Is Moral Injury the Defining Problem of Our Time?

In January 1994, a young, relatively unknown instructor at Harvard Medical School published a paper in the Harvard Review of Psychiatry, in which he outlined a radical concept: trauma didn’t just leave a psychological scar, but a physical one too. The body, he argued, “keeps the score.” You probably know how this story ends. Bessel van der Kolk’s insight would go on to reshape trauma treatment, helping move the field beyond the mind and into the body.

Until then, trauma treatment had been a predominantly cerebral venture, focused on cognition, memory, and narrative. But steadily, body-based approaches once dismissed as fringe began to enter the mainstream, and in this new era, many clinicians felt the landscape of treatment had not only become diverse and robust, but complete.

Surely no stone had been left unturned, right? Not quite.

Just three miles from Harvard Medical School, at the very same time van der Kolk was rethinking trauma treatment, another clinician was doing the same, shining a light on a dimension of trauma that most psychotherapists had never really bothered to consider.

This clinician was Jonathan Shay, a psychiatrist who’d been working with Vietnam War veterans at a Boston Veterans Affairs clinic. And after listening to story after traumatic story, he noticed an interesting pattern. Trauma didn’t just disrupt the mind, or the body, for that matter; it wounded the human spirit—a moral injury, he coined it.

It was a concept as old as humanity itself, the stuff of countless ballads, epics, and tragedies. But Shay gave this phenomenon clinical language. What he saw in his patients wasn’t just fear-based trauma—codified as PTSD—but something different: a sense of betrayal by leaders; violations of one’s own moral beliefs; and a corrosive mix of guilt, shame, and loss of trust. Whether these veterans had committed a moral transgression on their own accord, at the order of superiors, or simply witnessed harm they felt powerless to stop, the result was the same: a wound not just to the psyche, but to the conscience itself. And in Shay’s view, the whole system was to blame.

“I believe that numerous military, cultural, institutional, and historic factors conspired to thwart the griefwork of Vietnam combat veterans,” he wrote in his 1994 book Achilles in Vietnam—published the same year as van der Kolk’s landmark paper—in which he likened the veterans who’d suffered moral injury to the titular Greek warrior.

“Homer’s dramatic method conveys Achilles’ grief by showing his actions,” he wrote. “Blunt self-mutilation, weeping, and loss of appetite…and by poetic stratagems that make us understand that Achilles is ‘already dead.’”

Then, Shay drew a sobering parallel. “’I died in Vietnam’ is a common utterance of our patients,” he continued. “Most viewed themselves as already dead at some point in their combat service, which may also be the prototype of the loss of all emotion, the prolonged states of numbness, the inability to feel love or happiness, or to believe that anything matters.”

A Quiet Revolution

While van der Kolk’s pronouncements about trauma and the body spread like wildfire amongst the clinical community, Shay’s flickered at the margins, mainly contained to psychiatric and military circles. After all, while van der Kolk’s idea felt concrete, the concept of moral injury felt abstract—ethical, even philosophical—and far harder to operationalize in treatment.

But today, interest in moral injury is alive and well. Over the last decade, research has expanded significantly, especially in the VA system, where clinicians have developed tools to identify it, like the Moral Injury Events Scale (MIES) and the Moral Injury Questionnaire-Military Version (MIQ-M). The demand for treatment has grown as well. In 2021, psychiatrist and Duke University professor Harold Koenig, considered one of the leading experts on moral injury, found that over 90 percent of veterans reported high levels of at least one moral injury symptom, while 59 percent reported five or more.

But recently, something incredible has happened: more than three decades after Shay introduced the concept, moral injury has expanded beyond military contexts, driven by a combination of research, clinical adoption, institutional recognition, and media attention. Increasingly, it’s being applied to anyone routinely exposed to high-stakes situations that strain or violate their moral beliefs. To doctors forced to choose which patients get a hospital bed during a pandemic. To prison guards enforcing controversial policies like solitary confinement. To humanitarian aid workers deciding who receives food or medicine when resources are limited. And to abuse survivors who complied with perpetrators in order to survive, who now think, I should’ve fought harder or I went along with it.

Meanwhile, moral injury has entered the broader cultural conversation. Major outlets like The Washington Post have published advice columns about non-military moral injury. Psychology graduate programs are incorporating it into training. And on social media, the term is increasingly being used to describe a growing feeling of ethical distress.

Perhaps the clearest indication that moral injury is having a breakout moment in clinical circles came last September, when it was added to the DSM-5-TR, the version that includes revised text and new codes. Listed as a Z-code—not a formal diagnosis, but a designation used to describe factors that affect mental health—and in a category called “Moral, Religious, or Spiritual Problem,” advocates saw this inclusion as groundbreaking.

