Combat-related guilt in Vietnam veterans was described as early as 1973 [1], but it was only in 1994 that Jonathan Shay first coined the term of moral injury to describe the psychological suffering that resulted from moral transgressions in war [2]:
“I’ve come to strongly believe through my work with Vietnam veterans (…) that moral injury is an essential part of any combat trauma that leads to lifelong psychological injury. Veterans can usually recover from horror, fear, and grief once they return to civilian life, so long as “what’s right” has not also been violated” (p. 20).
Thirty years later, in 2013, persistent feelings of guilt or shame were introduced in the DSM-5 as part of the symptom cluster of negative alterations in cognitions and mood that constitutes, along with the stressor criterion, the other symptom clusters (intrusions, avoidance, and hyperarousal), and the time criterion, the diagnosis of posttraumatic stress disorder (PTSD) [3].
As a psychological construct in a stricter sense, moral injury was developed and introduced to psychotraumatology by Litz and collaborators in order to describe the effects of being exposed to moral transgressions in the context of combat [4]. Litz et al. [4] defined moral injury as “the lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” Regarding the question of who is most at risk of developing moral injury, ter Heide hypothesized that it is “those who have a high exposure to a victim’s expressions of distress, feel personally connected to the victim, experience great desire to help the victim, and are prevented from or fail in helpful or respectful behavior” [5, 6]. However, to date, the field is far from a consensus with regard to a unified definition of what constitutes an event involving deep violations of one’s sense of right and wrong [7], usually referred to as a potentially morally injurious event (PMIE). There is no universally accepted operational definition of moral injury either [8].
More recently, moral injury is increasingly being applied to nonmilitary settings including child protection [9], police [10], educational contexts [11], peacekeeping missions [12], and following accidental or intentional perpetration of moral transgressions against another person [13]. During the COVID-19 pandemic, moral injury was studied in healthcare workers [14‒17]. Forcibly displaced persons, including refugees, asylum seekers, as well as internally displaced persons, many of whom are severely traumatized in multiple ways before, during, and after their often long journey, have also become a major focus of attention in moral injury research [18‒21]. Given that child maltreatment can be understood as a moral transgression par excellence, and given that exposure to child maltreatment increases the risk of perpetrating transgressions in adulthood, it is somewhat surprising that the relationship between moral injury and child maltreatment has only been investigated scarcely so far [22‒25].
Cross-cultural validation of the moral injury construct globally has only started very recently [26]. The Global Collaboration on Traumatic Stress (GCTS: https://www.global-psychotrauma.net) emphasizes moral injury as a topic of major interest. According to the GCTS topic leaders Shira Maguen and Sonya Norman, moral injury involves both an exposure to a PMIE during which individuals experience or witness a transgression, as well as resulting symptoms of intense self-condemnation, spiritual struggles, and internal conflict regarding the moral implications of their actions. Experiencing moral injury carries significant emotional risks, as individuals may perceive their transgressions as irreparable, resulting in feelings of shame, guilt, despair, and loss of morale. Research suggests that moral injury is linked to cognitive, emotional, and behavioral changes, including social withdrawal, suicide behaviors, burnout, and psychiatric disorders such as depression and PTSD (https://www.global-psychotrauma.net/moral-injury).
Assessment of PMIEs and Moral Injury
Moral injury should be viewed as a multisystemic syndrome which involves (neuro)biological, psychological, behavioral, emotional, and religious/spiritual aspects [27]. In this issue, Frankfurt et al. [7] suggest that moral injury may explain why someone develops, e.g., guilt, while PTSD describes what this person experiences in the aftermath of traumatic exposure. This is an interesting idea which deserves more research. This may also lead to the question whether moral injury should actually be conceptualized as a mental disorder, possibly as a subtype of PTSD, or whether it might rather be seen as a construct rooted in a different dimension, beyond psychopathology.
Regarding PMIEs, Frankfurt and colleagues suggest to distinguish between cruel acts, regrettable acts, and annoying acts on a continuum of morally relevant life experiences and life stressors. They posit that “primary cognitions associated with PMIEs include perceived harmfulness and an affective response involving shame, guilt, rage, and/or disgust” [7]. Moreover, Frankfurt et al. [7] propose to distinguish between an event’s perceived wrongfulness versus harmfulness in order to compare the contribution of the potentially morally injurious versus the potentially traumatic aspects of a given event to negative life outcomes. At the same time, they emphasize that an event can very well be both morally injurious and traumatic and thus potentially lead to the development of both moral injury and PTSD.
