Moral injury has entered into the vernacular of clients seeking assistance often after something that they have experienced as traumatic. There is also mention of moral problems under a code Z65.8 Moral, religious, or spiritual problem in the DSM5. However, it is not defined as a specific disorder. It is defined as a problem of clinical focus, but not a mental health illness.
You may have had the experience of a client attending and describing one of the following scenarios
- “X happened to me at work, and the organisation didn’t care for me, I have moral injury”.
- “I am a police member, and I had to investigate a fellow officer – I have moral injury, because I did not want to do it.”
- “My boss at work told me I had to retrench people. I was put in a position at work where workplace politics meant that if I did not do it, I would be seen in a bad light. I did not want to fire people, it felt awful.”
- “I had to report someone for doing the wrong thing at work and they lost their job, I have moral injury.”
Despite these events being emotionally difficult and potentially having characteristics that could be viewed as related to morality, they don’t represent moral injury.
Definitions of Moral Injury
Definitions of moral injury do appear in the literature. However, as Metcalf, et al. (2022) stated “few are empirically validated, and even fewer have been informed by veterans and others with lived experience of moral injury.” (pg 7.)
Litz and colleagues (2009) in their seminal study on moral injury, stated that potentially morally injurious events, were those where a person may perpetrate, fail to prevent, or bear witness to acts that transgress deeply held moral beliefs and expectations. They also outlined that this may be detrimental in the long-term, across these domains,
- Emotional
- Psychological
- Behavioral
- Spiritual
- Social
The Development of Moral Injury
Mental health professionals may do well to keep in mind that the construct of Moral Injury is still in the early stages of being investigated. In his review of the science Brett Litz (2025) noted that since 2009 the science had not progressed, he highlighted some key points.
- There is an absence of a broadly accepted, testable overarching theory on the
causes and consequences of moral behaviour and moral violations.
- There is insufficient attention to construct validation.
- Many empirical studies have not been theory-driven (i.e., they lack hypotheses and predictions)
- Empirical studies have had significant internal validity problems, most notably the
poor content validity of measures.
- The published epidemiological studies have used measures with problematic
content validity.
- Existing treatments, particularly for PTSD have been used, before a consensus about what the construct of Moral Injury is and before a valid measure of Moral Injury as an outcome could be used to test their efficacy.
What do know
Adaptive disclosure (Grey et al. 2021) is a therapy that was designed to address moral injury after exposure to war-zone events. It has been found to be no less effective than CPT in military context, for reduction of PTSD symptoms (Litz et al. 2021).
LoSavio, et al, (2024) in their review of clinicians’ concerns stated, “In sum, while there is a need for additional studies examining the efficacy of CPT for morally injurious events, initial data are promising, and the theory and principles of CPT can be applied to these events.”
Similarly, LoSavio, et al, (2023) examined the effect of CPT treatment for PTSD in active-duty military personnel and Veterans endorsing traumas primarily characterized by moral violation compared with those not endorsing such traumas. They reported, “Results suggest that CPT is a good PTSD treatment option for military personnel with morally injurious trauma.”
Summary
The concept of Moral injury is still in its infancy and not clearly defined. Therapies that have been used to address moral injury, appear to have only been used in military populations. Clinicians should tread carefully.
References
Gray, M. J., Binion, K., Amaya, S., & Litz, B. T. (2021). Adaptive disclosure: A novel evidence-based treatment for moral injury. In J. M. Currier, K. D. Drescher, & J. Nieuwsma (Eds.), Addressing moral injury in clinical practice (pp. 183–201). American Psychological Association. https://doi.org/10.1037/0000204-011
Litz, B. T. (2025). Moral injury: State of the Science. Journal of Traumatic Stress, 38, 187–199. https://doi.org/10.1002/jts.23125
Litz, B. T., Rusowicz-Orazem, L., Doros, G., Grunthal, B., Gray, M., Nash, W., & Lang, A. J. (2021). Adaptive disclosure, a combat-specific PTSD treatment, versus cognitive-processing therapy, in deployed marines and sailors: A randomized controlled non-inferiority trial. Psychiatry Research, 297, 113761. https://doi.org/10.1016/j.psychres.2021.113761
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706. https://doi.org/10.1016/j.cpr.2009.07.003
LoSavio, S. T., Hale, W., Straud, C. L., Wachen, J. S., Mintz, J., Young-McCaughan, S., Vacek, S. N., Yarvis, J. S., Sloan, D. M., McGeary, D. D., Taylor, D. J., Keane, T. M., Peterson, A. L., & Resick, P. A. (2023). Impact of morally injurious traumatic event exposure on cognitive processing therapy outcomes among Veterans and service members. Journal of Military, Veteran and Family Health, 9(2), 40–51. https://doi.org/10.3138/jmvfh-2022-0048
LoSavio, S. T., Holder, N., Wells, S. Y., & Resick, P. A. (2024). Clinician Concerns About Cognitive Processing Therapy: A Review of the Evidence. Cognitive and Behavioral Practice, 31(2), 152–175. https://doi.org/10.1016/j.cbpra.2022.08.005
Metcalf, O., Phelps, A. Watson, L., & Varker, T. (2022). The current status of moral injury: A narrative review and Rapid Evidence Assessment. Report prepared for the Department of Veterans’ Affairs. Phoenix Australia – Centre for Posttraumatic Mental Health.
