Moral Injury as a Treatment-Resistant Disorder and the ‎Prospects of God-Centered Spiritual Therapies for Its Healing

Document Type : Professional

Authors

1 Professor, Department of Psychology, Research Institute for Hawzah and University, Qom, Iran (Corresponding Author)‎

2 Ph.D. Student in Psychology, Research Institute for Hawzah and University, Qom, Iran

3 Ph.D. Student in Psychology, Islamic Azad University, International Branch of Kish, Kish, Iran‎

4 M.A. in Psychology, Faculty of Humanities, Azad University, Shahr-e-Quds Branch, Tehran, Iran

Abstract

Moral injury is a serious challenge in the field of mental health. This psychological harm arises when an individual encounters an act that contradicts their core values. The present article aims to deeply examine this phenomenon by exploring its psychological consequences through systematic review methods and analysis of Islamic sources. Findings indicate that moral injury originates from a profound conflict with an individual’s fundamental values. It is aligned with feelings of guilt and corresponds with the concept of major sin in Islamic sources. This conflict, along with efforts to conceal or protect it, leads to severe guilt and, eventually, to treatment-resistant psychological disorders. Research shows that spiritual therapeutic approaches have so far proven more effective in helping individuals recover from this type of trauma. It is anticipated that moral injury will soon be formally recognized as a fundamental psychological disorder. Damage to one’s values—often caused by the individual themselves—is not easily reparable, and only spiritual models can offer true relief from the torment of guilt. Although spiritual models based on mental constructs that are not measurable by real criteria may offer temporary relief, only genuine spirituality grounded in reliable revelatory and rational sources can provide true healing. In this regard, the God-centered spiritual therapy model and the adapted cognitive-behavioral therapy model with Islamic interventions (Koenig, 2025) are proposed as effective methods for managing and addressing this condition.

