This document introduces the concept of moral injury, which involves emotional and psychological distress arising from actions that conflict with an individual’s moral beliefs. It differentiates moral injury from PTSD and discusses its implications for psychotherapy, highlighting the importance of morality in understanding the self and emotional responses. The document includes clinical examples and potential interventions for addressing moral injury in therapy.

1. Introduction to Moral Injury
Theory and Practice
John D. Gavazzi, PsyD ABPP
TW Ponessa and Associates
March 19, 2021

2. www.ethicalpsychology.com

3. Course Objectives
At the end of the session, the participant will be able
to:
1. Describe the concept of moral injury;
2. Differentiate between moral injury and PTSD; and,
3. Explain how moral injury can be applied to
psychotherapy.

4. Outline
Biology & Morality
Morality and the Moral Self
Moral Injury: Defining Features
Moral Injury versus PTSD
Clinical Examples of Moral Injury

5. General Definition of Moral Injury
Moral Injury refers to longstanding emotional,
psychological, social, and spiritual suffering related
to an individual’s moral compass, conscience, or
spiritual beliefs.
Moral injury differs from Post-Traumatic Stress
Disorder (PTSD), but there are some overlaps.

6. General Definition of Moral Injury
Moral Injury begins to incorporate the concept of
the moral self within every human, which is not
typically the realm of psychology or mental health.
We all have moral aspects of our self. We all have
beliefs, morals, and value systems.
We need to delve into the concept of morality.

7. Moral Origins
Religions, Biology, & Psychology

8. Moral Origins: Religion
King James Version - Genesis 2:17
Adam and Eve were not to eat from tree of
knowledge of good and evil, lest they die.
Eating the fruit would give Adam and Eve the
wisdom of God (right & wrong; good & bad).
Ate fruit, felt moral emotions of shame and
embarrassment

9. Moral Origins: Religions
Morality occurred very quickly
Moral knowledge considered god-like
First moral emotions were negative (shame, guilt)
God became angry (from the moral transgression)
Existential crisis: They would die (and know it)

10. Moral Origins: Evolution
From a purely evolutionary perspective, morality is
a pre-human concept
Two pillars of morality found in nature
Caring
Reciprocity
Franz DeWaal found these characteristics in elephants,
chimpanzees, and other mammals (non-linguistic)

11. Moral Origins: Evolution
Morality is derived from emotional (sometimes non
conscious) components:
These violent delights have violent ends
Friar Laurence in Romeo and Juliet
What does this mean and why is it important?

12. Moral Origins: Evolution
Emotions can create attachments.
Attachments form the basis of cooperation and
tribalism.
Tribalism creates in-groups and out-groups, which
form the basis of competition
In-group good; out-group bad

13. Moral Origins: Moral Brains
1. Reciprocity needs sufficient brain power to
determine if fair or not.
Many non-human primates and mammals can assess
fairness.
2. Humans are homo cooperatus, meaning that we
cooperate better than any other species on earth.

14. Moral Origins: Evolution
In the dynamics of group formation, morality helps
individuals bind to beliefs, values, and behaviors.
This occurs with any group: religions, teams,
fraternities, sororities, professional groups, sports,
politics, green eyes, social class, etc.
Groups are strong, non conscious processes that help
shape identity, meaning, thinking, and behaviors.

15. Moral Origins: Social Identity
Race Ethnicity
Gender Social Economic Status
Social Class Sexual Orientation
Religion Education
Occupation Intersectionality

18. Moral Origins: Moral Brains
Ventromedial Prefrontal Cortex (VMPC)
Moral judgment & mediating moral emotions
Social norms & social values
Orbital Frontal Cortex (OFC)
Reward & punishment processing
Anterior Cingulate Cortex (ACC)
Error detections and theory of mind (ToM)

19. Moral Origins: Moral Animals
Emotional Components of Morality
Cognitive Components of Morality

20. Moral Origins: Moral Emotions
Positive Negative
Love Disgust
Compassion Anger
Empathy Contempt
Sympathy Embarrassment
Gratitude Guilt
Elevation Shame

21. Moral Origins: Moral Brains
Our larger brains help us to determine non-zero sum
thinking.
Zero Sum Thinking: I win, you lose.
Exploitation, Dominance, Hierarchies
Non-zero Sum Thinking: I will acquiesce to this point
or give a little in order to receive what I actually need.
Mutual advantage, Cooperation, Collaborations

22. Large Brains: Better Cooperators
Language Skills Ability to Plan
Specialization Ability to Write
More sophisticated tools Larger Tribes

23. The Moral Self
The Self is essentially moral, as compared to
-Memories
-Personality (smart, ambitious, outgoing)
-Desires & Preferences (libido, hobbies)
-Perceptions (health, body)
Evolutionary Advantages to Moral Self
-Moral character promotes cooperation and trust
-Morality help groups bind together (moral units)

