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As part of the recent surge of interest in Moral Injury (MI), there have been efforts to differentiate this developing construct from Posttraumatic Stress Disorder (PTSD). We thank Farnsworth (2019) for his contribution and attempt to build on his valuable application of philosophical concepts to psychological construct development. Farnsworth (2019) proposed basing this distinction on the philosophical is/ought divide, applied to DSM-5 PTSD’s Criteria D (Negative Alterations in Cognitions and Mood). It was proposed that PTSD cognitions could be considered descriptions about what the world is like whose accuracy can be targeted by cognitive therapies, whereas MI cognitions are prescriptions about what the world should be like, which cannot be assessed for truth or falsehood and so are unsuitable for cognitive therapies.

In practical usage, it is unlikely that when people express cognitions, they are only describing the world and not evaluating it as well. The evaluative aspects of PTSD cognitions (for instance, the difference between describing the world as dangerous vs. exhilarating, both of which describe a high degree of risk but have different affective qualities) likely remain operative as much as the non-evaluative aspects of MI cognitions (for instance, the difference between describing actions as regrettable vs. foolish, both of which describe undesirable behavior but likely have different consequences). These evaluative aspects, importantly, convey emotional and affective valence. It seems that the artificial division of negative cognitions and negative affect, as outlined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) PTSD Criteria D.2–D.4 (American Psychiatric Association, 2013), does not reflect actual practice but actually obfuscates phenomenology. 
We suggest that the metaethical concept of “thick terms” provides a more practical conceptualization of both PTSD and MI cognitions. Thick terms simultaneously convey description and evaluation in a way that supposedly cannot be disentangled and can include affective and moral valence (V”ďyrynen, 2016); thus, these reflect how people actually articulate their experiences. Usefully, the accuracy of thick terms can be assessed, albeit using methods other than empirical falsifiability (see Morrow, 2005). The use of thick terms addresses what we see as concerning treatment implications that stem from the suggestion that MI-related cognitions cannot be true (or false). For example, if an individual thinks a statement such as, “I let them down,” is incapable of being true, this is likely to affect his or her response to it in therapy. We worry that disallowing any truth (or falseness) of moral statements might mystify the political or moral impact of war as idiosyncratic, undermine veterans’ accounts of the impact of war as relativistic, and support militarism.
It may be that the surge of interest in MI owes more to structural weaknesses of the PTSD diagnosis than to the identification of a novel trauma reaction. Rather than pulling apart moral evaluations, emotions, and cognitions according to the needs of a mechanistic postpositivist paradigm, psychiatry would benefit from recognizing how these aspects of trauma are inextricably entangled. Thus, a rigorous engagement with metaethics and phenomenologically driven research (Ponterotto, 2005) to better account for the interwoven nature of these aspects would serve to clarify both the PTSD diagnosis and MI model and improve treatments.


American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). American Psychiatric Publication.
Farnsworth, J. K. (2019). Is and ought: Descriptive and prescriptive cognitions in military‚Äźrelated moral injury. Journal of Traumatic Stress, online access only.
Morrow, S. L. (2005). Quality and trustworthiness in qualitative research in counseling psychology. Journal of Counseling Psychology, 52(2), 250.
Ponterotto, J. G. (2005). Qualitative research in counseling psychology: A primer on research paradigms and philosophy of science. Journal of Counseling Psychology, 52(2), 126.
V√§yrynen, P. (2016). Thick ethical concepts. Stanford Dictionary of Philosophy. https://plato.stanford.edu/entries/thick-ethical-concepts/

Reference Article

Frankfurt, S. B. and Coady, A. (2019), Bringing Philosophy to Bear on Moral Injury and Posttraumatic Stress Disorder Construct Validation: Commentary on Farnsworth (2019). JOURNAL OF TRAUMATIC STRESS, 32: 639-641. doi:10.1002/jts.22423

Questions for Discussion:

  1. What, if any, is the potential incremental validity or value of the moral injury construct over the PTSD diagnosis?
  2. Do readers agree or disagree with the assessment of problems in DSM-5’s Criterion D symptom cluster?

About the Authors:

Sheila Frankfurt, PhD, LP, is an investigator and counseling psychologist at the VA’s VISN 17 Center of Excellence for Research on Returning War Veterans, in Waco, TX. She is currently supported by a Career Development Award-1 (IK1RX002427-01A2) from the VA’s Rehabilitation Research and Development Service to evaluate the measurement of moral injury events.

Alanna Coady, MDiv, was most recently a research assistant in the Massachusetts Veteran Epidemiological Center, Boston VA Medical Center. Ms. Coady earned her Master of Divinity at Harvard Divinity School and will matriculate to the University of British Colombia’s clinical psychology PhD program in Fall 2019.