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There is increasing recognition of the impact of moral injury - the psychological harm caused by experiences that violate someone’s moral or ethical code. Those affected by it need appropriate and effective treatment, say Amanda Bonson, Gavin Campbell and Dominic Murphy.
There is increasing recognition of the impact of moral injury – the psychological harm caused by experiences that violate someone’s moral or ethical code. Those affected by it need appropriate and effective treatment, say Amanda Bonson, Gavin Campbell and Dominic Murphy.

The concept of PTSD arising from traumatic experiences is widely understood. Accidents, conflict exposure, and violence can, for some, result in lingering psychological difficulties. But what about those experiences which don’t impact a person’s sense of safety, but instead threaten their deeply held moral beliefs about themselves and the world? For those people, we talk not of PTSD, but of moral injury.  

While the exact definition and application of moral injury is still being discussed by researchers and healthcare professionals, the central features of lasting feelings of guilt, shame and anger differentiate moral injury from the classic symptoms of PTSD. Crucially, moral injury results in a breakdown in the relationship the morally injured person has with themselves, their loved ones and the world around them. This contrasts with those with PTSD who often describe a loss of feeling safe as central to their difficulties.

Military veterans in the UK and around the world have described exposure to morally injurious events during their military service, and experiencing mental health difficulties as a result. These potentially morally injurious events may include situations where a veteran is unable to prevent harm, may bring harm to others or feel deeply betrayed by a trusted authority. For example, a soldier may be unable to intervene when a child is suffering or harmed due to their rules of engagement, a drone operator may take the lives of innocent civilians when dropping a bomb to take out an insurgent, or a medic treating casualties may be left with insufficient information or equipment to treat gravely injured patients safely or effectively.   

Mental Health

The impact of exposure to these events on the lives of veterans is significant. They are more likely to experience other mental health disorders such as PTSD and depression, have strained relationships with others and experience suicidal thoughts – they are also more likely to behave in a way that is self-destructive or self-sabotaging. These veterans also tend to have poorer treatment outcomes when accessing therapy services and often feel undeserving of support or recovery, preventing them from accessing support in the first place. 

Increasingly, research is also finding that it isn’t just military veterans who are at risk of moral injury. Journalists, firefighters, police, and veterinarians have also described similar struggles with their mental health following exposure to potentially morally injurious events. In particular, the COVID-19 pandemic shone a light on moral injury among healthcare workers. Frontline workers across roles and specialisms demonstrated being particularly susceptible to moral injury when faced with the death of vulnerable people and when they felt unsupported and unprepared for the moral load of the work they were undertaking. 

Currently there isn’t a specialist treatment approach that therapists can draw on to target moral injury symptoms. Instead, clinicians have told us that they rely on combining a number of different approaches in an attempt to best meet the needs of their patients. Clear clinical guidance on best treatment approaches and how to ensure confidence in what is being provided is also currently lacking. As previously mentioned, research has demonstrated that existing treatments may not fully address the needs of those with moral injury and the barrier to positive changes that such strong feelings of guilt and shame can create. With a significant numbers of people reporting being exposed to potentially morally injurious events, there is a clear need for effective treatments to be developed.

New Treatment

Alongside our colleagues at King’s College London, the research department at Combat Stress – the UK’s leading veterans’ mental health charity – have developed a new treatment for moral injury to meet this need. We’ve collaborated with leading clinical, pastoral and research professionals across the globe to better understand the needs of those with moral injury, and the most effective treatment approaches. From this we have developed a moral injury treatment plan which was then refined in partnership with veterans who had experienced moral injury or exposure to morally injurious events. 

These veterans provided a valuable insight into their experiences of moral injury and how to improve upon the treatments currently provided. From this we developed Restore and Rebuild (R&R), a novel treatment for moral injury. This 20-session treatment was piloted at Combat Stress between 2021 and 2022, with 20 military veterans struggling with conflict-related moral injury. The one-to-one treatment with a therapist aims to provide veterans with an opportunity to share their morally injurious experiences, with a specific focus on understanding and overcoming guilt and shame-based thought patterns and beliefs. R&R also supports veterans in overcoming some barriers and problems in relationships with others following their moral injury, and helps them shape future goals and directions that are meaningful to them. 

Early assessment

The results of the early assessment of this R&R treatment are promising. Veterans demonstrated a significant reduction in symptoms of moral injury related distress, as well as associated symptoms of PTSD, depression and alcohol misuse. There were no drop-outs in treatment, which can often be a particular difficulty when working with veterans who’ve experienced military trauma. When interviewed, veterans who received the treatment described a ‘light bulb’ moment when moral injury was explained to them, finally having a name for the difficulties with which they had been battling. They reflected on improved self-care and relationships with others, as well as being more in touch with the personal values of importance to them. Veterans described an improved quality of life as a result of treatment and, despite the pain of talking through such distressing events, the treatment was seen to be well tolerated. 

So what next? While these results are encouraging, our R&R treatment still needs further rigorous assessment before it can be rolled out to other clinical settings and populations. The next stage of this assessment process is a stringent randomised control trial, which will again be running at Combat Stress starting in 2023 for three years. In this stage, R&R will be compared with the standard combination treatments currently provided to veterans with moral injury, and we hope to be able to report on the findings in 2026. 

Moral injury is a novel term to many people, and it is still finding its place in academia, diagnostic tools and clinical settings. Although research into the field has grown exponentially in recent years, this isn’t a novel experience or type of trauma. It is increasingly clear that there are a significant number of people who struggle with symptoms of moral injury as a result of often impossible moral situations encountered as part of their profession, including professions centred around protecting, caring for and serving those most in need. We hope that R&R offers a treatment option that meets the needs of this population, in a way which current treatments may not. In doing so, we aim to provide effective relief from the heavy weight of moral injury which encourages compassion, understanding and hope for the future. 

Amanda Bonson is a research therapist, Gavin Campbell is a research assistant and Dominic Murphy is head of research at Combat Stress 

John’s Story

‘I joined the Royal Engineers in 1984 when I was 16 and straight out of school. I served in Germany, Northern Ireland, Canada and served in the first Gulf War.

‘I left the army after 14 years as I felt I’d reached the end of my time – I’d done and seen everything I needed to, been to war, got the T shirt and wore medals. I got a civilian job working as a development analyst for an airline and had a successful career in project management, but I knew inside I was an angry man. I didn’t realise I had mental health issues, although I guess everyone  around me soon realised.

‘I had no patience and it wouldn’t take me long to go from calm to taking the world on – it didn’t matter what the consequences would be, in my mind it wasn’t me who had the issue, everyone else had the problem.

‘By 2015 everything was going wrong around me and my relationships were rubbish, I was alienating people who cared about me. In my mind I had a deep, dark secret stemming from my time in the army and I thought if people knew what it was, they wouldn’t like me. I hated myself so how could anyone like me, let alone love me? So, I did all I could to make people dislike me first, no matter who it was – parents, partners, whoever.

‘I finally went to the doctor in 2016 on the ‘advice’ of my family – it was to get help or get out. The doctor suggested I needed help. He had a friend who had served and who had suffered, so I called Combat Stress and within 90 minutes I was talking to a nurse.’

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