Moral challenges, moral injury, and PTSD

Litz and Kerig (Reference Litz and Kerig2019) proposed a continuum of morally relevant experiences and corresponding responses. They noted that in everyday interactions we frequently encounter moral challenges – ongoing but minor or impersonal morally relevant experiences that cause mild and transient discomfort. Less frequently, we encounter moral stressors, which are more notable and focal experiences of moral violation that can lead to moderate, somewhat persistent experiences of moral distress. Morally injurious events involve severe violations of core assumptions about how humans should relate to one another, and result in moral injury (MI) – i.e. markedly distressing and functionally impairing alterations in emotional experience, beliefs and assumptions about self, others, and the world, and damaged or broken relationships with other people.

Moral injury

The concept of MI was introduced by Jonathan Shay (Reference Shay1994), who drew on Homeric literature to illuminate the moral dimensions of the experiences of Vietnam war veterans. He identified three necessary conditions for the creation of a potentially morally injurious experience: (1) a betrayal of what’s right, (2) by someone who holds legitimate authority, (3) in high stake situations. Litz et al.’s seminal 2009 paper on moral injury and moral repair in war veterans identified potentially morally injurious events (PMIEs), which included: ‘perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations’ (p. 700). Echoing Shay’s idea that these experiences must involve ‘high stakes’, Litz et al. (Reference Litz, Stein, Delaney, Lebowitz, Nash, Silva and Maguen2009) specified that the transgressive act must ‘severely and abruptly contradict’ (p. 700) personal or shared expectations about moral behaviour.

Since its inception, the concept of MI has been closely tied to PTSD as it was developed to elucidate and explain the moral dimensions of traumatic experiences (Griffin et al., Reference Griffin, Purcell, Burkman, Litz, Bryan, Schmitz, Villierme, Walsh and Maguen2019; Litz et al., Reference Litz, Stein, Delaney, Lebowitz, Nash, Silva and Maguen2009; Litz, Reference Litz2025). However, in more recent conceptualizations MI extends beyond trauma exposure alone, encompassing emotional, cognitive, and behavioural reactions that vary depending on the nature of the morally injurious event, the context in which it occurred, and individual difference variables (Litz, Reference Litz2025; Litz and Walker, Reference Litz and Walker2025). This conceptualization is consistent with Hall et al. (Reference Hall, Everson, Billingsley and Miller2022) who found that MI was associated with a wide range of adverse mental health outcomes beyond PTSD, including depression, anxiety, suicidality, and substance use.

Post-traumatic stress disorder and moral injury

The constructs of MI and PTSD have considerable overlap. According to Farnsworth (Reference Farnsworth, Currier, Drescher and Nieuwsma2021), MI and PTSD involve (1) exposure to a precipitating stressor, (2) automatic and involuntary stress reactions, and (3) maladaptive coping responses that exacerbate and prolong distress and functional impairment. In his model, the automatic and involuntary stress reactions in MI involve natural and expectable experiences of moral distress, defined as ‘expanded social, psychological, and spiritual suffering’. An MI develops when, following the PMIE the individual engages in ‘costly and unworkable attempts to manage, control, or cope with the experience of moral pain’ (Farnsworth et al., Reference Farnsworth, Drescher, Evans and Walser2017 Reference Farnsworth, Drescher, Evans and Walser; p. 392). The efforts to control moral pain include situational and experiential avoidance, emotional numbing, rumination on the causes, meanings, and implications of the event, and changes in interpersonal behaviours, such as social withdrawal, all of which align with PTSD (Griffin et al., Reference Griffin, Purcell, Burkman, Litz, Bryan, Schmitz, Villierme, Walsh and Maguen2019; Litz et al., Reference Litz, Stein, Delaney, Lebowitz, Nash, Silva and Maguen2009). Furthermore, in MI and PTSD people typically experience intrusive, unwanted, distressing memories of the evoking incident, engage in overt avoidance, develop entrenched and over-generalized incident-altered beliefs about self, others, and the world, and experience increased frequency and intensity of negative emotion, and decreased ability to access positive emotion, especially in the context of interpersonal relationships (Currier et al., Reference Currier, Holland and Malott2015; Drescher and Farnsworth, Reference Drescher, Farnsworth, Currier, Drescher and Nieuwsma2021; Litz et al., Reference Litz, Stein, Delaney, Lebowitz, Nash, Silva and Maguen2009; Litz, Reference Litz2025).

More recently, Litz and Walker (Reference Litz and Walker2025) proposed a social-functional framework in which moral injury is conceptualized as a multi-dimensional outcome arising from exposure to potentially morally injurious experiences and ensuing moral emotions, changes in perceptions of self and others, social disconnection, and efforts to cope and repair. Within this framework, moral injury is not defined solely by the objective characteristics of an event but by the enduring psychological, social, and moral consequences that follow exposure to it. It has been proposed that different subsyndromes of MI may emerge depending on the nature of the morally injurious event (Griffin et al., Reference Griffin, Purcell, Burkman, Litz, Bryan, Schmitz, Villierme, Walsh and Maguen2019; Litz et al., Reference Litz, Stein, Delaney, Lebowitz, Nash, Silva and Maguen2009; Shay, Reference Shay2014). When the self is the moral agent responsible for causing actual or potential harm to another ‒ either deliberately through acts of commission (e.g. causing death or injury through morally indefensible excessive use of force), unwillingly through acts of omission (e.g. obeying orders not to intervene despite believing intervention is morally necessary), or inadvertently through mistakes with grievous consequences ‒ the resulting moral injury is likely to involve self-conscious moral emotions such as guilt and shame, internalizing symptoms, and potentially self-directed harm, including self-injury and self-handicapping (Bryan et al., Reference Bryan, Bryan, Morrow, Etienne and Ray-Sannerud2014; Litz et al., Reference Litz, Stein, Delaney, Lebowitz, Nash, Silva and Maguen2009; Griffin et al., Reference Griffin, Purcell, Burkman, Litz, Bryan, Schmitz, Villierme, Walsh and Maguen2019; Tangney et al., Reference Tangney, Stuewig and Mashek2007).

