There is no predictable set of causes, but there are experiences that create a risk for moral injury. They involve high stakes situations, such as life and death, a high risk for failure, no clear right and wrong choices, and harm done. A person can have moral injury not only from directly inflicting harm, but also from witnessing it happening, hearing about it, or surviving being harmed. Moral injury from being harmed involves trusting people with power who fail to do the right thing. Experiencing harm may involve feeling betrayed, humiliated, frustrated, furious, and ashamed of being contaminated by evil. People may also do things to survive that violate their conscience and believe they are no longer good.

People will often feel grief, as well as guilt, remorse, shame, outrage, and despair. They lose trust in themselves and their moral foundations; their relationships may be disrupted because they cannot trust others not to judge them, and they self-isolate. They may mask their inner pain with alcohol or drugs. They can become alienated from societal norms and lash out in anger at the slightest provocation.

Post-traumatic stress disorder is fear-based. Moral injury is based in moral judgment, and having it requires a working conscience. The two can share some symptoms, like anger, addiction, or depression, but moral injury has no diagnosis or treatment protocols. Some PTSD treatment protocols can aggravate moral injury. For example, Dr. William Nash, a psychiatrist and expert on moral injury, points out that reliving a traumatic incident many times in a safe environment to defuse the fear can sometimes bring moral injury “to emotional immediacy” and make it harder to address.

With something as complicated as moral injury, there is no single best agreed-upon treatment, but this complexity means that it can be processed in a number of ways. When people have trouble accessing what is wrong, having them create an image, go through a guided meditation, or write a poem or story can help them externalize their moral injury, and see that they are more than the injury. In externalizing it, they can begin processing it and access a fuller memory that integrates the experience instead of having it dominate their identity.

Prayer, chanting, and various forms of meditation offer collective ritual processes for calming inner turmoil and restoring capacities to reflect on and make sense of inner pain. A conversation with a benevolent moral authority, such as a chaplain or religious leader can help, but this will not be helpful if they impose their religious views. Helping people think is important; telling them what to think can delay or derail recovery.

At some point, the precipitating incident(s) must be shared, talked about, and looked at reflectively. This sharing requires people prepared to listen deeply, with an open heart and without judgment. But how such sharing and listening are structured can vary by culture and spiritual tradition. Affinity groups can provide an effective point of entry for building trust so that sharing is easier, for example, veterans who share military culture, refugees from a particular region, or survivors who share a common experience. According to Rita Nakashima Brock, PhD, Volunteers of America’s senior vice president and director of the Shay Moral Injury Center, “Recovery is a lifelong process because it requires the restoration of love and empathy.”

It applies to everyone. Under duress, people can violate their moral code in many situations. For example, a doctor misdiagnoses a patient with fatal consequences; a mother living with addiction loses custody of her children; an office worker fabricates documents for fear of losing a job; an expectant mother has to abort a problem pregnancy; a minister has an affair with a married parishioner; or a train conductor fails to see a warning light and crashes his train.

Attending to the behavior of someone you love is important. If they seem distant, reluctant to share, preoccupied, controlling, cold, drinking too much, overworked, or otherwise not able to be present, that may mean they have shut down because of inner emotional pain. They may be unaware of why they feel terrible, or they may be reluctant to share what bothers them if they believe you will think less of them or will be disturbed by what they hear. Ask them if they’ve heard of moral injury. When people are introduced to the term, their eyes often light up in recognition. They know it for themselves, or they know someone who has it. Ways to introduce it include films, books, blogs, essays, stories, and conversations with someone who has experienced it. Just remember that you may not be the person they want to talk to, but make sure they have someone to talk to.