Moral distress? Moral trauma? An important update on definitions and concepts

The folks at Harvard’s Human Flourishing Program, led by Dr. Tyler VanderWeale, have published a paper updating the definitions of moral injury and distress. If you work with people suffering betrayal trauma–especially religious betrayal trauma–you may want to take the time to read their piece and recognize the aspects of moral trauma that may not be well addressed in the classic treatment of PTSD.

What is moral distress and trauma?

Years ago, moral injury was something described primarily in terms of an added impact on veterans of war. The symptoms of moral injury were seen to be in addition to PTSD, defined as an added injury when an individual perceived themselves as having transgressed basic human morals (e.g., a soldier is forced to kill civilians who are being used as shields by enemy fighters). It was commonly understood as the idea that I have done something so terrible that it is unforgiveable (or I have supported leaders who have done something that betrays basic humanity). Key features of moral injury focused on the experience of guilt/shame whereas key features of PTSD centered on horror and terror.

As the concept became better understood, we began to understand it’s existance among civilians as well. Here are some examples:

• Someone who did something wrong (e.g., distracted driving) and badly wounded or killed another person
• First responders who have to triage and, in essence, decide who lives and dies (e.g., the impossible decision between two terrible outcomes)
• Victims of abuse who may have enlisted friends who also became victims of abuse
• Someone who supported and defended a well-known leader who was later found to be harming others

Understanding moral distress of victims of trauma

This paper expands the idea of moral distress beyond the (perceived) perpetrator to that of the experience of victims of trauma/abuse. Consider the new definition offered by VanderWeale and summarized in a recent newsletter,

In trying to bring these concepts together, we conceived of such moral distress as lying on a “moral trauma spectrum” that included matters of both the severity and the persistence of distress. After months of synthesis of prior work, we defined “moral distress” as “distress that arises because personal experience disrupts or threatens: (a) one’s sense of the goodness of oneself, of others, of institutions, or of what are understood to be higher powers, or (b) one’s beliefs or intuitions about right and wrong, or good and evil.” When that distress became sufficiently persistent it would constitute “moral injury.” For such moral distress or moral injury, it was not only that some moral code was violated, but rather that whatever took place somehow challenged one’s whole understanding of right and wrong, or of good and evil, or of the goodness of oneself, others, institutions, or even the divine. That disruption of one’s moral understanding would then give rise to, sometimes severe, distress. When that distress was persistent and would not go away it would be appropriate to speak of “moral injury.” When the distress was sufficiently severe so as to seriously impair functioning over extended periods of time, it might sometimes even be appropriate to speak of “moral injury” disorder.

(Newsletter from Human Flourishing Program, received via email Sept 17, 2025)

Re-read the bolded text. It is not just that some moral code was violated by myself, but that one’s whole understanding of right/wrong of self, others, institutions or the divine has crumbled. Notice how this distress might be observed in individuals having experienced certain types of traumas:

• Victim of sexual assault seeks help from justice system but ends up feeling blamed for it
• Whistleblower in a church who seeks institutional support to stop the abuse by a leader but is then scapegoated for disrupting the ministry
• Someone who is scammed out of money feels they have irreparably harmed others
• Child experiencing abuse by a family member and when telling a parent is then told to be quiet no longer believes they have value
• Person prays for justice and expects to be exonerated but ends up feeling abandoned and forgotten by God

How might this change our treatment of trauma?

The treatment of trauma focuses first on the care of one’s nervous system. Learning to modulate and calm one’s body is essential since the very nature of chronic trauma is an overactivated vigilance system even when the danger has passed. As a person develops capacity to return more quickly to baseline then there may be more of a focus on addressing the narrative and memory of how the traumatic experience changed perceptions of self and the world.

When we make room for the spiritual/moral impacts of both trauma and how communities respond to people who have suffered trauma, we can better address the moral distress experienced. Treatment modalities that only focus on the reduction of nervous system overload may miss addressing the existential and spiritual crises that haunt survivors. This is especially true when (a) faith communities implicitly (or explicitly) discourage expressing doubt about God, or (b) when clinicians ignore spiritual and moral discussions in therapy. Inviting and validating the very deep moral questions of hurting people is essential for their recovery, even when answers are not readily (or ever?) available. Any treatment that ignores moral distress will not be sufficient to the task of recovery. While I am hopeful that some of the recent trauma treatment modalities may speed recovery, I notice that these newer treatments often ignore questions of existence, narrative, and faith and focus almost solely on nervous system function. This may be needed in the first line of care but let us now be more alert to moral distress and injury in those who have survived abuse, assault, and other forms of betrayal trauma.