What Is Moral Injury?

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DSM-5-TR now includes moral distress and moral injury as focus areas for clinical attention.

These terms encompass experiences that disrupt our sense of the goodness of others or our institutions.

Moral distress activates chronic stress, impacting sleep, appetite, and social trust.

A young Iranian woman came into my office carrying what she called a heaviness she could not explain. Anahita — I will call her that — was 35, the daughter of Iranian parents who had left Tehran before she was born. She had trouble sleeping. She said she felt as though something had been torn inside her. Not grief exactly, though grief was there. Not fear, though fear was present too. Something else. A feeling that the world had broken a promise she had not even known she had trusted.

As a clinician, I recognized what she was describing. I have heard it many times in my 35 years as a psychotherapist.

In December 2024, the American Psychiatric Association took a historic step: It formally approved the addition of moral distress and moral injury to the DSM-5-TR—not as diagnoses, but as conditions that may be a focus of clinical attention. Moral distress and moral injury apply to experiences that disrupt our sense of the goodness of ourselves, others, or our institutions. To provide a more unified approach to understanding and assessing this type of distress, researchers at Harvard's Human Flourishing Program have formulated what they call the moral trauma spectrum.

At one end is moral distress: the suffering that arises when our sense of right and wrong — or our trust in the goodness of the world —........

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