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The Hidden Toll: Exploring the unseen strain of Moral Stress

What I talk about in this blog, stems from my own experience of MI when serving in the Army and how it ultimately led to me developing Post-Traumatic Stress Disorder (PTSD). I wrote this blog because I want to share some of the things that I’ve learnt from trying to make sense of everything, on my journey through recovery.

I also want to explore a different perspective to explain the ‘why’ of our current modern day stress epidemic. Unlike workplace burnout, often experienced because of overwork and symptoms such as exhaustion and disengagement, I want to explore another potential reason underlying burnout…

Moral Stress

Unlike burnout, the solution to Moral Stress isn’t resolved through individual efforts such as resilience training or wellness apps, although they may help. Moral Stress is generated from systemic cultural issues and its’ impact, health wise, can be harder to overcome.

Moral Stress derives from the term Moral Injury (MI), initially coined by Jonathan Shay in military research, before MI gained relevancy in society and business contexts to explain the symptoms experienced from working in toxic work environments where extreme moral issues are rife.

Toxic work environments are a hot topic at present which is why I’m putting it out there that maybe burnout and the current modern day stress epidemic may also potentially relate to issues of Moral stress.

What exactly is Moral Injury/Stress?

MI is a trauma response which includes feelings such as injustice, anger, guilt, shock or shame, cognitive responses such as intrusive thoughts, social withdraw, loss of trust and avoidant behaviours after experiencing events which contradict your ethical beliefs, rock your self-identity and semblance of the world.

When we can’t seem to integrate the experience, this can lead to cognitive dissonance, a type of psychological stress, as a result of what has happened.

I am sure that whilst reading this, some of you, can probably think of at least one example of a situation in the Armed Forces (AFs) where this might have happened and just how hard it was to move on.

In the long-term though, if we don’t deal with our hurt, it can lead to outcomes such as PTSD, like it did for me.

My Own Experience

I was posted out to Afghanistan as the only female attached initially to an infantry battalion (800 men) where from the onset of arriving in the battlespace, I experienced extreme humiliation & bullying, the betrayal of leadership, sexism and at worst:

I was sexually assaulted by an Afghan National Army (ANA) Officer I was training.

When I reported the assault to my Commanding Officer (CO) I was told, I would go back and train the ANA officer but this time, I should take a pistol with me.

At that point, it suddenly dawned on me that I really was alone, a mere object in his agenda of keeping the ANA happy and onside and that this took precedence over his humanity.

As these events piled up it became more and more apparent that no-one else had my back which was one of my biggest lessons; always have your own.

But why didn't I speak up sooner?

Partly because I feared the consequences of speaking up on my career, of being seen as a failure and of the backlash by peers especially when this was all happening in a war zone.

It is amazing how our conditioning and being in a minority in the AFs can lead us to putting up with and normalising bad behaviours as ways to fit in and to survive.

My advice to anyone now would be to speak up earlier and nip things in the bud, even if the outcome is difficult and not what you want, because putting up with their behaviour enables it to continue and on a personal level this fact caused me so much pain.

Eventually I did call the CO out and when other people heard about it, I was ostracised.

However, at this point I had given up caring.

At the end of the tour, I was posted back on my own, straight onto a new job, whilst those on tour came back together and had 2 weeks in Cyprus to ‘decompress’.

When invites went out to those on tour to be awarded their medals at ceremony, my medal was sent to me in the post.

No-one checked on me and with the ‘just get on with it’ mentality kicking in, I tried to push the memories and hurt down…

But this was a massive mistake.

Funnily enough it wasn’t the incidents that led to me losing my career but the fall out of the emotional pain I felt. I now know you can't get rid of hurt by running away from it, you have to face it, but it would take me spiralling slowly down to a rock bottom before I figured out what was wrong and how to help myself.

Causes of Moral Injury/ Moral Stress

Events don’t need to be catastrophic to cause MI but can include the gradual build-up of transgressions. MI is present in certain conditions and affects people in different locations within an event(s).

This includes the person who carries out, witnesses, fails to prevent, or encounters betrayal by those in a position of power. This might look like an inability to deliver the appropriate level of care to a patient due to resource shortages, being put in hazardous situations without the proper protection, dealing with misogyny, racism or sexism in unhealthy workplace cultures that is never addressed. You may experience or witness toxic bullying and a leadership that look the other way or are the bully, or you may face unwritten rules that lead to being passed over for promotion that is really, blatant ageism, racism or sexism.

MI can affect anyone at any level, from the frontline worker to every layer of leadership in situations that leave us feeling powerless and lacking agency.

Sometimes the distress we experience is happening because it isn’t as simple as weighing up what is the right thing to do and then acting because ethically, you already know what the right thing to do is. You may feel torn though because the situation could involve someone higher up the chain, speaking up could be costly for your career, the family you support or the organisation and at the same time as all of this, not speaking up can mean you become complicit to the problem.

In my case how I was treated violated my deeply held beliefs of equality, humaneness, and respect. It rocked my sense of self; I lost my trust in others and of feeling safe in the world.

I internalised and personalised the experiences thinking I was a failure and therefore something must be wrong with me. Wrestling with insidious shame, deep feelings of anger and injustice at being left with the consequences of something that was never my fault, I struggled to make peace with what had happened to me.

Over a period of years, clueless to what was wrong and as no-one seemed to understand my symptoms, my health deteriorated.

4 years after leaving the Army I had spent my mortgage trying to help myself, I was socially isolated, my hair was falling out, I had flashbacks, chronic stress and I was so frightened.

Little did I know that this continued struggle psychologically, was actually leading to PTSD.

I eventually figured out myself what was wrong and because I had some support and resources, I consider myself one of the lucky ones, whilst others unfortunately are not.

How do we deal with Moral Injury/Stress?

Through lived experience of MI and being clueless to what I was experiencing at the time, plus through research and further education my learnings are this:

  1. Don’t ignore how circumstances are impacting your emotional health.

  2. Find allies at work and even if uncomfortable nip situations like bullying in the bud.

  3. If you are not in work; find safe spaces, groups, and communities like ‘The V Word’ to be part of. Know you are not alone.

  4. Reflect on whether you might be suited in an organisation more aligned with your values, but I would suggest working through what happened to you first, because you might carry the residue of the impact on to your next job.

  5. Get the help you need to work things through and gain perspective which might look like getting help from a Trauma-Informed Coach (like me!)

The truth is everyone’s situation and backstory are unique and so what worked for me might not work for you.

I do know however, that for me, if I hadn’t found the acceptance of one person that had my back, I wouldn’t be here now…

They gave me my faith back in humanity.

Therefore, the biggest takeaway I have learned throughout all my struggles and successes, both in and out of service, that I offer you today is:

You MUST find healthy and supportive relationships, where you are accepted, so you can learn to trust once again.

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