Treating Moral Injuries

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PSYCHIATRIC VIEWS ON THE DAILY NEWS

Physical injuries can heal with bandages, rest, and procedures. Psychological injuries have always-evolving treatments centered on DSM-5 disorders. But treatment for moral injuries is in early development.

We now know that moral injuries start early in our professional careers.¹ As psychiatric residents recently wrote:

“Residents want advocacy training to better serve patients facing structural barriers while also protecting themselves from moral injury and burnout.”

Residents report being demoralized daily as their systems of care fail patients. Seasoned clinicians seem to be feeling the same.²

Given that loss of trust—trust in oneself and trust in leaders—is an essential component of moral injures, it needs to be a focus of interventions. Trust and well-being seem to reinforce each other in a cyclical way over lifetimes.³ To establish and sustain trustworthiness, trust must be proven in actions, sometimes repeatedly. Right now, trust in our government via Health and Human Services is in jeopardy, as services and research are being dismantled.

Current treatments are both secular and spiritual.⁴ Most of the secular ones are variations of cognitive behavioral therapy, particularly with incorporation of forgiveness. Spiritual and religious interventions derive from traditional moral transgressions processed by clergy and chaplains. Both orientations can be integrated in religiously integrated cognitive behavioral therapy. Caregivers knowledgeable in both mental health and given religious beliefs would seem to be ideal. It is unknown to date whether medication can be a helpful addition.

In an organization, Schwartz Rounds can be helpful day by day. These are forums where caregivers discuss their challenging emotional, social, and moral challenges in caring for patients.⁵

Much verification research of most any intervention is still needed.² There may be biological and child developmental vulnerabilities. Moral beliefs vary individually and to some extent along political, cultural, religious, age, and gender lines.^6,7

There can be gray areas, as we are all neither good nor bad. Creating and expanding goodness may best occur with cross-cutting change agents, including compassion training, cognitive therapy, forgiveness support, behavioral reinforcement, community engagement, prosocial action, and “separation of church and state.” The complexity of change agents suggests why treating moral injuries is so hard. While it may take a village to raise a child, it takes a society to develop and maintain valued moral health.

Dr Moffic is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and retirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He presented the third Rabbi Jeffrey B. Stiffman lecture at Congregation Shaare Emeth in St. Louis on Sunday, May 19, 2024. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.

References

1. Liu A, Bishop R, Rooney A, Khaira P. The time is now: psychiatry residents call for more advocacy training. Psychiatric News. September 9, 2025. Accessed September 15, 2025. https://www.psychiatryonline.org/doi/10.1176/appi.pn.2025.09.9.33

2. Litz BT, Walker HE. Moral injury: an overview of conceptual, definitional, assessment, and treatment issues. Annu Rev Clin Psychol. 2025;21(1):251-277.

3. Bi S, Maes M, Stevens GWJM, et al. Trust and subjective well-being across the lifespan: a multilevel meta-analysis of cross-sectional and longitudinal associations. Psychol Bull. 2025;151(6):737-766.

4. Koenig HG, Al Zaben F. Moral injury: an increasingly recognized and widespread syndrome. J Relig Health. 2021;60(5):2989-3011.

5. Mabern J, Taylor C, Reynolds E, et al. Realist evaluation of Schwartz rounds for enhancing the delivery of compassion healthcare: understanding how they work, for whom, and in what contexts. BMC Health Serv Res. 2021;21(1):709.

6. Kohlberg L, Levine C, Hewer A. Moral Stages: A Current Formulation and a Response to Critics. Karger; 1983.

7. Gilligan C. In a Different Voice: Psychological Theory and Women’s Development. Harvard University Press; 2016.