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The experience of military service members who serve in combat is complex and can include multiple elements of fear, traumatic loss of friends and comrades, and provocative situations that challenge one’s basic sense of right and wrong (Stein et al., 2012). The increase of scholarly and clinical interest in the moral and ethical dimensions of combat and their enduring mental health effects has coalesced around the term ‘moral injury.  Moral injury refers to a set of reactions to an event that involves “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (Litz et al., 2009, p. 700). To illustrate, we recently treated a combat veteran who described a situation where he took the life of a young child who was approaching a military checkpoint with an explosive device.  This veteran faced an impossible dilemma: if he acts, he has taken the life of a young child, but if he does not act, many of his fellow soldiers would have been killed or injured in the blast.  Other examples of such potentially morally injurious situations might involve deciding not to render aid to injured civilians or engaging in acts of revenge. The experience of these morally injurious events can evoke a wide range of symptoms, some of which are thought to involve intrusive thoughts about moral conflict, guilt, shame, depression, anxiety, anger, spiritual struggles, and a basic loss of trust, as well as self-harm, and social alienation (Drescher et al., 2011; Jinkerson, 2016). 

Researchers and clinicians have raised questions about how best to treat moral injury.  On one hand, there are those who suggest that existing protocols that have an established evidence-base for treating PTSD such as Cognitive Processing Therapy (CPT; Resick, Monson, & Chard, 2016; Wachen et al., 2015) and Prolonged Exposure (Foa, Hembree, & Rothbaum, 2007; Smith, Duax, & Rauch, 2013) may be sufficient. On the other hand, some argue that moral injury is a special case, and that novel treatment approaches, such as Adaptive Disclosure (Litz, Lebowitz, Gray, & Nash, 2016), are needed in order to appropriately address the reactions to the morally injurious event.  

A critical question for better understanding how best to treat moral injury is ‘how does the experience of morally injurious events lead to mental health symptoms?’  We know that negative and extreme thoughts that form after a traumatic event play a crucial role in the development and maintenance mental health symptoms across a range of disorders (Gonzalo, Kleim, Donaldson, Moorey, & Ehlers, 2012), including the specific symptoms that are part of moral injury (Litz et al., 2009). Research on related psychological problems, such as PTSD, suggests that reducing negative and extreme thinking results in decreased trauma-related symptoms (Zalta et al., 2014).  Because negative and extreme thoughts play such a crucial role in trauma-related distress, we became interested in determining if these thoughts played a role in moral injury.       

To answer our question, we measured experiences of morally injurious events using the Moral Injury Events Scale (Nash et al., 2013), negative and extreme thinking that forms after a trauma using the Posttraumatic Cognitions Inventory (Foa, Ehlers, Clark, Tolin, & Orsillo, 1999), PTSD (Clinician-Administered PTSD Scale for DSM-5; Weathers et al., 2013a; PTSD Checklist-5th edition, Weathers et al., 2013b), and depression symptoms (Patient Health Questionnaire-9, Kroenke, Spitzer, & Williams, 2001).  We examined the clinical intake measures from 121 veterans who attended the Road Home Program’s intensive outpatient program for PTSD (Held et al., 2017).
We found that the greater the degree of experiencing morally injurious events, the more strongly individuals held negative and extreme thoughts. In turn, the more strongly individuals held these thoughts, the higher their PTSD and depression symptoms. In other words, the meaning an individual makes of their involvement in a morally injurious event is critical as it appears to influence trauma-related symptoms. In our experience, such thoughts often involve an exaggerated sense of responsibility and blame for the event and the outcome. For example, the veteran from the earlier example may think: “I shot that child when I could have saved her life. I must be a monster.”  Such thoughts would understandably lead to guilt, shame, spiritual struggles and loss of basic trust in oneself as well as other symptoms.  Negative and extreme beliefs about the morally injurious event may therefore be an important treatment target and determining whether there are more balanced or helpful ways of evaluating the moral injury may alter some of the resulting symptoms may be an important common principle across effective moral injury treatment. However, more research on the treatment of moral injury-related symptoms is needed to offer specific guidance.

