Have you heard about moral injury? Healthcare providers, settlement workers and others in certain situations are likely to be affected by it. Moral injury is the distress caused when an individual experiences violations of their moral beliefs. This can occur when someone is placed in a situation where they may be forced to violate some of their own beliefs in lieu of others or where they have to violate core beliefs. Moral injury can happen for providers and newcomers.

In this article I share two case scenarios, one of a service provider and the other, a client; both are experiencing moral injury. I conclude with the early and limited evidence of what approaches seem to work in addressing moral injury.

Case Scenario 1: Service Provider

Idris, a nurse working in a public health refugee clinic, has dedicated his career to advocating for human rights of all people and to volunteering with medical groups providing care to areas impacted by war, famine, and other crises. Idris works long hours attending to the starvation-related and other medical conditions of refugees. After a challenging day, Idris is listening to the news and learns that his country’s government is providing military and financial support to a country harming people like the refugees with whom he works. Idris begins to feel less fulfilled by his work, to be irritable, and to have bursts of anger towards his colleagues and manager. He feels anxious around people and withdraws. Idris starts to have difficulty sleeping at night and he begins to use alcohol to cope.

Case Scenario 2: Service Provider

Fatima, a refugee in the clinic where Idris works, relieved to be out of the country from which she sought refuge, is experiencing similar symptoms as Idris. Pre-immigration, Fatima hoarded food and medical supplies for her children. Fatima feels guilt and shame that she did not share the supplies with other families and as a result, other people suffered. When Fatima hears the same news story as Idris did, she begins to feel anger at her country of refuge. Fatima’s friends notice that she is angry all the time. Fatima stops attending religious services and disconnects from those around her.

How did the news story trigger similar paths for Idris and Fatima?

Moral injuries occur when exposed to potentially morally injurious events (PMIEs). PMIEs are events during which a person perpetuates, witnesses, or fails to prevent acts that violate that person’s fundamental values, ethics, and/or codes of conduct (Feinstein et al., 2018; Griffin et al., 2019). When exposed to PMIEs, we feel guilt, shame, anger, a numbing of emotional response, and/or social alienation (Griffin et al., 2019). Situations in which moral injuries are more likely to occur include (1) witnessing excessive violence, death, or immoral acts; (2) offending one’s own morals by engaging in behaviour that harms others or fails to protect others; and (3) having one’s morals betrayed by authority figures (Vaknin and Ne’eman-Haviv, 2025).

Idris fundamentally values human life and caring for others. In hearing the news about his government’s support of a country harming people, Idris experienced a significant betrayal of his moral standards by an authority figure in a situation with significant consequences for others. Further, given that Idris is a government employee, he felt significant shame that his organization supported the devaluing of human life and harm of the very people for whom he provided services. For Fatima, she felt shame and guilt for her own actions of hoarding supplies for her children as well as those actions of her country of refuge for not using its power to stop the situation in which she felt she had to violate her own morals.

The concept of a psychological injury caused by violations of our own morals and ethics is not new, it is an important concept to consider, particularly in the case of psychological injuries that would not meet diagnostic criteria for post-traumatic stress disorder. These types of situations are more likely to arise for clients of refugee services and individuals working with them, given the higher likelihood for direct or vicarious exposure to starvation, poor living conditions, government prosecution, genocide, violence, and other human acts of cruelty.

Individuals with children, higher workloads, solitary workplaces, lack of organizational support, lack of resources, and less experience working in an area were more likely to experience a moral injury in response to exposure to PMIEs (Feinstein et al., 2018). Further, factors such as organizational dehumanization of others, cultural/religious factors, perceived or actual rejection of the individual by others (e.g., colleagues, family members), feelings of separateness from others who did not experience the same events, and organizational discouragement of speaking about PMIEs (Griffin et al., 2019) were all related to development of a moral injury subsequent to PMIE exposure.

For refugees, moral transgressions during pre, migration and post migration have been identified as important factors to assess, as they can be a source of perceived betrayal by the country of refuge (Donovan et al., 2025). Passardi et al. (2022) found that refugees initially perceived their country of refuge to be a place of safety; however, upon arrival, refugees faced deprivation, lack of agency, dehumanization, and loss of dignity.

How would we go about assisting Idris and Fatima?

Moral injuries require us to face our “understanding of our capacity as human beings for destruction and cruelty” (Griffin et al., 2019, p. 357). Research into the treatment of moral injury is in the early stages with many studies looking at adaptation of approaches used to treat post-traumatic stress disorder.

Many of these studies have found reductions in guilt and shame post-treatment, when a person can:

• reframe and put into context their responsibility in a particular situation (if possible)
• and/or a lessening of any rigid beliefs about the meaning of the moral injury.

However, more research is needed to determine effective ways to address refugees in certain contexts in which blame may not be appropriate to be reframed, for example, when culpability is accurate and actions were cruel. An example of accurate culpability and cruel action could be harming people on the instructions of a leader. A person chose to act in a way that was cruel and their choice makes them culpable, even when circumstances were such that they may have felt they had to do the action.

The overlap of spirituality/religiosity may lead to a need for mental health clinicians to consult with those in other fields (e.g., theology, philosophy, ethics, etc.) and expand their knowledge of these areas to effectively address moral injury. Integration of spiritual concepts/religious tenets may be key in addressing self-forgiveness, self-compassion, and making amends to those harmed or to society as a whole, for clients whose spirituality/religiosity is important.

References:

• Donovan, N., Lukic, G., and Mason, O. (2025). A scoping review of moral injury in refugees. European Journal of Psychotraumatology, 16(1), 2501369. DOI: 10.1080/20008066.2025.2501369.
• Feinstein, A., Pavisian, B. & Storm, H. (2018). Journalists covering the refugee and migration crisis are affected by moral injury not PTSD. Journal of the Royal Society of Medicine, 9(3), 1-7. DOI: 10.1177/2054270418759010.
• Griffin, B. et al. (2019). Moral Injury: An Integrative Review. Journal of Traumatic Stress, 32, 350-362. DOI: 10.1002/jts.22362.
• Passardi, S. et al. (2022). Moral injury related to immigration detention on Nauru: A qualitative study. European Journal of Psychotraumatology, 13 (1), 2029042. DOI: 10.1080/20008198.2022.2029042.
• Vaknin, O. & Ne’eman-Haviv, V. (2025). Beyond right and wrong: A new theoretical model for understanding moral injury. European Journal of Trauma and Dissociation, 9, 100569. DOI: 10.1016/j.ejrd.2025.100569