What is moral injury and what helps with recovery?

A journalist is sent to knock on the door of a bereaved family immediately after a newsworthy death. They fear that refusing would be career-damaging and experience huge pressure from their editor to get the story before competitors. They are left feeling guilty, ashamed and betrayed as they value behaving professionally in a fair and ethical way.

A young woman gives consent to what she thought was a temporary placement in foster care for her son when she had to go into hospital. Several years later, the child is still in care. The mother feels betrayed by the social workers who did not give her enough information. 

A soldier has recently been involved in a conflict situation where he caused the death of children. On returning home from his tour of duty, he feels suicidal.

A Black man witnesses police brutality towards Black individuals. He feels profound betrayal by a government institution which should protect all people. 

A public librarian in the USA comes under pressure to purchase what they consider to be harmful and anti-science material and to ban certain books. As they have been professionally trained to value their role in serving an informed democracy, they experience shame and anger.

All these examples are taken from recent research projects exploring moral injury. 

The term ‘moral injury’ was first used in 1995 by American psychiatrist Jonathan Shay in his comparison of the mental harms caused to Vietnam veterans and Ancient Greek warriors by transgressive or ineffectual leadership. These harms included rage, shame, alienation and broken-heartedness. The concept of moral injury was brought into the field of clinical psychology in 2009 by Brett Litz and his colleagues.

In this article, I’m aiming to explore the current understanding of moral injury, including how counsellors and psychotherapists can best help those affected. The resources I’ve drawn on are Litz and Walker’s up-to-date overview [1]; my learnings from the International Centre for Moral Injury’s 2025 Conference at Durham [2]; and my own experience in clinical practice as a trauma therapist. 

What is moral injury?

Moral injury is a set of symptoms which have psychological, biological, social, behavioural and spiritual aspects. These symptoms mean a person can experience significant negative changes in six dimensions:

1. ideas about their own and others’ humanity
2. moral thinking, including moralistic judgements of self and others
3. social behaviour, such as being socially excluded and losing valued relationships
4. moral moods and emotions
5. self-harming and self-sabotaging
6. beliefs about the meaning and purpose of life.

These changes are linked to a distressing experience, known as a ‘potentially morally injurious event’ or PMIE, that transgresses deeply held moral expectations. Moral injury has two types: it can be related either to shame or to violation of trust. The shame-related type involves either doing or failing to do something, whereas the trust-violation type involves being the victim of or witnessing transgressive actions. People’s responses to PMIEs lie on a spectrum from moral discomfort through moral distress to moral injury, the most serious. For a person to be experiencing moral injury, their symptoms need to be intense and affect their functioning in life to the extent that they may need extra resources to recover, such as help from a counsellor. Moral injury symptoms have some overlap with PTSD, including being haunted by the experience, trying to avoid memories and linked places, being unable to feel enjoyment, and social withdrawal. It is possible to be suffering from PTSD and moral injury at the same time, as many traumatic experiences are also PMIEs.

Who experiences moral injury?

Most moral injury research has focused on military veterans, but other groups of people have also been studied. Examples include frontline health workers in the Covid pandemic, carers of sexually abused children, partners of people with dementia, survivors of religious abuse, business executives, Black people, and journalists. Gender differences have been found; men were more badly affected by events where they were the perpetrator, whereas women suffered worse from betrayal events. People exposed to more frequent PMIEs had more severe guilt and higher suicide risk.

Moral injury has been described as a ‘social wound’, and some groups in society are more likely to experience frequent PMIEs, for example, Black people, women, and members of the LGBTQ+ community. The risk of moral injury may be higher for autistic people [3] as they often display high moral rigour and conscientiousness, giving them a lower threshold for experiencing PMIEs. They may also experience strong, immediate emotional reactions to PMIEs, which are difficult to override. 

Can moral injury be prevented?

Moral injury can be caused by individuals and by institutions. Institutions may harbour two harmful myths relating to moral injury: that the institution is benevolent and infallible, and that individuals need to be more resilient and do more self-care. Such institutions can benefit from the help of an advisor who understands the systemic and structural causes of moral injury.

Prevention of moral injury in settings where there is a higher potential for PMIEs (such as healthcare and the military) can be helped by managing people’s moral expectations and setting realistic, practical expectations in advance, during training. This helps build moral resilience, i.e., the capacity to preserve or restore integrity when meeting moral challenges. Encouraging people to wrestle with moral frustration and distress and make adjustments where possible to systemic factors may help to prevent these effects from progressing to more serious moral injury. Moral challenges are an inevitable part of life, and it is important to normalise moral discomfort and distress, rather than see them as an individual’s failure to cope. 

What helps recovery from moral injury?

Therapists can assess individuals to find out if they have moral injury using the Moral Injury Outcome Scale (MIOS)[4]. Shame-related moral injury involves inward-focused experiences, such as feelings of unease and painful awareness of social exclusion, whereas the trust-violation type involves outward-directed behaviour, like getting angry and distrusting other people. Litz and Walker [1] suggest that a single broad approach can be used by therapists to encourage recovery in both cases. This approach entails helping clients engage in humanising and corrective experiences that take account of what has been lost. These experiences can be emotional and social. This broad approach is appropriate as moral injury is, at its heart, about loss of belonging and humanity. Therapists need to assess where the client has potentially prosocial resources in their individual environment, including a faith community if appropriate.

Litz and Walker [1] give the following examples of corrective learning opportunities which therapists can support their clients to access: 

• Daily purposeful virtuous behaviours, especially compassion, in ad hoc and planned ways.
• Mindful allowing of others to show their humanity and be kind, trustworthy, and selfless.
• Working on belonging: increasing the size and reach of “Us” groups and reducing the size and reach of “Other” groups.
• Doing valued things and being a part of groups that are valuing.
• Generating a maintenance plan and planning response to setbacks.

Their two further learning opportunities require particular care in tailoring these for individual clients, as they may not be appropriate in every case. These suggestions are: 

• Confess/disclose the harm, share/express impact, get compassionate validation, clarify meaning/implication, and get feedback from caring others (and professionals) about the implications of the event and help generate a repair plan.
• Taking misdeeds, missteps, and unempathetic, rejecting, and selfish behaviours by oneself and others in stride – developing perspective and tolerance.

Professionals from all types of therapeutic approaches can encourage their clients to get involved in activities which increase their sense of belonging and restore trust in their own and other people’s humanity. Therapists can draw on their compassionate therapeutic relationship with the client as an integral part of the humanising connective process. Some people who have suffered or witnessed severe inhumanity experience deep despair, hopelessness and anger which need to be fully witnessed and honoured by the therapist before the process of rebuilding trust in others can begin. 

References: 

1. Litz, B.T. and Walker, H.E., 2025. Moral injury: An overview of conceptual, definitional, assessment, and treatment issues. Annual Review of Clinical Psychology, 21.
2. Envisioning and Exploring Recovery from Moral Injury, Durham University. Available at: https://www.durham.ac.uk/research/institutes-and-centres/moral-injury/events/conferences/
3. Al-Attar, Z. & Worthington, R., 2024. Moral distress and moral injury in the context of autism. Advances in Autism 10 (3): 200–219. 
4. Moral Injury Outcome Scale. Available from https://www.osiresearch.ca/mios.