Total VeteranMoral Injury vs PTSD: The Difference, the Research and Where Veterans Get Help
PTSD centres on fear. Moral injury centres on guilt, shame and betrayal. Here is how researchers define each, how common moral injury is, and where to get help.
- Litz et al. (2009) define moral injury events as perpetrating, failing to prevent, witnessing or learning about acts that break deep moral beliefs.
- Shay (2014) defines it as a betrayal of what's right by someone with legitimate authority in a high-stakes situation.
- The VA treats moral injury as a reaction to events; it can lead to PTSD or depression or occur without a formal disorder.
- In a 2013 US survey of 564 combat veterans, 25.5% reported betrayal and 10.8% reported transgressions by themselves.
- The UK Restore and Rebuild treatment showed promising pilot results in 2023 and moved to a randomised trial.
PTSD is a diagnosable mental health condition rooted in fear and threat. Moral injury is the lasting distress that follows acts which violate a person's deeply held moral beliefs: things they did, failed to prevent, witnessed or learned about, or a betrayal by people in authority. Its hallmark reactions are guilt, shame, betrayal, disgust and anger. The VA treats moral injury as a reaction to events and does not classify it as a mental disorder. The two often overlap, and a veteran can have one, the other or both. The difference matters because treatments built around fear may leave guilt and shame untouched.
Two foundational definitions
Most current research builds on two definitions, one from a team of clinical psychologists and one from a VA psychiatrist who spent decades treating Vietnam veterans.
| Litz and colleagues (2009) | Jonathan Shay (2014) | |
|---|---|---|
| Source | Clinical Psychology Review, vol. 29, pp. 695 to 706 | Psychoanalytic Psychology, vol. 31(2), pp. 182 to 191 |
| Definition | "Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations" | "A betrayal of what's right" by "someone who holds legitimate authority" in "a high stakes situation" |
| Focus | The person's own acts and the acts of others they saw or learned about | Betrayal by leaders and institutions |
| Background | Proposed a preliminary model and an eight-step treatment approach | Developed from his 1994 book Achilles in Vietnam, which drew on Homer's Iliad |
The two views fit together. The VA's National Center for PTSD describes moral injury as "the distressing psychological, behavioral, social, and sometimes spiritual aftermath" of such events. The research measures reflect both strands. The 9-item Moral Injury Events Scale asks about perpetration by self or others and about betrayal, and the newer Moral Injury Outcomes Scale captures two factors, shame and trust.
Moral injury and PTSD side by side
| PTSD | Moral injury | |
|---|---|---|
| Status | A formal mental health diagnosis | A reaction to events; can lead to disorders such as PTSD or depression, and can occur without any formal disorder |
| Core driver | Fear and threat; Litz and colleagues note PTSD models are built on fear | Violation of moral beliefs; driven mainly by shame and guilt |
| Typical reactions | Re-experiencing, avoidance and hyperarousal | Guilt, shame, betrayal, disgust and anger, with social withdrawal |
| UK research picture | Nightmares, flashbacks and memory problems | More shame, guilt, anger, depression and social isolation (King's College London, 2020) |
| Treatment | Established trauma-focused therapies | Specific treatments still under investigation |
The VA notes significant overlap between the two, and that having both is associated with greater severity and higher suicide risk. Hyperarousal, a central PTSD symptom, is less central to moral injury. For the wider distinctions within trauma diagnoses, see our guide to PTSD and complex PTSD.
How common it is
United States. The National Health and Resilience in Veterans Study surveyed 564 US combat veterans in 2013. Results published in Depression and Anxiety showed 10.8 percent reported transgressions by themselves, 25.5 percent transgressions by others and 25.5 percent betrayal. Transgressions by self were associated with suicidal ideation.
United Kingdom. In October 2020, King's College London and Combat Stress published the first UK study of military moral injury, led by Dr Victoria Williamson and funded by the Forces in Mind Trust. Risk factors included lack of social support, childhood adversity and poor psychological preparation. Shame and guilt made veterans reluctant to speak, which led to missed diagnoses. A related 2021 survey of 204 UK veterans in BMC Psychology found 66 had experienced a potentially morally injurious event and 31 a mixed event. Exposure was linked to likely anxiety disorders and suicidal ideation, compared with veterans who reported no such event. The team has also developed a UK measure, the Moral Injury Scale (MORIS).
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Treatment: what exists now
Litz and colleagues argued in 2009 that standard fear-based exposure treatment does not fully address shame and guilt. Their proposed model includes a trusting therapeutic relationship, a guided recounting of the event to uncover harmful beliefs, an imagined dialogue with a forgiving moral authority, reparation and self-forgiveness, and reconnection with others. Several treatments have since been developed:
| Treatment | Format | Evidence so far |
|---|---|---|
| Adaptive Disclosure (US) | 12 individual sessions | Under investigation; uses imagined dialogue with a compassionate moral authority, apportioning blame and making amends |
| Acceptance and Commitment Therapy for moral injury (US) | 12 group sessions | Under investigation; focuses on living in line with personal values |
| Impact of Killing (US) | 10 individual sessions, after PTSD treatment | A randomised trial found it more effective than Present-Centered Therapy for improving functioning |
| Restore and Rebuild, R&R (UK) | 20 weekly online one-to-one sessions | A 2023 pilot with 20 veterans showed reduced PTSD symptoms, depression, alcohol misuse and moral injury distress; it had no control group. A 46-person randomised trial against usual treatment was set out in BMJ Open in May 2024. |
Sources: the VA's moral injury guidance for clinicians (updated September 2026), the R&R pilot study in the European Journal of Psychotraumatology, and the R&R trial protocol. When the protocol was published, its authors stated that no validated treatment for moral injury was yet available to UK veterans.
