see that danger ahead,” or “I did think my decisions would cause so much pain to others or myself,” we can lose our sense of self. Our identity becomes fractured, and it cannot identify the bad things that happen to us. It is the disturbances in identity, selfregulation, and self-compassion that result in complex trauma (Herman, 2015).

While abusive relationships impair integrative brain regions, healthy relationships can downregulate the vagal system, promoting restoration, safety, and trust required for healing (Porges, 2015). Therefore veterans, parents, caregivers, teachers, practitioners, and first responders must learn to emotionally regulate and connect with themselves and others. This is especially true when dealing with children: connection before correction assists a child with coregulation difficulties and assists the developing brain of a child. A child needs one present, emotionally stable, stress-free care giver to build resilience (Siegel, 1999). If we humble ourselves to stoop down to simply listen to children, to those in challenging situations, and most importantly to ourselves, this will pave a way for a safer world for future generations. Begin with listening as the quickest road to another’s heart. To support others in difficult situations, we must remain strong and be able to enter into those situations with empathy, but still remain steadfast (Chambers, 2014). I think the same goes for listening to ourselves. We should listen to our own heart with selfcompassion. Being able to accept and experience painful emotions such as shame makes it possible to sit with our own suffering and avoid becoming disconnected from self and others. And listening with self-compassion can help us to alleviate our suffering (Neff, 2003).

There is an old saying that we have two ears, as compared to one mouth, so that we can hear (or listen) more than we talk. This is something worth remembering, whether listening to the traumatic experiences of others or listening to ourselves. The Dalai Lama makes this useful observation: “When you talk, you are only repeating what you already know. But if you listen, you may learn something new” (Cited in Salzberg & Kabat-Zinn, 1997). We should be brave, weaving together hope and courage, around the unseen wounds of moral injury. And by listening, we may see new generations of hope emerge.

Dr. McGillivray’s team runs a free program, Parenting Beyond Trauma, to help carers dealing with the impact of childhood maltreatment and sexual abuse. For more information on the Parenting Beyond Trauma program, visit: https://bond.qualtrics.com/jfe/formSV_51NsMTeB2mghzAW

References

Farnsworth, J. K., Drescher, K. D., Nieuwsma, J. A., Walser, R. B., & Currier, J. M. (2014). The role of moral emotions in military trauma: Implications for the study and treatment of moral injury. Review of General Psychology, 18(4), 249-262. https://doi.org/10.1037/gpr0000018 Herman, J. L. (2015). Trauma and Recovery: The aftermath of violence–from domestic abuse to political terror. Hachette United Kingdom. Koenig, H. G., Youssef, N. A., & Pearce, M. (2019). Assessment of moral injury in veterans and active-duty military personnel with PTSD: A review. Frontiers in psychiatry, 10, 443. https://www.frontiersin.orgarticles/10.3389fpsyt.2019.00443/full Levine, P. A., & Mate, G. (2010). In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley:

North Atlantic Books. Litam, S. D. A., & Balkin, R. S. (2021). Moral injury in health-care workers during COVID-19 pandemic. Traumatology, 27(1), 14–19. https://doi.org/10.1037/trm0000290 Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706. https://doi.org/10.1016/j.cpr.2009.07.003 Mathews B, Pacella R, Scott JG, Finkelhor D, Meinck F, Higgins DJ, Erskine HE, Thomas HJ, Lawrence DM, Haslam DM, Malacova E, Dunne MP. The prevalence of child maltreatment in Australia: findings from a national survey. Medical Journal Australia. 2023 April 3;218 Suppl 6:S13-S18. http://doi.org/10.5694/mja2.51873 McGillivray, C. (2022). Empirical Extension of the Theory of Moral Injury: Investigating the Role of Intrapersonal Moral Injury Cognitions in Non-offending Parents of Children who have Experienced Sexual Abuse. https://pure.bond.edu.au/ws/portalfiles/portal/197623117/Cher_McGillivray_Thesis.pdf Neff, K. D. (2003). The Development and Validation of a Scale to Measure Self-compassion. Self and Iden-tity, 2, 223-250. https://doi.org/10.1080/15298860309027

Pfeffer, C., Hart, R., Satterthwaite, M., Bryant, R., Knuckey, S., Brown, A. D., & Bonanno, G. A. (2022). Moral injury in human rights advocates. Psychological Trauma: Theory, Research, Practice, and Policy. https://doi.org/10.1037/tra0001404 Porges, S. W. (2015). Making the world safe for our children: Down-regulating defence and upregulating social engagement to ‘optimise’ the human experience. Children Australia, 40, 114 -123. https://doi.org/10.1017/cha.2015.12 Reitsema, A. M., & Grietens, H. (2016). Is anybody listening? The literature on the dialogical process of CSA disclosure reviewed. Trauma, Violence, & Abuse, 17, 330-340. https://doi.org/10.1177/1524838015584368 Salzberg, S., & Kabat-Zinn, J. (1997). Mindfulness as medicine. Healing Emotions: Conversations with the Dalai Lama on Mindfulness, Emotions and Health (Ed.D.Goleman), Boston, MA: Shambhala, , 107-144. Siegel, D. J. (1999). The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. New York, NY: The Guilford Press. Shay, J. (1994). Achilles in Vietnam: Combat trauma and the undoing of character. New York, NY: Scribner