Moral Injury and PTSD

What is moral injury?

Moral injury refers to the psychological, social and spiritual impact of events involving betrayal or transgression of one’s own deeply held moral beliefs and values occurring in high stakes situations. While not a recognised mental health disorder, moral injury is associated with increased rates and symptom severity of Post Traumatic Stress Disorder (PTSD), Depression, and Substance-Use Disorder.

It is thought to have 3 key components:

• Transgressions by Others – Observing actions that clash with one’s ethical beliefs (e.g., a teacher observing school administrators ignore reports of bullying).

• Transgressions by Self – Engaging in or feeling responsible for behaviours that go

  against one's core values (e.g., a police officer ordered to move on the homeless).

• Perceived Betrayal – Experiencing a loss of trust in institutions, leaders, or society due

  to perceived abandonment or deception (e.g., under-resourced healthcare workers during

  the COVID-19 pandemic).

Moral injury was initially recognised in military personnel who, after deployment, struggled to reconcile experiences at odds with their morals, beliefs, and values. These experiences effected wellbeing in a manner broader than typical symptoms of PTSD or depression. In addition to military personnel, research identified law enforcement, first responders, healthcare workers, and even teachers as experiencing increased vulnerability to moral injury. Moral injury is driven by guilt, shame, and existential conflict. This can erode a person’s sense of integrity, leading to self-condemnation, isolation, and heightened risk of suicide.

Signs of moral injury

• Recurrent feelings of guilt, shame, anger, or disgust

• Sense of betrayal from others or by an institution

• Inability to forgive oneself or others

• Believing that oneself or others deserve punishment

• Survivor’s guilt

• Not seeking or ceasing help for distress incurred through experience

• Self- sabotage

• Social withdrawal

Moral injury vs PTSD

Moral injury and PTSD share significant overlap, as both can result from harmful or life-threatening events and involve emotions like guilt, shame, and betrayal. However, PTSD includes additional symptoms such as hyperarousal, which are not central to moral injury. While moral injury can co-occur with PTSD, it can also exist independently, often producing a different symptom profile. For example, events involving moral transgressions (perpetration-based) may lead to more intense guilt, self-blame, and re-living than fear-based traumatic events.

Therapy for moral injury

• Cognitive Processing Therapy (CPT) - CPT posits that faulty cognitions about the morally injurious event stop integration into preexisting belief systems about the self, others, and the world. CPT helps patients work through beliefs underlying guilt, shame, and betrayal such as believing one should have responded differently. CPT focuses on acceptance of reality and associated emotions using Socratic dialogue to alleviate moral pain.

• Prolonged Exposure - PE is a trauma-focused therapy wherein Morally injurious events are revisited to process associated thoughts, behaviours, and emotions. PE utilises psychoeducation, in vivo and imaginal exposure to enhance emotional processing, gather context to help make sense of the trauma, and reconnect with important values.

• Acceptance Commitment Therapy (ACT) - ACT emphasises changing the relationship to pain and its function in daily life. Instead of centering on morally injurious events, ACT reduces avoidance of internal experience through unhelpful attempts to manage symptoms. ACT fosters acceptance of moral pain to increase cognitive flexibility through six processes: acceptance, cognitive diffusion, mindfulness, self-as-context, values, and committed action.

Authored by Katelin Watson, Provisional Psychologist.

Katelin is a provisional psychologist who supports a diverse range of clients and presentations, including individuals experiencing moral injury. Katelin currently has capacity for new clients and offers sessions both before and after-hours four days per week.