Williamson, V., et al. (2025).
European journal of psychotraumatology,
16(1), 2567721.
Abstract
Background: Those working in high-risk occupations may often face ethical dilemmas that violate their moral code which can lead to moral injury (MI). While research into the impact of MI is growing, evidence for effective treatment interventions and prevention approaches remains limited.
Objective: To review recent developments in treatment and prevention approaches for MI-related mental health difficulties.
Method: We synthesised emerging treatments, including trauma focused therapies and spiritual approaches, as well as possible prevention strategies.
Results: Conventional treatments for post-traumatic stress disorder (PTSD) (e.g. prolonged exposure) often inadequately address MI and may exacerbate symptoms. Adapted or novel approaches, including Impact of Killing, Adaptive Disclosure, and Restore and Rebuild, show promise, particularly when co-produced with patients and clinicians. Spiritual interventions demonstrate mixed outcomes. Prevention research remains very limited but highlights the potential of systemic reforms, leadership fostering psychological safety, preparedness training, structured reflection, and peer support. Evidence remains constrained by small samples, military-focused populations, and inconsistent measurement of MI.
Conclusions: While no gold-standard intervention exists, values-based and compassion-focused approaches appear promising. Prevention strategies targeting organisational culture and fostering preparedness are urgently needed, particularly for civilian and diverse occupational groups, to better support and protect those exposed to potentially morally injurious events.
Highlights
- Moral injury (MI) occurs when potentially morally injurious events (PMIEs) violate an individual’s moral code, leading to intense guilt, shame, and anger. Strongly associated with PTSD, depression, and suicidality, MI is increasingly recognised beyond military contexts, affecting first responders, healthcare, and media workers, with significant consequences for psychological wellbeing and occupational functioning.
- Standard PTSD treatments often fail to address MI-specific symptoms and may worsen guilt or shame. Emerging approaches such as Adaptive Disclosure, Impact of Killing, and Restore and Rebuild show promise, especially when co-produced with patients. These therapies emphasise values-based behaviour, self-compassion, and moral repair, but evidence remains limited to small, predominantly military-focused studies.
- Prevention research is extremely limited. Leadership that fosters psychological safety, preparedness training, structured reflection, and peer support may reduce risk of MI. Systemic reforms – such as improved working conditions and fairer workloads – are also recommended.
My short summary: Moral injury is the psychological distress resulting from events that violate one's moral code, increasingly recognized in various high-stress occupations, yet current treatments are often inadequate and prevention research is scarce, highlighting a need for specialized therapies and systemic reforms.
