Dr Bernadette Boss CSC
GMR Board Member

It is a truism that where there is war there is trauma. Trauma in conflict is recorded from the very first written records, from Marathon to Waterloo so to speak.

The names given to this trauma have varied over the years. Arguably, the First World War thrust “shell shock” into the popular consciousness as a descriptor. Following the Vietnam War the term Post Traumatic Shock Disorder, or PTSD, has become the recognised term to describe the changes identified in an individual who has experienced a major traumatic event.

In 1994 psychiatrist Jonathan Shay and colleagues are credited as the first to tease out from PTSD a distinct injury that they termed “Moral Injury” or MI.  In 2009 Brett Litz and colleagues wrote that MI was a term designed to explain the “entrenched distrust, demoralisation and isolation experienced by some Vietnam veterans with chronic and severe mental and behavioural health problems.”[i]

MI is described as the psychological, social and spiritual impact of events involving betrayal or transgression of one’s own deeply held moral beliefs and values occurring in high stakes situations.[ii]

As research into MI progresses the vital importance of identifying whether a person is suffering from PTSD or MI has become clear.  The mechanisms triggering PTSD and MI are now seen as very different but most importantly, the therapeutic treatments and supports are different.

Current PTSD treatments are primarily centred on evidence-based psychological therapies that target trauma-related symptoms, particularly fear-based trauma responses. MI treatments, in contrast, focus more on guilt, shame, betrayal, loss of meaning, and damage to a person’s moral identity. Therefore, while current PTSD treatments primarily target trauma-related psychological symptoms, MI treatments should address moral, existential, and spiritual consequences of experiences that violate a person’s core beliefs and values.

The ability to distinguish and appropriately treat MI was recently highlighted in the Royal Commission into Defence and Veteran Suicide Prevention where MI was recognised as a driver of suicidal ideation and action.

The stakes could not be higher. Continued research into the diagnosis and treatment of MI as well as prevention and recognition, is vitally important to ensure the safety and wellbeing of veterans and serving members of the Australian Defence Force.

References

[i] “Moral injury: State of the Science” Brett T. Litz in Journal of Trauma and Stress 2005;1-13 at 1 Published by International society for Traumatic Stress Studies. Wiley.

[ii] Open Arms https://www.openarms.gov.au/signs-symptoms/moral-injury accessed 15 April 2026.

Photo: Australian Defence Force