“We’re thrilled to share a milestone for whole-person care,” read a press release from Harvard’s Human Flourishing Program, a collection of university staff, researchers, and postdocs who spearheaded the effort. “For years,” it continued, “veterans, healthcare workers, and survivors of institutional betrayal have described anguish rooted not in psychiatric dysfunction but in moral conflict, experiences of shame, betrayal, or violations of conscience. Now that suffering has an official home in the DSM’s taxonomy, creating common language for documentation, research, and care planning.”

For some, the recognition was more than procedural. It was personal.

Forgiving, Not Forgetting

Jennifer Wortham still remembers the first time she heard about the concept of moral injury—and recognized her own family in it.

“It really resonated with me,” she says. “My family founded the church we worshipped in. My grandparents served on its board. My mother welcomed priests into our home. And then both of my brothers were abused by the clergy. It was a betrayal by an institution we’d trusted deeply.”

Wortham, who holds a doctorate in public health, has spent over two decades in public health practice and consulting. In 2016, she published A Letter to the Pope, a book on forgiveness that led to an invitation to meet Pope Francis at the United Nations General Assembly. But it wasn’t until 2020, during postdoctoral work at Harvard, where she joined the university’s Human Flourishing Program, that she first learned about moral injury.

“The language and definition felt incomplete,” she says. “Jonathan Shay’s work is foundational, but moral injury extends far beyond combat veterans. It shows up across society—among social workers making impossible decisions where children are at risk, lawyers defending clients they know are guilty, and doctors choosing between patients. It affects people like my mother and grandmother, who feel intense shame for what happened to my brothers.”

Soon after arriving at Harvard, Wortham received a grant to help develop a consensus definition of moral injury. She assembled a team of 20 researchers from around the world, including expert Harold Koenig, and spent a year crafting this definition, highlighting symptoms like shame, humiliation, and a persistent feeling of unworthiness. Then, they sent a proposal to the APA for DSM inclusion. They knew there wasn’t enough research to support a full diagnosis, but a Z-code was a start.

“It conveys that this deserves clinical attention,” Wortham says. “From there, we could build the research base needed for a formal diagnosis.” In the end, the APA incorporated moral concerns into an existing category, noting the overlap between moral, spiritual, and religious distress.

Wortham was happy to hear the team’s proposal had been accepted. “Even though just a few words were added, that’s a big deal,” she says. “The APA doesn’t do this every day.” But even so, the victory felt bittersweet.

“I still struggle,” she admits. “I have my own moral injury.” After her brother was abused, he joined a gang, so Wortham convinced her mother to send him to a rehabilitation program—and unbeknownst to them, the same priest who’d abused him was there too. “He begged my mom not to send him,” Wortham says. “Begged her. But we didn’t know. We just thought he was trying to get out of trouble. After I found out, I felt deep remorse and shame because I knew I’d put him back in harm’s way. I struggled for a long time. I eventually forgave myself, but I still have moments where I think, I should’ve, I could’ve. That’s hard.”

A Double-Edged Sword?

For Omar Reda, a psychiatrist and trauma counselor who’s treated medical staff caring for trauma survivors, moral injury isn’t some niche concern—it’s pervasive.

“Our world is getting more violent and traumatized by the minute,” he says. “We all hold two core beliefs: that the world is safe, and humans shouldn’t hurt other humans—especially children. So when these injustices are unfolding right in front of us, those beliefs are shattered, and we feel that moral injury deep in our core.”

Since the pandemic, Reda has focused increasingly on how caregivers are impacted by moral injury. He says he’s had colleagues—doctors, nurses, and therapists—who’ve not only left the field because of moral injuries, but continued to suffer in silence, with consequences rippling into their personal lives: conflict at home, divorce, substance misuse, and even self-harm. And, Reda adds, the culture of silence is rampant in the field.

“Our professional schools have taught us that expressing our emotions is a sign of weakness, that we shouldn’t disclose to our supervisors or human resources, because we might lose our license. We hide the pain, and it breaks my heart.”

In 2022, Reda published The Wounded Healer, a collection of first-person accounts and clinical case studies that document this hidden toll. “I had to speak up,” he says. “Too often we think of ourselves as our clients’ only resource, that we should be available 24/7. That’s unsustainable. It’s why burnout is everywhere.”

So is the recent DSM recognition of moral injury progress? Reda isn’t so sure.

“I’m cautiously optimistic,” he says, “but when the DSM gets involved, I worry that we’re going to overpathologize, overdiagnose, and overmedicate folks who don’t actually have a mental illness.” Moral injury isn’t a mental disorder, Reda clarifies—it’s moral distress, and once something enters the diagnostic ecosystem, it risks being medicalized, monetized, and even misused.

