PTSD: National Center for PTSD

Moral Injury and PTSD

Moral injury can happen after someone takes part in, fails to prevent or witnesses an event that goes against their morals or values. These kinds of events are called potentially morally injurious events. Many people feel distress after an event like this. If someone feels long-lasting emotional and sometimes spiritual distress after such an event, they may have moral injury.

Who Might Be at Risk for Moral Injury?

Anyone who experiences a potentially morally injurious event may be at risk for moral injury. The event could be something a person actively takes part in, fails to prevent, or witnesses.

War and combat can put combatants into situations where they have experiences that go against the values they live by in civilian life. Examples of war events that may lead to moral injury include:

• Killing or harming others
• Making decisions that affect the survival of others
• Being unable to care for all who were harmed
• Freezing or failing to perform a duty during a dangerous or traumatic event (for example, falling asleep on patrol)
• Failing to report an event that violates rules
• Engaging in or witnessing acts of over-the-top violence
• Feeling nothing or excitement while causing harm or killing others

Moral injury may also happen in non-military settings. For example, health care workers may experience moral injury if they need to make difficult decisions related to life and death—such as deciding who gets care first, or how limited resources are distributed—or when they believe they should have been able to save a patient's life but were not able to do so.

There is also research showing that first responders, refugees and civilians who experience community violence can experience moral injury.

How Does Moral Injury Affect Someone?

Moral injury involves upsetting emotions, changes in behavior, difficulties relating to others, and/or a spiritual crisis. Many people may experience distress after a potentially morally injurious event but most feel better over time. Those who continue to struggle emotionally and possibly spiritually long after the event, such that it effects their day-to-day functioning in relationships or work, school or other activities may have moral injury.

People with moral injury often feel guilt, shame, disgust and/or anger. Another common reaction with moral injury is not being able to forgive oneself or feeling a need to punish oneself. Someone with moral injury may end a relationship because they do not believe they are worthy of love, or they may not show up for therapy appointments because they do not believe they deserve to feel better or are too ashamed.

Moral injury can have an impact on a person's faith and spirituality. For example, someone may have difficulty understanding how their beliefs and relationship with a Higher Power can be true given the horrific event. This can lead to questioning prior spiritual beliefs.

Moral Injury and PTSD

Moral injury can occur together with mental health conditions like posttraumatic stress disorder (PTSD) and depression, but it is not a diagnosis itself. Moral injury and PTSD have a great deal in common, both:

• Often start with a traumatic event (in the case of moral injury, the event also violates morals and values)
• Cause people to feel distress that lasts long past the initial event
• Share some common features like feelings of guilt and shame and losing trusting in others

There are also differences between moral injury and PTSD. For example, people with PTSD may be feel like they need to be on high alert, which is not usually a feature of moral injury.

Research studies have shown that when someone has moral injury in addition to PTSD, the PTSD symptoms may be more severe. They may also have more severe depression symptoms, be more likely to think about suicide, and have more trouble functioning in their everyday lives.

How Do I Know If I Have Moral Injury?

A mental health provider or chaplain can help to assess whether you have moral injury. They might do this by talking with you or by asking you to answer a set of questions on a form. Questions might be about the kind of stressful situations you've experienced and/or about how you reacted to these events. They are likely to ask you about the symptoms mentioned above such as guilt, shame and self-blame. They might also ask you about how your spiritual beliefs have changed since the event.

PTSD is diagnosed by a mental health provider. To learn more, see How Is PTSD Assessed?

How Is Moral Injury Treated?

It can be difficult to talk about the events that led to moral injury or PTSD. Especially because of guilt and shame, some people have never talked to anyone about what happened. It is common to wonder about how a therapist will react. For example, thinking "Am I being judged? Is my therapist disgusted with me? Is this too much for my therapist to handle?" Therapists are trained to be accepting and non-judgmental and are experienced in hearing about very troubling and horrible situations.

While treatment cannot undo events that happened in the past, it can help people find a way to live a meaningful, fulfilling life going forward.

Researchers are studying several treatments to understand the best ways to help people with moral injury. Most of these studies involve meeting with a therapist to process (or work through) what happened and to learn new ways to cope. So far there are no medications that are known to help with moral injury.

For people who have both PTSD and moral injury, researchers are looking at whether treating PTSD can also help moral injury. Studies have shown that PTSD treatments still work well to treat PTSD even when someone also has moral injury.

Researchers are also studying treatments that focus on moral injury alone with service members or Veterans, health care workers and other groups. Examples of these treatments are:

• Acceptance and Commitment Therapy (ACT; adapted for moral injury): A 12-session group treatment focusing on helping people live according to their values.
• Adaptive Disclosure: A 12-session individual treatment that helps people process moral injury through imaginary discussion with a compassionate moral authority. It helps people evaluate blame and make amends. Some versions include self-compassion and mindfulness meditation.
• Impact of Killing: A 10-session individual therapy that happens after PTSD treatment and helps people explore the impact of not forgiving oneself, develop a forgiveness plan (including letter writing to the individual(s) killed) and helps people develop a plan to honor the values that were violated in the act of killing.
• Moral Injury Group: A 12-session group treatment with both a chaplain and psychologist that includes a public ceremony where participants share the story of their moral injury.
• Trauma Informed Guilt Reduction Therapy: A 6-session individual therapy that helps people consider beliefs and the broader context that leads to their guilt and shame, identify important values including those that were violated during the trauma, and make a plan to live in line with those values going forward.
• Building Spiritual Strength: An 8-session group therapy that can be led by a chaplain and addresses concerns about one's relationship with a Higher Power as well as challenges with forgiveness.

Conclusion

After a highly stressful or traumatic event in which deeply held morals or values are violated, people may develop moral injury. Feelings such as guilt, shame, betrayal and anger are common parts of moral injury. If someone also has PTSD or depression, they may have more severe symptoms if they also have moral injury. It is also possible to have some of these feelings without having PTSD, depression, or moral injury.

The study of moral injury is new, and we are still learning how to help. We know that PTSD treatment can help to reduce some distress (such as guilt and shame). Many types of therapy are being studied.

If you experienced a harmful event in which a moral line was crossed and you continue to feel distressed about it, treatment can help. You can start by talking to a mental health provider or chaplain.