Where to get help
| Service | Country | How to access it |
|---|---|---|
| Op COURAGE | England | NHS veterans' mental health service. Self-referral accepted. You need to live in England, have served at least one full day, be registered (or eligible to register) with a GP and give your service number. Regional lines include North 0300 373 3332, Midlands 0300 323 0137 and London 020 3317 6818. |
| Combat Stress helpline | UK | 24 hours, 365 days: 0800 138 1619, text 07537 173683, email helpline@combatstress.org.uk |
| Samaritans | UK | 116 123, free, any time |
| Vet Centers | US | No-cost individual, group and family counselling for eligible veterans, service members and families. 24-hour line: 1-877-927-8387. |
| Veterans Crisis Line | US and overseas | Dial 988 then press 1, text 838255, or chat online. From Europe: +1 844-702-5495. |
Outside England, start with your GP, Samaritans or the Combat Stress helpline. Our guide to Op COURAGE explains the referral process in more detail.
Raising moral injury with a clinician
- Use the term directly and describe the event in outline: something you did, failed to stop, saw, or a betrayal by leadership.
- Describe the feelings that dominate, such as guilt, shame, anger or disgust, separately from fear or nightmares.
- Ask whether the treatment offered addresses guilt and shame as well as fear-based symptoms.
- If you also have PTSD symptoms, ask how the two will be treated together.
UK: call Samaritans free on 116 123, day or night. The Combat Stress 24-hour helpline for veterans is 0800 138 1619 (text 07537 173683). In England, call NHS 111 and select the mental health option, or contact Op COURAGE, the NHS mental health service for veterans. Call 999 if a life is at risk. US: contact the Veterans Crisis Line: dial 988 then press 1, text 838255, or chat online. From Europe, including the UK, the line takes calls on +1 844-702-5495.
What to do this week
- Save the Combat Stress (0800 138 1619) or Veterans Crisis Line (988, press 1) number in your phone today.
- Write down the event and the feelings it leaves you with, guilt, shame, anger or betrayal, to take to an appointment.
- In England, contact your regional Op COURAGE service directly; you can self-refer.
- In the US, call 1-877-927-8387 to reach your nearest Vet Center.
- Ask any clinician you see whether their treatment addresses guilt and shame as well as fear.
Questions people ask
What is the difference between moral injury and PTSD?
What are the signs of moral injury?
Is moral injury a mental illness?
Where can UK veterans get help for moral injury?
- Litz, Stein, Delaney, Lebowitz, Nash, Silva and Maguen, "Moral injury and moral repair in war veterans", Clinical Psychology Review (2009). https://sites.bu.edu/litzlab/files/2023/04/Moral-injury-and-moral-repair-in-war-veterans-Litz-2009.pdf
- Shay, "Moral injury", Psychoanalytic Psychology 31(2) (2014), excerpt hosted by Penn CERL. https://www.penncerl.org/wp-content/uploads/2022/01/4602-moralinjuryshayexcerptpdf.pdf
- U.S. Department of Veterans Affairs, Norman and Maguen, "Moral Injury" (updated September 2026). https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp
- King's College London, "Ex-service personnel suffering from moral injury, according to new research" (October 2020). https://www.kcl.ac.uk/news/ex-service-personnel-suffering-from-moral-injury-according-to-new-research
- Centre for Evidence Based Early Intervention, summary of Jones, Greenberg, Murphy, Stevelink, Allen and Williamson, BMC Psychology (May 2021). https://www.centreforevidence.org/article/20210505-the-impact-of-moral-injury-on-the-wellbeing-of-uk-military-veterans
- Depression and Anxiety, "Moral injury in U.S. combat veterans: Results from the National Health and Resilience in Veterans Study" (2013 survey data). https://metatoc.com/papers/101523-moral-injury-in-u-s-combat-veterans-results-from-the-national-health-and-resilience-in-veterans-study
- Centre for Evidence Based Early Intervention, summary of Greenberg, Murphy, Serfioti et al., "Restore and Rebuild (R&R)", European Journal of Psychotraumatology (September 2023). https://www.centreforevidence.org/article/20230921-restore-and-rebuild-r-r-a-feasibility-pilot-study-of-a-co-designed-intervention-for-moral-injury-related-mental-health-difficulties
- Murphy, Williamson, Greenberg et al., "Restore and Rebuild (R&R): a protocol for a phase 2, randomised control trial", BMJ Open (May 2024). https://doaj.org/article/1f13edc89970464e85c23a7c9db90aec
- NHS, "Mental health support for veterans, service leavers and reservists" (Op COURAGE). https://www.nhs.uk/nhs-services/armed-forces-community/mental-health/veterans-reservists/
- U.S. Department of Veterans Affairs, "Vet Centers". https://www.vetcenter.va.gov/
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