Brisco, G. et al. (2025)
The Lancet Psychiatry,
Volume 12, Issue 12, 874 - 876
Moral injury has garnered increasing attention in contemporary research, expanding from its initial association with military veterans to encompass a broader range of populations exposed to trauma and adversity. Potentially morally injurious events involve perceived transgressions of one's own moral code (perpetration) or betrayals by trusted authorities who have exposed the person to unnecessary danger or harm. The betrayal dimension was first highlighted by Shay in Vietnam veterans, by Freyd in people who have experienced child abuse, and more recently in ethnic, sexual, and gender minorities following perceived breaches of trust by family, friends, and public services, with adverse outcomes.
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The article's most novel contribution is the proposed two-axis conceptual framework (Figure 1) to guide assessment and intervention. The axes—degree of illness attribution (how much the individual attributes their actions to their illness) and current severity of illness—provide a practical clinical tool. This framework helps clinicians determine the appropriate timing and type of intervention, whether it's immediate treatment for moral injury, stabilization of the mental illness first, or a focus on restorative processes. By advocating for targeted therapies like Compassion-Focused Therapy, Acceptance and Commitment Therapy, and restorative justice, the authors make a compelling ethical and clinical case for formally recognizing and addressing moral injury to alleviate distress and improve outcomes in some of the most complex and vulnerable patient populations in both forensic and acute psychiatric settings.