Five years ago, as the COVID-19 pandemic began overwhelming healthcare systems worldwide, a term once confined to military psychology began appearing in mainstream medical discussions: moral injury. Today, in late 2025, we stand at a transformative moment. The inclusion of moral problems in the DSM-5-TR represents not just diagnostic evolution, but validation of experiences that healthcare workers, veterans, and first responders have long struggled to name.
As we’ve explored in our previous examination of moral injury during the pandemic, what began as crisis recognition has evolved into systematic clinical understanding. This comprehensive guide synthesises the latest research, assessment tools, and treatment approaches, offering both professionals and those experiencing moral injury a complete resource for understanding and addressing this complex condition.
What causes moral injury?
Understanding Moral Injury: Core Definitions and Concepts
What Is Moral Injury?
According to the Moral Injury Project at Syracuse University, moral injury is damage done to the soul of the individual. It occurs when someone perpetrates, witnesses, or fails to prevent acts that transgress deeply held moral beliefs and expectations. Unlike physical wounds or even psychological trauma rooted in fear, moral injury strikes at the core of one’s identity as a moral being.
Integrated Model of Traumatic Stress Injuries
The Ethics Centre of Australia emphasises that moral injury involves a betrayal of what is right, either by oneself or by someone in a position of legitimate authority, in a high-stakes situation. This betrayal leads to profound psychological, social, and spiritual suffering that extends beyond traditional mental health categories.
The DSM-5-TR Recognition: A Historic Milestone
In September 2025, the American Psychiatric Association published a groundbreaking update to the DSM-5-TR, formally recognising moral problems under code Z65.8: “Moral, Religious, or Spiritual Problem.”¹ This classification acknowledges that moral problems “include experiences that disrupt one’s understanding of right and wrong, or sense of goodness of oneself, others or institutions.”
This recognition matters because it:
Legitimises the distinct nature of moral suffering
Enables specific clinical documentation and treatment planning
Facilitates insurance coverage for specialised interventions
Promotes research through standardised classification
Distinguishing Moral Injury from Related Conditions
As detailed in The Lancet Psychiatry, moral injury differs fundamentally from other psychological conditions:²
Moral Injury vs PTSD:
PTSD stems from life-threat and fear
Moral injury arises from moral violations
PTSD involves hypervigilance and avoidance of triggers
Moral injury involves shame, guilt, and spiritual crisis
Moral Injury vs Burnout:
Burnout results from chronic workplace stress
Moral injury stems from specific moral violations
Burnout causes exhaustion and cynicism
Moral injury causes deep shame and loss of meaning
Moral Injury vs Depression:
Depression involves persistent low mood and anhedonia
Moral injury specifically relates to moral transgressions
Depression may occur without precipitating events
Moral injury always links to identifiable moral conflicts
Research published in BMC Psychiatry identifies specific ongoing triggers:⁴
Chronic understaffing forcing compromised care
Resource allocation decisions
Institutional policies conflicting with patient needs
Inability to provide culturally appropriate care
Veterans and Military Personnel
Open Arms reports that Australian veterans experience moral injury from:⁵
Witnessing civilian casualties
Following orders conflicting with personal values
Inability to help local populations
Perceived betrayal by leadership or government
Transition challenges to civilian life
The DVA’s rapid evidence assessment highlights that military moral injury often co-occurs with PTSD but requires distinct treatment approaches focusing on:
Values reconciliation
Meaning-making
Spiritual repair
Community reintegration
First Responders: The Overlooked Population
Recent Australian research reveals first responders face unique moral injury risks:
Police: Use of force decisions, witnessing preventable tragedies
Engage in self-care to prevent vicarious moral injury
For Organisations
Implementation Strategies:
Conduct organisational assessment
Develop moral injury policies
Train leadership and staff
Establish support systems
Monitor and evaluate outcomes
Creating Psychologically Safe Workplaces:
Open communication channels
Transparent decision-making
Values-aligned policies
Adequate resources
Support for staff wellbeing
Conclusion: The Path Forward
The journey from hidden wound to clinical recognition represents tremendous progress, yet much work remains. The DSM-5-TR inclusion of moral problems validates experiences long dismissed or misunderstood. For the healthcare workers who made impossible decisions during the pandemic, veterans carrying the weight of war, and first responders witnessing daily tragedies, this recognition offers hope for understanding and healing.
As we move forward, addressing moral injury requires more than individual treatment—it demands systemic change, organisational accountability, and cultural transformation. The path from moral injury to moral repair is challenging but possible. Through continued research, clinical innovation, and commitment to addressing root causes, we can support those whose service to others has come at profound personal cost.
