What is Moral Injury?

TL;DR Summary:

Moral injury is the psychological, emotional, or spiritual pain that arises when someone feels they have violated their deeply held moral or ethical values, or been betrayed by others in positions of authority. Unlike PTSD, which is often rooted in fear, moral injury is rooted in shame, guilt, anger, and a loss of trust. It is common in healthcare workers, military personnel, first responders, and others exposed to high-stakes ethical decisions or systemic injustice, but can of course happen to anyone.

What is Moral Injury?

Moral injury occurs when a person commits, fails to prevent, or witnesses actions that conflict with their moral beliefs and values. It can also result from being betrayed by a trusted authority in a high-stakes situation.

Unlike PTSD, which is associated with threat and fear, moral injury involves a rupture in a person’s sense of self, moral identity, or worldview. It often brings intense feelings of guilt, shame, anger, or a sense of betrayal.

Who Experiences Moral Injury?

Moral injury is commonly reported in:

• Military and veterans who were involved in or witnessed acts that conflict with their values.

• Healthcare professionals forced to make impossible decisions, especially under resource constraints.

• First responders who face repeated exposure to suffering and system failures.

• Humanitarian workers, police, teachers, and others working in systems that sometimes conflict with their values.

• Anyone experiencing a violation of their deeply held values in high stakes situations.

What Causes Moral Injury?

Common experiences include:

• Being ordered to do something against your conscience.

• Failing to act when you believe you should have.

• Witnessing or participating in harm to others.

• Feeling complicit in systemic injustice or institutional failure.

• Betrayal by a leader or institution you trusted.

What Are the Signs of Moral Injury?

Signs can include:

• Shame, guilt, or self-condemnation

• Anger or loss of trust in others

• Withdrawal or emotional numbness

• Difficulty forgiving oneself or others

• Depression, hopelessness, or thoughts of self-harm

• Loss of meaning or spiritual distress

  
  

Of course moral distress, and the feelings that contribute to it, are normal when we experience violations of our values. It isn't the presence of the feelings that are the problem, (although we would usually prefer not feel these painful feeling they have evolved as important signals to help us navigate our social worlds and keep us aligned with what is important to us) but the ways in which we can become locked into unhelpful patterns of response that cause us difficulty in our ability to lead our lives in the ways we want to live them.

How is Moral Injury Different From PTSD?

While moral injury and PTSD often occur together, they are distinct:

• PTSD is typically fear-based (e.g., experiencing or witnessing a life-threatening event).

• Moral injury is based on moral-emotional pain (e.g., guilt, shame, betrayal).

• Someone can have moral injury without PTSD, or both at the same time.

How Can ACT Help With Moral Injury?

Acceptance and Commitment Therapy (ACT) helps by:

• Supporting people to make space for painful thoughts and feelings instead of avoiding them - thus disrupting unworkable patterns of responding that keep people locked into their pain and prevent them from living in the ways they wish.

• Reconnecting with deeply held values, and recommitting to actions to align with them.

Seeking Support for Moral Injury

If you believe you may be experiencing moral injury, it's important to seek help. Therapeutic approaches like ACT, EMDR, and Compassion-Focused Therapy, and Cognitive Behaviour Therapy (CBT) can all support recovery. Just as importantly, speaking with a clinician familiar with moral injury can make a significant difference.

Frequently Asked Questions

What professions are most at risk for moral injury?

Military personnel, healthcare staff, paramedics, police, and are all at high risk, especially when systems are under stress and ethics are challenged. But, as we are all moral beings, anyone in a sufficiently high stakes situation, that risks a violation of their values, can experience moral injury.

Is moral injury a mental illness?

No. Moral injury is not in itself an official psychiatric diagnosis, but it can contribute to mental health conditions like depression, PTSD, or suicidal ideation.

Can moral injury heal?

Yes. With the right support, many people find new meaning, forgive themselves or, if they choose to, others (although this is not a prerequisite) and restore a sense of integrity and purpose.

Christian Hughes is a Psychotherapist and Consultant specialising trauma, moral injury, and ethical strain. His work draws on over 15 years of experience in trauma, identity, and moral complexity. To explore working together, visit www.christiankhughes.com or get in touch at hello@christiankhughes.com.