When assessing moral injury, negative appraisals about one’s own actions (MI-self appraisals) should be distinguished from negative appraisals about others’ actions (MI-other appraisals). In a large longitudinal study of over 1,000 refugees, MI-other appraisals predicted increased reexperiencing and hyperarousal symptoms, and feelings of sadness and shame. MI-self appraisals predicted decreased feelings of shame and decreased reexperiencing symptoms [21]. In various populations, moral injury appraisals have been shown to be associated with mental health outcomes such as PTSD, depression, anger, anxiety, burnout, and suicidal ideation [17, 19, 28]. A longitudinal study showed that moral injury appraisals exacerbate symptoms of classic PTSD as well as complex PTSD [29].
Moral-injury cognitions (beliefs regarding moral violations) represent a potential mechanism that may underlie the association between PMIEs and psychological symptoms. For instance, Hoffman and colleagues used an experimental paradigm (i.e., the simulation of a PMIE using mental imagery) to investigate the impact of moral-injury cognitions on psychological outcomes in refugees and found that moral injury was associated with greater negative emotional responses following the simulated PMIE [30].
There is a multitude of published instruments for assessing PMIEs and/or moral injury. However, some of these instruments do not distinguish clearly between event (PMIE) and outcome (moral injury). Another problem is that some of the measures overlap with other well-established psychometric instruments, and others are not sufficiently validated [7]. An exception is the Moral Injury and Distress Scale (MIDS) which has recently been developed to disentangle PMIEs from their consequences. Using a population-based sample of 645 military veterans, healthcare workers, and first responders who had endorsed PMIE exposure, a cut score of 27 was found useful for detecting clinically significant posttraumatic stress and depressive symptom severity, trauma-related guilt, and functional impairment, i.e., clinically meaningful and impairing moral injury [31]. Further refinement of instruments to measure PMIEs and moral injury should take into account even more explicitly the principles of clinimetrics [32‒34].
Treating Moral Injury
The treatment of moral injury is still in its infancy. Interestingly, morally injured military personnel seem to be more likely than other service members to seek help for mental health problems [35]. Cognitive approaches are potentially useful to address distorted cognitions regarding responsibility. It also goes without saying that treatment needs to be tailored to the particular PMIEs a person may have been exposed to. A “Moral Injury Experience Wheel (MIEW)” has been proposed by a chaplain, for therapeutic use in morally injured individuals, to address a variety of complex emotions related to exposure to moral injury, and to “elicit adaptive psychological processes (e.g., emotion differentiation, acceptance processing)…” [36]. De la Rie et al. developed a treatment protocol for moral injury based on brief eclectic psychotherapy for PTSD [37, 38] and tested it in a morally injured refugee [39]. Other examples are Adaptive Disclosure [4, 40], Trauma-Informed Guilt Reduction Therapy [41], and Acceptance and Commitment Therapy for Moral Injury [42]. Treatment protocols for moral injury are also being developed by other research groups [43] [Angela Nickerson, personal communication]. Whether or not moral injury will be established as a formal diagnosis, the need to examine tailored interventions to alleviate moral injury seems obvious [6]. Once an evidence base for effective interventions to address moral injury has been established, a system of staging and sequential treatment [44‒46] for morally injured trauma survivors will need to be developed and tested.
Conclusions
What is moral injury? At this point in time, we do not know with sufficient clarity. From a clinical viewpoint, the construct certainly has important heuristic value. There is also some evidence showing that moral injury, although overlapping with PTSD to some extent, provides additional, clinically relevant information above and beyond PTSD [18]. The treatment protocols that are currently available or in the process of being developed promise to add to the range of evidence-based therapeutic approaches that can be offered to survivors of trauma and moral injury. However, there is a lack of conceptual clarity with regard to both PMIEs and moral injury. More specifically, there is no consensus definition and gold-standard measure of moral injury as an outcome [27]. Many questions remain unanswered to date. For instance, are guilt feelings (that are frequently observed in patients suffering from PTSD, e.g., following rape) identical to real guilt that results from having perpetrated an atrocity? Tricky, but clinically relevant questions! To give another example, we know almost nothing about the relationship between moral injury and allostatic load [47‒49], in other words, about moral injury’s potential negative impact on physical health. Unsurprisingly, the current evidence from neuroimaging studies is too varied to provide clear conceptual guidance. A neurobiological framework would be extremely helpful to advance the study of moral injury. However, as we know from other fields of psychiatry and psychosomatic medicine, the development of such a framework, both testable and clinically meaningful, is a challenging task given the complexity of the matter and the multitude of biological, psychological, and other systems involved.
Conflict of Interest Statement
The author has no conflicts of interest to declare.
Funding Sources
This study was not supported by any sponsor or funder.
Author Contributions
Ulrich Schnyder conceived and wrote the entire manuscript.
