What is moral injury, and how does it affect journalists covering bad stuff?

By Dean Yates
Best Defense guest columnist

While covering the 2015 refugee crisis, Will Vassilopoulos, a Greek freelance video journalist, was devastated when he and other reporters had to carry the bodies of a young boy and an old man off a Greek island beach to an undertaker because there was no one else to do it. “This is a beach on an island in a country that’s not at war …  It’s evil…. Why would this happen to a small boy?” Vassilopoulos wrote in a blog post.

Veteran Reuters photographer Yannis Behrakis sometimes questioned if he was doing enough while chronicling the crisis: “A lot of times you are not sure what to do: leave the camera and actively help people come out of the sea or do practical things for them, drive them up the road, or give them clothes, or take their pictures. Of course, I always think this is the way I help and this is my job to make sure that everybody around the world knows what is happening and that is my mission.”

Behrakis, who is Greek, realized he needed a break from covering the story after he had a nightmare in which he saw his 10-year-old daughter drowning in a shipwreck.

Patrick Kingsley, then of the Guardian newspaper, questioned the value of his work. “As time goes on you are just dealing relentlessly with the same wretched situation: the shipwrecks, the same stupid policies. No one in power is really interested in listening to what is happening on the ground.”

These three accounts were contained in a groundbreaking report released last month, which found that many journalists who covered the 2015 refugee crisis in Europe experienced difficulties related to moral injury — a concept few people have heard of.

The authors of the report — “The Emotional Toll On Journalists Covering The Refugee Crisis” — were Anthony Feinstein, professor, Department of Psychiatry, University of Toronto, and Hannah Storm, director of the International News Safety Institute.

They noted that moral injury is the damage done to a “person’s conscience or moral compass by perpetrating, witnessing, or failing to prevent acts that transgress personal moral and ethical values or codes of conduct.”

While not all journalists were affected the same way, the most common reactions were feelings of guilt at not having done enough personally to help refugees and shame at the behavior of others, such as local authorities, they wrote.

Journalists with children had more moral injury-related distress while those working alone said they were more likely to have acted in ways that violated their own moral code. Those who said they had not received enough support from their organization were more likely to admit seeing things they perceived as morally wrong. Less control over resources to report on the crisis also correlated significantly with moral injury. And moral injury scores correlated significantly with guilt. Greater guilt, in turn, was noted by journalists covering the story close to home and by those who had assisted refugees, the report added.

Feinstein and Storm wrote that moral injury can cause “considerable emotional upset.” They noted that journalists reported symptoms of intrusion. While they didn’t go into detail, intrusion can mean flashbacks, nightmares and unwanted memories. These can disrupt normal functioning. In my view, guilt and shame can also be debilitating.

Feinstein and Storm also said moral injury could prove a “significant stumbling block” for journalists reintegrating back into society after covering a story like the 2015 refugee crisis.

While the report noted that journalists are generally resilient, its findings underscore the need for much greater awareness of moral injury. Indeed, Feinstein and Storm said the findings, in principle, also applied to coverage of events such as terror attacks or other humanitarian disasters.

“I think we are beginning to understand that it is not just the visual exposure to the horror alone that is debilitating, but the compromise of one’s own moral compass can undermine the well-being of media practitioners,” Cait McMahon, managing director of the Dart Center for Journalism and Trauma in the Asia-Pacific region, told me recently.

To better understand moral injury, it’s useful to look at the research into serving and retired American soldiers. Journalism is obviously a different profession, but we can find ourselves in similar situations, especially as witnesses to traumatic events in warzones.

Moral injury, which has its genesis in ancient Greek writing, was a nebulous concept until the 1990s, when American psychiatrist Jonathan Shay defined it as the betrayal of what’s right by a military superior in a high-stakes situation. Shay drew his conclusion from years of treating psychologically wounded U.S. veterans of the Vietnam War. Think of soldiers ordered to carry out acts in this divisive guerrilla war that deeply contravened their moral code, such as killing civilians because of poor intelligence and then getting awarded medals for it. That was one example Shay gave in his 1994 book, Achilles in Vietnam.

In 2009, Brett Litz, a clinician and professor of psychiatry and psychology at Boston University, wrote a seminal paper with several others that defined a second form of moral injury among U.S. soldiers: “Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations. This may entail participating in or witnessing inhumane or cruel actions, failing to prevent the immoral acts of others, as well as engaging in subtle acts or experiencing reactions that, upon reflection, transgress a moral code.”