Our findings are encouraging for clinicians who treat moral injury because these negative and extreme thoughts may provide a common element of effective treatment of moral injury regardless of the specific approach used. Our data encourage attempts to identify and address the negative and extreme meanings that individuals have made of their involvement in morally injurious events.  Additional good news for clinicians is that these negative and extreme thoughts are easily assessed with widely available and well-validated tools (the PTCI, Foa et al., 1999) and these thoughts are treatable with existing methods and evidence-based protocols.  For a recent case report on how evidence-based protocols for PTSD were successfully applied to moral-injury based PTSD, please see Held, Klassen, Brennan, and Zalta (2017).

Although our findings are directly relevant to clinicians, there are some limitations to this study that also need to be considered.  First, because the sample consisted only of treatment-seeking veterans with severe PTSD, findings may not generalize to other, less-severe groups.  The second limitation is that, because of our study design, we cannot claim that negative and extreme thoughts cause moral injury, we can only claim that the two are related. We recommend that future studies collect several waves of data over time to better understand the relationship between these processes.    


Drescher, K. D., Foy, D. W., Kelly, C., Leshner, a., Schutz, K., & Litz, B. (2011). An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology, 17, 8–13. doi: 10.1177/1534765610395615

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Foa, E.B., Hembree, E.A., & Rothbaum, B.O. (2007). Prolonged Exposure therapy for posttraumatic stress disorder. New York, NY: Oxford University Press.

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Held, P., Klassen, B. J., Brennan, M. A., & Zalta, A. K. (2017). Using Prolonged Exposure and Cognitive Processing Therapy to treat veterans with moral injury-based PTSD: Two case examples. Cognitive and Behavioral Practice. doi: 10.1016/j.cbpra.2017.09.003

Jinkerson,J.D. (2016) Defining and assessing moral injury: A syndrome perspective. Traumatology, 22(2), 122-130. doi/10.1037/trm0000069

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Litz, B. T., Lebowitz, L., Gray, M. J., & Nash, W. P. (2016). Adaptive disclosure: A new treatment for military trauma, loss, and moral injury. New York, NY: Guilford Press.

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Resick, P. A., Monson, C. M., & Chard, K. M. (2014). Cognitive processing therapy treatment manual: Veteran/military version. Boston, MA: Veterans Administration.

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Wachen, J.S., Dondanville, K.A., Blankenship, A.E., Wilkinson, C., Yarvis, J.S., & Resick, P.A. (2015). Implementing Cognitive Processing Therapy for Posttraumatic Stress Disorder with active duty U.S. military personnel: Special considerations and case examples. Cognitive and Behavioral Practice, 23(2), 133-147. doi.10.1016/j.cbpra.2015.08.007

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Zalta, A. K., Gillihan, S. J., Fisher, A. J., Mintz, J., Mclean, C. P., Yehuda, R., & Foa, E. B. (2014). Change in negative cognitions associated with PTSD predicts symptom reduction in prolonged exposure. Journal of Consulting and Clinical Psychology, 82, 171–175. doi: 10.1037/a0034735

Discussion questions

  1. What are some ways in which these study findings might impact your day-to-day clinical practice with those affected by moral injury?
  2. What kinds of negative, extreme, and counter-productive thoughts may show up in those struggling with moral injury?  What are the best ways to identify and challenge these thoughts?

Reference Article

Held, P., Klassen, B. J., Zou, D. S., Schroedter, B. S., Karnik, N. S., Pollack, M. H. and Zalta, A. K. (2017), Negative Posttrauma Cognitions Mediate the Association Between Morally Injurious Events and Trauma-Related Psychopathology in Treatment-Seeking Veterans. JOURNAL OF TRAUMATIC STRESS. doi:10.1002/jts.22234

Author Biography

Brian Klassen, PhD, is a licensed clinical psychologist and Assistant Professor of Psychiatry at Rush University Medical Center in Chicago, Illinois.  Dr. Klassen provides evidence-based PTSD treatment through the Road Home Program: Center for Veterans and Their Families (www.roadhomeprogram.org).