Keywords

References

* The Holy Quran
Ames, D., Erickson, Z., Youssef, N. A., Arnold, I., Adamson, C. S., Sones, A. C., ... & Koenig, H. G. (2019). Moral injury, religiosity, and suicide risk in US veterans and active-duty military with PTSD symptoms. Military Medicine, 184(3-4), pp. e271-e278.
Ames, D., Haynes, K., Adamson, S. F., Bruce, L. E., Chacko, B. K., Button, L., & Koenig, H. G. (2018). A structured chaplain intervention for veterans with moral injury in the setting of PTSD. Durham, NC: Duke University Center for Spirituality, Theology and Health. (Christian, Buddhist, Hindu, Jewish, and Muslim versions available)
Backholm, K., & Idås, T. (2015). Ethical dilemmas, work‐related guilt, and posttraumatic stress reactions of news journalists covering the terror attack in Norway in 2011. Journal of Traumatic Stress, 28(2), pp. 142-148.
Bagheri Sheykhangafsheh, F., & Fathi Ashtiani, A. (2023). Psychometric properties of the Persian version of the Moral Injury Symptoms Scale in a military unit. Military Medicine, 25(4), pp. 1960-1972. https://doi.org/10.30491 /jmm.2023.1006466.1 [In Persian]
Barnes, H. A., Hurley, R. A., & Taber, K. H. (2019). Moral injury and PTSD: Often co-occurring yet mechanistically different. The Journal of Neuropsychiatry and Clinical Neurosciences, 31(2), pp. A4-103.
Battaglia, A. M., Protopopescu, A., Boyd, J. E., Lloyd, C., Jetly, R., O’Connor, C., ... & McKinnon, M. C. (2019). The relation between adverse childhood experiences and moral injury in the Canadian Armed Forces. European Journal of Psychotraumatology, 10(1), p. 1546084.
Breazeale, C. E. (2019). An examination of moral injury, acceptance, meaning-making, and posttraumatic growth among individuals with symptoms of PTSD (Doctoral dissertation, Southern Illinois University at Carbondale).
Bryan, A. O., Bryan, C. J., Morrow, C. E., Etienne, N., & Ray-Sannerud, B. (2014). Moral injury, suicidal ideation, and suicide attempts in a military sample. Traumatology, 20(3), p. 154.
Bryan, A. O., Theriault, J. L., & Bryan, C. J. (2015). Self-forgiveness, posttraumatic stress, and suicide attempts among military personnel and veterans. Traumatology, 21(1), p. 40.
Bryan, C. J., Bryan, A. O., Anestis, M. D., Anestis, J. C., Green, B. A., Etienne, N., ... & Ray-Sannerud, B. (2016). Measuring moral injury: Psychometric properties of the Moral Injury Events Scale in two military samples. Assessment, 23(5), pp. 557-570.
Bryan, C. J., Bryan, A. O., Roberge, E., Leifker, F. R., & Rozek, D. C. (2018). Moral injury, posttraumatic stress disorder, and suicidal behavior among National Guard personnel. Psychological Trauma: Theory, Research, Practice, and Policy, 10(1), p. 36.
Bryan, C. J., Morrow, C. E., Etienne, N., & Ray‐Sannerud, B. (2013). Guilt, shame, and suicidal ideation in a military outpatient clinical sample. Depression and Anxiety, 30(1), pp. 55-60.
Carey, L. B., & Hodgson, T. J. (2018). Chaplaincy, spiritual care and moral injury: Considerations regarding screening and treatment. Frontiers in Psychiatry, 9, p. 619.
Carey, L. B., Hodgson, T. J., Krikheli, L., Soh, R. Y., Armour, A. R., Singh, T. K., & Impiombato, C. G. (2016). Moral injury, spiritual care and the role of chaplains: An exploratory scoping review of literature and resources. Journal of Religion and Health, 55, p. 1218-1245.
Currier, J. M., Farnsworth, J. K., Drescher, K. D., McDermott, R. C., Sims, B. M., & Albright, D. L. (2018). Development and evaluation of the Expressions of Moral Injury Scale—Military Version. Clinical Psychology & Psychotherapy, 25(3), p. 474-488. https://doi.org/10.1002/cpp.2407
Currier, J. M., Holland, J. M., & Malott, J. (2015). Moral injury, meaning making, and mental health in returning veterans. Journal of Clinical Psychology, 71(3), pp. 229-240.
Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schutz, K., & Litz, B. (2011). An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology, 17(1), pp. 8-13.
Evans, W. R., Stanley, M. A., Barrera, T. L., Exline, J. J., Pargament, K. I., & Teng, E. J. (2018). Morally injurious events and psychological distress among veterans: Examining the mediating role of religious and spiritual struggles. Psychological Trauma: Theory, Research, Practice, and Policy, 10(3), p. 360.
Farahani, H., Motaseq-Elahyari, R., Roshan Chesli, R., & Dehghani Arani, M. (2023). Meta-synthesis and meta-analysis in practice using R. Clinical Psychology and Personality, 21(2), pp. 205-221. [In Persian]
Frankfurt, S., & Frazier, P. (2016). A review of research on moral injury in combat veterans. Military Psychology, 28(5), pp. 318-330.
Greenberg, N., & Tracy, D. (2020). What healthcare leaders need to do to protect the psychological well-being of frontline staff in the COVID-19 pandemic. BMJ Leader, 4(3).
Grimsley, C. W., & Grimsley, G. (2017). PTSD & moral injury: The journey to healing through forgiveness. Xulon Press.
Higgins, J. P. (2008). Cochrane handbook for systematic reviews of interventions. Cochrane Collaboration and John Wiley & Sons Ltd.
Hines, S. E., Chin, K. H., Glick, D. R., & Wickwire, E. M. (2021). Trends in moral injury, distress, and resilience factors among healthcare workers at the beginning of the COVID-19 pandemic. International Journal of Environmental Research and Public Health, 18(2), p. 488. https://doi.org/10.3390/ijerph18020488
Hodgson, T. J., & Carey, L. B. (2017). Moral injury and definitional clarity: Betrayal, spirituality and the role of chaplains. Journal of Religion and Health, 56(4), pp. 1212-1228.
Ioannidis, J. P. (2009). Integration of evidence from multiple meta-analyses: A primer on umbrella reviews, treatment networks and multiple treatments meta-analyses. CMAJ, 181(8), pp. 488-493.