Shay defined the violator as the powerholder. For Litz et al, it was the self.

There is no consensus among experts on whether moral injury is a subset of PTSD or a distinct condition. Where there appears to be agreement is that moral injury and PTSD can coexist and that it’s possible to have one, and not the other.

PTSD results from exposure to actual or threatened death, serious injury or sexual assault, either directly or witnessing it happening to others. The main clusters of symptoms are reliving the traumatic incident, hyper-arousal, avoiding reminders of the event and emotional numbness. (I should point out that journalists in the above report revealed few symptoms of PTSD or depression).

In a book published last year called Adaptive Disclosure, which sets out a treatment regime for moral injury in U.S. soldiers, Litz and three other authors wrote that the consequences of moral injury were akin to the re-experiencing, avoidance, and emotional numbing symptoms of PTSD. In addition, like PTSD, moral injury entailed severe social withdrawal. Unlike PTSD, it led to pervasive shame and guilt, they added.

“An individual with moral injury may begin to view him or herself as irredeemable or believe that he or she lives in an immoral world,” Litz et al wrote in the 2009 paper.

So, while PTSD affects the fear circuitry in the brain, moral injury damages your soul.

Until recently, moral injury was applied exclusively to U.S. soldiers who fought in Afghanistan, Iraq or Vietnam. Australian clinicians, however, now say that police and emergency service workers suffer moral injury. And as we have seen above, it can affect journalists.

I suspect some journalists who covered the refugee crisis and other traumatic events over the course of their careers would relate to an expanded definition of moral injury put forward by Australian trauma experts Zachary Steel and Dominic Hilbrink — bearing witness to horror. They contend this is where themes of inhumanity, gross injustice and moral culpability dominate, rather than fear and terror as in the usual PTSD model.

Steel and Hilbrink base their conclusions on their clinical work with defense and emergency services personnel at the St John of God psychiatric hospital in Richmond, near Sydney.

“This exposure to horror and malevolence creates a first-hand knowledge that destroys and pollutes the individual even though the individual in no way contributed to the atrocity and had no power to prevent it,” they wrote in an essay for a 2015 book called Moral Injury: Unseen Wounds In an Age of Barbarism.

“A threat to one’s psychological integrity via an event that shatters one’s sense of self, community, relationships and world order can have a profound effect on someone’s sense of themselves in the world.”

McMahon, who is also a registered psychologist, said she had concluded from extensive research that guilt and regret for reporters who had covered traumatic stories was a lingering and ongoing problem long after any physical threat or injury had passed.

I asked Litz some months ago what he thought about moral injury and journalists. He said: “I would assume that most journalists would be more haunted and impacted by being exposed to violence as an observer in real-time or bearing witness to violence and cruelty. The outcome would not be a racing heart in the sense of phobias and PTSD from life-threat, but more akin to a broken heart.”

Good books on moral injury:

Moral Injury: Unseen Wounds in an Age of Barbarism, edited by Tom Frame

Shooting Ghosts. A U.S. Marine, a Combat Photographer, and Their Journey Back from War, by Thomas Brennan and Finbarr O’Reilly.

Afterwar: Healing the Moral Wounds of Our Soldiers, by Nancy Sherman

Adaptive Disclosure: A New Treatment for Military Trauma, Loss, and moral Injury, by Brett Litz, et. al.

War and the Soul, by Edward Tick

Achilles in Vietnam and Odysseus in America, by Jonathan Shay

A Memoir, by Eric Fair

What It Is Like to Go to War, by Karl Marlantes

God Is Not Here: A Soldier’s Struggle With Torture, Trauma, and the Moral Injuries of War, by Lieutenant Colonel Bill Edmonds.

Dean Yates spent more than 20 years covering Asia and the Middle East as a reporter and bureau chief for Reuters. He was the company’s bureau chief in Iraq when Reuters photographer Namir Noor-Eldeen, 22, and driver Saeed Chmagh, 40, were shot dead by a U.S. Apache helicopter on the streets of Baghdad on July 12, 2007, along with around 10 other people. Dean also covered the Boxing Day tsunami in Indonesia’s Aceh province in 2004 and the Bali bombings in 2002.
Dean has PTSD and moral injury. He’s been admitted twice in the past year to the Ward 17 psychiatric unit at Melbourne’s Heidelberg  Repatriation Hospital. In May, Reuters appointed Dean to the newly created role of journalist mental health and wellbeing advocate. 

Photo credit: Ggia/Wikimedia Commons