“Look at what happened with PTSD,” he says. “Unfortunately, many people are receiving interventions they don’t qualify for, or using their diagnosis for personal gain. So while the recognition is wonderful, it also comes with some baggage.”

Wortham sees it differently. “Were not pathologizing morality at all,” she says. “We’re identifying pathology related to it. If someone’s actions caused another person pain and suffering, over time that can create all sorts of psychiatric conditions, like anxiety, depression, and suicidal ideation. Shouldn’t we classify that as a disorder?”

Listening to Wortham and Reda, it becomes clear that the meaning of moral injury remains unsettled, shaped as much by individual interpretation as by the surrounding cultural climate and unfolding world events. “There remains considerable disagreement and lack of consensus regarding what falls under the category of ‘moral injury,’” Harold Koenig writes.

Wortham and Reda do agree on one thing: moral injury is a growing problem, and there’s an urgent need for help, whether you’re treating wartime trauma, spiritual trauma, or the trauma of witnessing someone else’s trauma day after day. But what exactly should therapists do when their client comes in with a moral injury? Especially when the problem feels so hard to pin down?

Reda says the most profound thing they can do is actually quite simple: “just bear witness.”

The Power of Being Seen

Five years ago, on a sunny afternoon at a small art gallery in upstate New York, psychotherapist Jack Saul took a seat in a circle of a dozen attendees who’d gathered for the latest installation of his touring art project, “Moral Injuries of War”—“an immersive landscape of sound and light.” Speakers lined the room. Sunlight dappled the ceiling. And a large tree outside a nearby window swayed in the breeze. Then, the lights began to dim, and a deep, soft voice came through the speakers.

“There are three rules you need to follow in order to survive in the military,” the voice said. “The first is do what you’re told. The second is do what you’re told. And the third—the most important—is do what you’re told.”

Then came another voice, strained and halting: “We were handing out toys and balls and candy to the kids. I heard somebody yell, ‘Grenade!’ and then it blew up. Body parts were raining onto our Humvee. And I saw this kid. I was like, Why would a five-year-old throw a grenade at a convoy? And out of reaction, out of rage, out of fear, I had to take the kid out.”

Another voice, tight and resolute: “The cynical part of me wants the public to understand that it’s your fault. We are all complicit in this horror. I don’t need other people to experience my pain; I need them to understand that they’re complicit in my pain.”

The room was silent. A few attendees closed their eyes. Another leaned back, gripping the seat of her chair. Another brought a hand to her mouth, taking in what had just been said.

Over the last 15 years, Saul has worked as a therapist and consultant with reporters, photographers, humanitarian workers, and veterans involved in the wars in Afghanistan and Iraq, and he’s collected these stories along the way. This project, he says, gives voice to experiences that are often carried alone.

“But moral distress not only affects witnesses of wars,” Saul adds. “It implicates us all as well. We, as a public, must contend with our collective responsibility for these recent wars. We must share the moral burdens of shame, guilt, and outrage. Out of this sharing, we may find connection, hope, and the possibility of building a cornerstone for collective healing and moral repair.” In other words, it’s the witnessing that heals.

After each installation, these witnesses are offered an opportunity to respond.

“Just by sitting here, you have to feel this pain and grief,” said one.

“I walked into this room as a mother of two boys,” said another, who went on to share that one son is thinking about enlisting. “I’ve completely shifted,” she added.

There was someone else in attendance that day: Bessel van der Kolk himself. “It was a wonderful occasion,” he wrote on Saul’s Instagram page after the event. “Still mulling over all the things we heard and talked about.”

Sometimes, even the architects of one revolution find themselves simply bearing witness, watching the unfolding of the next.

Will moral injury work eventually become a clinical fixture, the way body-based approaches did nearly three decades ago? Will it reach broader public awareness, stemming the rapidly expanding tide of societal unease? And if it becomes a formal diagnosis, what might this mean for treatment? For now, the answers remain uncertain. Some researchers, like Harold Koenig, say we’ve only begun to understand the scope of moral injury, that the biggest breakthroughs will come from studying how it manifests in different countries and cultures, where norms around guilt and shame are very different from our own.

Still, one thing is certain: simply naming the experience has helped countless people make sense of something that once felt isolating and inexpressible. For Wortham, that naming has been part of an ongoing process of reckoning and forgiveness. For Reda, it’s exposed blind spots in our field, helping him wade into even the bleakest situations with a little bit of hope. And for Saul, it reinforces a conviction: we’re all connected in each other’s healing. Collective resilience, he calls it.

“So much of my work is about helping people open up the conversation,” Saul says—”about letting these stories breathe. These storytellers aren’t just survivors; they’re messengers. They bring us the truth. They inspire us to grapple with it. When they bring us back into community, we can finally hear what they have to say.”