Janbozorgi, M. (2019). Multidimensional spiritual therapy: A God-centered approach. Qom: Research Institute for Hawzah and University. [In Persian]
Janbozorgi, M. (2025). Spiritual cognitive-behavioral therapies: The fourth wave. Qom: Research Institute for Hawzah and University. [In Persian]
Jinkerson, J. D. (2016). Defining and assessing moral injury: A syndrome perspective. Traumatology, 22(2), pp. 122-130.
Koenig, H. G. (2025). Psychiatric problems in medical patients relevant to primary care physicians and mental health providers. The International Journal of Psychiatry in Medicine, 60(1), pp. 3-6.
Koenig, H. G. (2025). Spiritual/Religious-Based Cognitive Behavioral Therapies. In Janbozorgi M. (Ed.), Spiritual/Religious Based Cognitive Behavioral Therapies: The Fourth Force. Publisher to be announced.
Koenig, H. G., & Al Zaben, F. (2021). Moral injury: An increasingly recognized and widespread syndrome. Journal of Religion and Health, 60(5), pp. 2989-3011.
Koenig, H. G., Ames, D., Youssef, N. A., Oliver, J. P., Volk, F., Teng, E. J., ... & Pearce, M. (2018). The Moral Injury Symptom Scale-Military Version. Journal of Religion and Health, 57, pp. 249-265.
Koenig, H. G., Youssef, N. A., & Pearce, M. (2019). Assessment of moral injury in veterans and active-duty military personnel with PTSD: A review. Frontiers in Psychiatry, 10, p. 443.
Koenig, H. G., Youssef, N. A., Ames, D., Teng, E. J., & Hill, T. D. (2020). Examining the overlap between moral injury and PTSD in US veterans and active-duty military. The Journal of Nervous and Mental Disease, 208(1), pp. 7-12.
Kopacz, M. S., Connery, A. L., Bishop, T. M., Bryan, C. J., Drescher, K. D., Currier, J. M., & Pigeon, W. R. (2016). Moral injury: A new challenge for complementary and alternative medicine. Complementary Therapies in Medicine, 24, pp. 29-33.
Lennon, R. P., Parascando, J., Talbot, S. G., Zhou, S., Wasserman, E., Mantri, S., ... & Dean, W. (2023). Prevalence of moral injury, burnout, anxiety, and depression in healthcare workers 2 years into the COVID-19 pandemic. The Journal of Nervous and Mental Disease, 211(12), pp. 981-984.
Litz, B. T., Lebowitz, L., Gray, M. J., & Nash, W. P. (2017). Adaptive disclosure: A new treatment for military trauma, loss, and moral injury. Guilford Publications.
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 and intervention strategy. Clinical Psychology Review, 29(8), pp. 695-706.
Mantri, S., Song, Y. K., Lawson, J. M., Berger, E. J., & Koenig, H. G. (2021). Moral injury and burnout in health care professionals during the COVID-19 pandemic. The Journal of Nervous and Mental Disease, 209(10), pp. 720-726.
McEwen, C., Alisic, E., & Jobson, L. (2021). Moral injury and mental health: A systematic review and meta-analysis. Traumatology, 27(3), p. 303.
Nash, W. P., Marino Carper, T. L., Mills, M. A., Au, T., Goldsmith, A., & Litz, B. T. (2013). Psychometric evaluation of the Moral Injury Events Scale. Military Medicine, 178(6), pp. 646-652.
Nash, W. P., Marino Carper, T. L., Mills, M. A., Au, T., Goldsmith, A., & Litz, B. T. (2013). Psychometric evaluation of the Moral Injury Events Scale. Military Medicine, 178(6), pp. 646-652.
Nash, W. P., Vasterling, J., Ewing-Cobbs, L., Horn, S., Gaskin, T., Golden, J., ... & Baker, D. G. (2010). Consensus recommendations for common data elements for operational stress research and surveillance: Report of a federal interagency working group. Archives of Physical Medicine and Rehabilitation, 91(11), pp. 1673-1683.
Nieuwsma, J. A., Brancu, M., Wortmann, J., Smigelsky, M. A., King, H. A., VISN 6 MIRECC Workgroup, & Meador, K. G. (2021). Screening for moral injury and comparatively evaluating moral injury measures in relation to mental illness symptomatology and diagnosis. Clinical Psychology & Psychotherapy, 28(1), pp. 239-250.
Nieuwsma, J. A., O’Brien, E. C., Xu, H., Smigelsky, M. A., VISN 6 MIRECC Workgroup, HERO Research Program, & Meador, K. G. (2022). Patterns of potential moral injury in post-9/11 combat veterans and COVID-19 healthcare workers. Journal of General Internal Medicine, 37(8), pp. 2033-2040.
Paul, L. A., Gros, D. F., Strachan, M., Worsham, G., Foa, E. B., & Acierno, R. (2014). Prolonged exposure for guilt and shame in a veteran of Operation Iraqi Freedom. American Journal of Psychotherapy, 68(3), pp. 277-286.
Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Religion and morality. In Cognitive Processing Therapy for PTSD, pp. 285-287.
Ritov, G., & Barnetz, Z. (2014). The interrelationships between moral attitudes, posttraumatic stress disorder symptoms and mixed lateral preference in Israeli reserve combat troops. International Journal of Social Psychiatry, 60(6), pp. 606-612.
Rozek, D. C., & Bryan, C. J. (2021). A cognitive-behavioral model of moral injury. In J. M. Currier, K. D. Drescher, & J. Nieuwsma (Eds.), Addressing Moral Injury in Clinical Practice, pp. 19-33. American Psychological Association. https://doi.org/10.1037/0000204-002
Shay, J. (1994). Achilles in Vietnam: Combat trauma and the undoing of character. Scribner.
Volk, F., & Koenig, H. G. (2019). Moral injury and religiosity in active-duty US military with PTSD symptoms. Military Behavioral Health, 7(1), pp. 64-72.
Wang, Z. Z., Koenig, H. G., Tong, Y., Wen, J., Sui, M., Liu, H., & Liu, G. (2020). Psychometric properties of the Moral Injury Symptoms Scale among Chinese health professionals during the COVID-19 pandemic. BMC Psychiatry, 20, p. 556. https://doi.org/10.1186/s12888-020-02954-w
Wang, Z., Harold, K. G., Tong, Y., Wen, J., Sui, M., Liu, H., Zaben, F. A., & Liu, G. (2021). Moral injury in Chinese health professionals during the COVID-19 pandemic. Psychological Trauma: Theory, Research, Practice, and Policy. https://doi.org/10.1037/tra0001026

Files

Share

How to cite

Statistics