25. Moral Origins: Biology/Evolution
Morality occurred very slowly
Moral knowledge are a function of our biology
Moral emotions are both negative and positive
Moral emotions bind groups together
Morality is the essential component to the self

26. Moral Dilemmas for Patients
Moral Conflicts
-Competing moral values
-Mild to moderate physical/emotional discomfort
-Moral distress
Moral Dilemmas
-Competing moral values
-Moderate to significant symptoms
-Higher risk scenario

27. Jackie is a patient who has been involved in psychotherapy for about six
months, predominantly working on issues related to depression and
relationships. During the course of psychotherapy, Jackie is working on
decreasing interpersonal conflicts, because she can create drama in
relationships.
Jackie’s close friend Beyoncé will be married in two months. Jackie
recently discovered ironclad, incontrovertible evidence that Beyoncé’s
fiancée has been cheating on her for at least several months of their
engagement. Jackie is consciously aware of her pattern of creating
conflicts in relationships; however, she does not want a close friend
married to a cheater.
Jackie is not sure how she can continue to be friends with Beyoncé and her
soon-to-be husband knowing this secret. However, Jackie is fearful she
will lose Beyoncé as her friend, in that Beyoncé may think Jackie is acting
erratically again, mainly for negative attention.

28. Moral Injury – Brief history
Moral distress, as applied to nursing (Jameton, 1984)
Moral injury applied to veterans (Shay & Monroe, 1999)
-Unit of moral cohesiveness (Honor, Duty, Country)
-Perception of betrayal from legitimate authority
-High stakes scenario
Moral injury as perpetrating, failing to prevent or
witnessing acts that transgress moral beliefs or
expectations (Litz et al, 2009)

29. Moral Injury
Moral injury violates the norms, expectations, and traditions
of the moral construct or unit (trauma-based)
Moral injury is the consequence of deep, foundational
betrayal that shatters the moral self (meaning)
Associated with religious, spiritual, cultural, or group-based
values (moral complexity)
Moral emotions of guilt, shame, and anger (emotional)

31. Examples of Moral Injury in therapy
A police officer who caused harm or death of civilians
-Conflict between protecting and serving versus harm
CYS worker who witnesses parental abuse
-Conflict between high value of being a parent versus
witnessing such abuse
A nurse who follows directives based on low staffing
patterns and profit margins
-Conflict between professional values and org demands

32. Potential Interventions and Ethics
Values Clarification and Meaning Making
Working with moral emotions such as guilt, shame, and
disgust
Understanding and working through the betrayal
Forgiveness and Compassion: Self and Others

33. Potential Interventions and Ethics
Potential Goals
Reduce shame and guilt
Re-balance moral emotions & cognitions
Appreciate complexity of moral values
Reparation, apologies, & forgiveness

34. Potential Interventions and Ethics
Potential Goals
Clarifying moral authority & relativity
Developing support network, depending on issue
Develop plan for long-term
Spiritual/religious healing

35. Potential for Post-Traumatic Growth
Examples may include:
-Greater appreciation for life
-Reset priorities: work, spirituality, relationships
-Enhance meaningfulness
-Personal strength for building from trauma

36. Professional Examples of Moral Injury
Institutional Betrayal: Transgressions by institutions upon
individuals who are dependent on that organization
Moral Distress:
-Too many high needs patients
-Repetitively discussing patient or cultural traumas
-Vicarious trauma
Intrusive Advocacy: Psychologist places his or her moral
values over the patient’s (trampling patient autonomy)

37. Question and Answer
Wrap Up

38. Refences Slide
Graham, J., Haidt, J., Koleva, S., Motyl, M., Iyer, R., Wojcik, S., & Ditto, P. H. (2013). Moral foundations theory: The
pragmatic validity of moral pluralism. Advances in Experimental Social Psychology, 47, p. 55-130.
Jameton A. (1984). Nursing practice: the ethical issues. Englewood Cliffs, NJ: Prentice Hall.
Litz B. T., Stein N., Delaney E., Lebowitz L., Nash W. P., Silva C., & Maguen, S. (2009). Moral injury and moral repair in
war veterans: a preliminary model an intervention strategy. Clinical Psychology Review, 29, 695-706.
Shay, J., & Munroe, J. (1999). Group and milieu therapy for veterans with complex posttraumatic stress disorder. In P. A.
Saigh & J. D. Bremner (Eds.), Posttraumatic stress disorder: A comprehensive text (p. 391–413). Allyn & Bacon.
Schwartz, S. H. (1996). Value priorities and behavior: Applying a theory of integrated value systems. In C. Seligman, J. M.
Olson, & M. P. Zanna (Eds.), The psychology of values: The Ontario Symposium (Vol. 8, pp. 1-24). Hillsdale, NJ: Erlbaum.
Smith, C.P. & Freyd, J.J. (2014). Institutional betrayal. American Psychologist, 69, 575-587.
Strohminger, N. and Nichols, S. (2014). The Essential Moral Self. Cognition, 131, 159-171.