Recovery involves not forgetting or minimising moral injuries, but integrating them into a life narrative that includes growth, meaning, and renewed purpose. As the Moral Injury Project reminds us, moral injury reflects the depth of human conscience—our capacity to care deeply about right and wrong. In acknowledging and treating moral injury, we honour both the suffering and the humanity of those affected.
The inclusion of moral injury in our clinical frameworks represents not an end but a beginning—an opportunity to transform how we understand and respond to the moral dimensions of human suffering. For all those carrying moral wounds, know that recognition, understanding, and healing are possible. The journey may be long, but you need not walk it alone.
1. American Psychiatric Association. DSM-5-TR Update: Supplement to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC: American Psychiatric Association Publishing; September 2025.
2. Williamson V, Stevelink SAM, Greenberg N. Moral injury: the effect on mental health and implications for treatment. Lancet Psychiatry. 2021;8(6):453-455.
3. Metcalf O, Phelps A, Watson L, Varker T. The current status of moral injury: A narrative review and Rapid Evidence Assessment. Phoenix Australia – Centre for Posttraumatic Mental Health; 2022.
4. Čartolovni A, Stolt M, Scott PA, Suhonen R. Moral injury in healthcare professionals: A scoping review and discussion. Nurs Ethics. 2021;28(5):590-602.
5. Open Arms – Veterans & Families Counselling. Moral Injury. Australian Government Department of Veterans’ Affairs; 2025.
6. The Moral Injury Project. What is Moral Injury. Syracuse University; 2025.
7. Norman SB, Griffin BJ, Pietrzak RH, et al. The Moral Injury and Distress Scale: psychometric evaluation and initial validation in three high-risk populations. Psychol Trauma. 2024;16(3):280-291.
8. Litz BT, Plouffe RA, Nazarov A, et al. Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium. Front Psychiatry. 2022;13:923928.
9. Held P, Klassen BJ, Brennan MB, Zalta AK. Using prolonged exposure and cognitive processing therapy to treat veterans with moral injury-based PTSD. Behav Ther. 2018;49(4):607-616.
10. Steenkamp MM, Litz BT, Hoge CW, Marmar CR. Psychotherapy for military-related PTSD: a review of randomized clinical trials. JAMA. 2015;314(5):489-500.
11. Farnsworth JK, Borges LM, Walser RD, et al. Case Conceptualizing in Acceptance and Commitment Therapy for Moral Injury. Front Psychiatry. 2022;13:910414.
12. Gray MJ, Schorr Y, Nash W, et al. Adaptive disclosure: an open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behav Ther. 2012;43(2):407-415.
13. Maguen S, Burkman K, Madden E, et al. Impact of killing in war: a randomized, controlled pilot trial. J Clin Psychol. 2017;73(9):997-1012.
14. Harris JI, Usset T, Voecks C, et al. Spiritually integrated care for PTSD: a randomized controlled trial of “Building Spiritual Strength.” Psychiatry Res. 2018;267:420-428.
15. Norman SB. Trauma informed guilt reduction therapy: treating guilt and shame resulting from trauma and moral injury. London: Academic Press; 2019.
16. Starnino VR, Sullivan JE, Angel CT, et al. Moral Engagement Group: A trauma-informed intervention for moral injury. Soc Work Groups. 2023;46(2):145-160.
17. Dean W, Talbot S, Dean A. Reframing clinician distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.
18. Department of Veterans’ Affairs. Framework for Moral Injury Support. Australian Government; 2023.
19. Gone JP, Hartmann WE, Pomerville A, et al. The impact of historical trauma on health outcomes for indigenous populations. Am Psychol. 2019;74(1):20-35.
21. Hundt NE, Robinson A, Arney J, et al. Veterans’ perspectives on benefits and drawbacks of peer support for posttraumatic stress disorder. Mil Med. 2015;180(8):851-856.
22. Frankfurt S, Frazier P. A review of research on moral injury in combat veterans. Mil Psychol. 2016;28(5):318-330.
Expert Review: This article has been reviewed by clinical psychologists specialising in trauma and moral injury treatment.
Medical Disclaimer: This article is for informational purposes only and does not constitute medical advice. If you are experiencing symptoms of moral injury or other mental health concerns, please consult with a qualified mental health professional.
Bulent is a Sydney-based psychologist and author with 20+ years of experience in psychology and mental health. Founder of Mind Health (formerly Life Psychologists), he takes an integrative approach to psychotherapy, blending traditional therapies with cutting-edge methods.
