The short answer
Moral injury is the psychological, social, and sometimes spiritual distress that follows events that violate a person's moral values, such as acts someone did, failed to prevent, or witnessed. It overlaps with PTSD through guilt, shame, and betrayal, but a Veteran can have moral injury without meeting PTSD criteria.
What is moral injury?
Moral injury is the distress that can follow events that conflict with a person's deeply held values. VA's National Center for PTSD describes it as the psychological, behavioral, social, and sometimes spiritual aftermath of those events. See VA's moral injury overview for providers.
The events usually fall into three kinds:
- Things a person did, such as harming civilians or following an order they believed was wrong.
- Things they failed to prevent, such as a death they think they should have stopped.
- Things they witnessed or experienced as betrayal, often by leaders or institutions they trusted.
Common reactions include guilt, shame, betrayal, disgust, and anger.
How is moral injury different from PTSD?
They overlap but aren't the same:
| PTSD | Moral injury | |
|---|---|---|
| Core | Fear and threat responses after trauma | Guilt, shame, and betrayal after a values violation |
| Diagnosis | A DSM diagnosis | Not a formal diagnosis |
| Hallmark symptoms | Re-experiencing, avoidance, hyperarousal | Self-condemnation, loss of trust, spiritual struggle |
| Can occur alone | Yes | Yes |
VA notes that someone can have moral injury without meeting criteria for PTSD. Many Veterans have both.
How might moral injury show up in therapy?
- A client says they don't deserve to feel better.
- Progress stalls, or the client sabotages it.
- Guilt that doesn't respond to reassurance or evidence.
- Anger at leadership, the military, or God.
- Pulling away from family, faith, or friends.
VA advises an accepting, nonjudgmental, empathic stance. Clients may fear that if they tell you what happened, you'll see them the way they see themselves.
How is moral injury assessed and treated?
VA lists measures such as the Moral Injury and Distress Scale (MIDS) and the Moral Injury Outcomes Scale (MIOS). Assessment usually starts by identifying the event, then asking about the distress tied to it.
Treatment research is still developing. CPT and PE may help with guilt and shame, but evidence is limited. Newer approaches are being studied. Spiritual care or chaplaincy can be part of the picture for clients who want it.
How ValorWell handles this
ValorWell leaves treatment decisions with you: how you assess, which approach you use, and how you pace the work. If moral injury is outside your experience, you can decline referrals that call for it, or take them and use VA's free PTSD Consultation Program as a sounding board.
Important limits
- Moral injury isn't a billing diagnosis. Document the diagnoses a client actually meets.
- The research is young. Be cautious with any approach presented as the definitive treatment.
- Don't assume it. Not every Veteran who saw combat has moral injury, and not every guilty feeling is moral injury.
- This is orientation, not a protocol. See VA's National Center for PTSD for in-depth training.