If I may repeat your question:

"My question is, when does moral distress become moral injury? What are the differences between moral distress and moral injury? Is moral injury the result of cumulative exposure to moral distress?"

Great question set (my emphasis above). Brief answer and let others step in:

(1) distress of any kind (of psychological perception) becomes an injury of any kind as a result of a cumulative exposure; that over time there is enough internal motivation for the distressed person to shift from a sense of distress into a state of injury. So, “when” is largely determined by the circumstances of the person in harm’s way. But, irrespective of when it happens, as soon as the injured know it, they need assistance. Injury means potential disability and most often temporary. This means that the injured requires treatment to bring them back to a state of wellness prior to the injury.

(2) So, the difference between moral distress and moral injury is that: one is a necessary condition (distress) for experiencing the consequence (injury).

Hope this is useful.

Cognitive dissonance is also a very important concept in our discussion of moral distress. Festinger (1957) offered a nifty way to see the consequences of “mental discomfort” but did not use the concept of stress in those days. We need balance; internal consistency to be mentally healthy. He suggested that we all strive to minimize our inconsistencies by becoming more comfortable and more motivated to reduce the dissonance.

Charles

Thanks Charles - my thoughts too. I think it has implications for how we define moral injury - current definitions rely on exposure to potentially morally injurious experiences, generally seen as discrete events. Moral stress seems to me to be a more pervasive issue, for example, individuals in various occupations such as child protection work or health/medicine being unable to do their job because of limited resources. Current discussions on whether burnout in medical professionals is in fact moral injury are relevant.

More or less since World War II there have been two images of trauma: one explaining it as the result of a frightening experience that acts like a blow to the system, a sudden event that upsets normal mental functions. The other explaining the result of a a cumulative stress overload, a depletion of resources that reaches sudden breaking point, which expresses itself for instance in battle exhaustion. The earlier picture Selye's precedes stress theory, the later picture emerged under its influence. It seems to me that the concept of moral injury is undergoing the same development. So far the concept of moral injury implied a discreet event -- the shooting of a child, of an innocent bystander etc. -- in asymmetrical warfare. It is portrayed as resulting from an experience that acts like a blow to the web of a soldier's moral values convictions. The moral distress theory suggests a second development, of the cumulative depletion of moral resources. In both instances, moral injury is construed in analogy to trauma.

The DSM-5 definition of a Criterion A event still fails to recognize the “straw that breaks the camel’s back” (i.e cumulative trauma) view of a traumatic event. This is particularly problematic in cases of compensation/litigation where single, discrete events must be identified. We have an opportunity perhaps while research is still in its infancy to address this deficiency in terms of developing a workable definition of moral injury?

I found Litz and Kerig's (2019) article in the Journal of Traumatic Stress (DOI 10.1002/jts) very helpful in clarifying the distinction between Moral Frustration->Moral Distress->Moral injury. Some PMIE do not neatly fit the DSM-5 Criterion A definition of a PTE. In my work (managing the Peer Support Program for DCFS employees) PMIEs such as a child reunified by court order, against the recommendation of Children Social Worker (that subsequently results in the death of a child) is akin to the kind of PMIE I observed as a Navy Psychologist embedded with the Marines. Decisions made, without complete data or against the recommendation of an NCO, have resulted in unecessary death of Marines, Corpsmen and non-combatants. Resulting in MI for the decision maker (Transgressioin of Self) and for the NCO (Transgression of other/betrayal). I think the concept of MI has applicablity to Child Protective Services work, but I worry that the lack of distinction between MF, MD & MI will result in misapplication of MI and the concept will lose its utility.

Grant H. Brenner (2017): Considering Collective Moral Injury following the 2016 Election, Contemporary Psychoanalysis, DOI: 10.1080/00107530.2017.1384683 To link to this article: http://dx.doi.org/10.1080/00107530.2017.1384683

This is a good answer to your question. If you are interested in moral stress and moral distress in general as well as in moral resilience you can read our papers (Lützen and Ewalds-Kvist 2012)

Moral Distress: A Comparative Analysis of Theoretical Understandings and Inter-Related Concepts

· March 2012

· HEC Forum 24(1):13-25

· DOI:

· 10.1007/s10730-012-9178-9

Research on ethical dilemmas in health care has become increasingly salient during the last two decades resulting in confusion about the concept of moral distress. The aim of the present paper is to provide an overview and a comparative analysis of the theoretical understandings of moral distress and related concepts. The focus is on five concepts: moral distress, moral stress, stress of conscience, moral sensitivity and ethical climate. It is suggested that moral distress connects mainly to a psychological perspective; stress of conscience more to a theological-philosophical standpoint; and moral stress mostly to a physiological perspective. Further analysis indicates that these thoughts can be linked to the concepts of moral sensitivity and ethical climate through a relationship to moral agency. Moral agency comprises a moral awareness of moral problems and moral responsibility for others. It is suggested that moral distress may serve as a positive catalyst in exercising moral agency. An interdisciplinary approach in research and practice broadens our understanding of moral distress and its impact on health care personnel and patient care.

Thanks Wayne - just read that article and I agree that it is very useful in clarifying those different dimensions of moral stressors - very helpful graphic. I still wonder though about the cumulative impact of moral stressors and subsequent moral distress and at what point the weight of that tips over into more intense moral emotions and intensely negative self-attribution which is more associated with what we know as moral injury. In the trauma sphere I have seen it many times where soldiers endure and endure and then some small thing will tip them out into that PTSD space. I wonder whether in not so much a combat or danger-based environment but in other contexts (e.g. child protection) there is a qualitatively different type of moral injury that comes from depletion of psychological resources to cope with any more assaults on one's moral compass as suggested by Jose. Thoughts?

Anne, There is pretty good evidence that a dosage effect exists for PTSD. It is not a big leap to think their might be a similar dosage effect with MI. I have worked with a lot of Marines with literally 100's of Danger Exposures who function very well, in fact are some of the top performers. I believe that Child Protective Social Workers, like military members, can deal with multiple Danger Exposures as long as the have adequate social support and caring leadership that does their very best to make the job as safe as possible. However, if a Child Protective Social Worker (or military member) feels betrayed, thrown under the bus so to speak, this kind of transgression of others (more like Shay's concept of MI) can really be devastating. So, I am not convinced that it is so much a cumulative effect multiple PMIE exposures but rather a qualitative difference. The question I liked to ask Military Members, as well as Child Protective Social Workers, is this: of all the traumatic events you have experienced which is the one that still haunts you, which one do you think about the most, which one do you conjure in your dreams. Usually that can pinpoint the event. Wendy Haight's 2016, study as well as data I have collected thus far at LA DCFS, suggests that Child Protective Social Workers experience more Transgression of Other and Betrayal than transgression of Self. I would bet if we were to survey CPS workers those who score high on measures of Compassion Fatigue, they would also score high on MI (particularly in transgression other, and betrayal). What Jose refers to, in the context of WW II, is the difference between Combat Shock vs Combat Fatigue. I am not sure that quantity of PMIEs is the key factor in MI but may be in Compassion Fatigue (akin to Combat Fatigue). Whereas MI seems to me qualitatively different, usually a very specific, particularly disturbing PMIE (more analogous to Combat Shock). Wayne

Hi, my perspective may be slightly different, but from my in-depth interviews with veterans on the concept of MI and the research I have been reviewing, it seems to me that a moral injury can be placed on a continuum, whereby some MI are more significant to some than others depending on numerous variables and confounding factors. In addition, what is also clear, is that it is somewhat of a process (not always linear) but generally speaking, a moral dilemma arises, that can lead to a moral decision making process, resulting in moral distress that can perpetuate moral injury, of course morals and values are far too subjective to simply label them in this way and religion, spirituality, culture (big C and little c culture) also play a huge factor in determining whether someone will go on and endure a MI. From my qualitative study in this area what is also clear is the MI is not something a person can be "healed" from, its something they adjust/transition and learn to live with. Not sure if that helps or not :) Thanks for the articles.