Alternatively, if the MIE involves the self as a moral ‘patient’ or victim (Gray et al., Reference Gray, Schorr, Nash, Lebowitz, Amidon, Lansing and Litz2012) ‒ as in cases of sexual or physical assault, or betrayal by a figure of rightful authority ‒ the moral injury may manifest quite differently (Drescher et al., Reference Drescher, Foy, Kelly, Leshner, Schutz and Litz2011; Shay, Reference Shay2014). If the victimization MIE involved life threat or serious personal harm, the sequelae may overlap substantially with PTSD and be diagnosable as such (Frankfurt and Frazier, Reference Frankfurt and Frazier2016; Litz et al., Reference Litz, Stein, Delaney, Lebowitz, Nash, Silva and Maguen2009). In contrast, if the victimization involved betrayal in the absence of personal life threat, the moral injury may manifest primarily in intense other-condemning moral emotions such as anger, moral disgust, and bitterness, alongside pre-occupying ruminations about retribution and externalizing symptoms, similar to what has been described in post-traumatic embitterment disorder (Farnsworth et al., Reference Farnsworth, Drescher, Evans and Walser2017; Griffin et al., Reference Griffin, Purcell, Burkman, Litz, Bryan, Schmitz, Villierme, Walsh and Maguen2019; Linden, Reference Linden2003; Linden, Reference Linden, Linden and Maercker2011).

Morality and OCD

It is generally accepted that obsessions are rooted in intrusive thoughts that are universally experienced. Those prone to developing OCD over-interpret the thought as meaningful, important, and as requiring immediate action, often because it poses a moral threat (see Purdon, Reference Purdon2023). Themes of morality in OCD arise in four different areas. First, obsessions often take the form of doubts, images, urges, and thoughts involving harm, either through omission (e.g. failing to notice a can was dented and serving one’s family contaminated food) or commission (e.g. swerving into the next lane while driving). Rachman and Hodgson (Reference Rachman and Hodgson1980) noted that such thoughts tend to reflect moral themes. Rachman (Reference Rachman1998) further observed that the perceived ‘victims’ of this harm are typically helpless, such as children, the elderly, innocent, trusting people, or, in the case of religious obsessions, sacred. Purdon and Clark (Reference Purdon and Clark1999) argued that whereas most people are able to assimilate the thought (‘Even a person like me can have a thought like this’, ‘I know a person like me would never act on this thought or want it to happen’) those prone to developing OCD accommodate it (‘Having this thought means I am (or maybe am) a bad/immoral/dangerous/untrustworthy/irresponsible/incompetent person who could cause this to happen’, ‘Maybe I secretly want this to happen’). In an elaboration of his model, Rachman (Reference Rachman1994, Reference Rachman1998) argued that appraisal of thoughts as signifying that the person may be ‘mad, bad, dangerous or immoral’ will capture attention, evoke strong negative emotions, and require action to prevent or ameliorate the harm they represent.

Second, according to leading models of OCD, people prone to developing OCD tend to hold beliefs about their obsessional thoughts that reflect moral themes. The first type of belief is ‘thought action fusion’ (TAF), which includes beliefs that having the thought will increase the probability of acting on it or it otherwise happening (‘probability fusion’) and/or that having a thought is the equivalent to carrying out a prohibited action (‘moral fusion’) (Rachman and Shafran, Reference Rachman and Shafran1999). The second is over-valued beliefs about personal responsibility for harm, such as ‘Failing to prevent (or failing to try to prevent) harm to self or others is the same as having caused the harm in the first place’, ‘Responsibility is not attenuated by other factors (e.g. low probability of occurrence)’, and ‘Not neutralizing when an intrusion has occurred is similar or equivalent to seeking or wanting the harm involved in that intrusion to happen’ (Salkovskis, Reference Salkovskis1985; p. 579).

Third, recent research suggests that many individuals with OCD experience a distinct internal ‘OCD voice’ that is neutral and dominant in tone and authority and with which they engage in an internal dialogue (Bowman et al., Reference Bowman, Eschenwecker, Rowa and Purdon2026; Chiang, Reference Chiang2020). In this preliminary work, the voice was found to have an omnipotent moral authority that issued warnings of potential harm and violation of norms, expectations, and responsibilities; that is, it spoke very much like the voice of conscience itself. Furthermore, according to the Interpersonal Circumplex model, a dominant assertion from one party pulls for submission from the other, who is seeking to avoid conflict (e.g. Pincus et al., Reference Pincus, Hopwood, Wright, Rauthmann, Sherman and Funder2020).

Gilbert proposed that external relationships can be enacted internally, with dominant parts of the self-attacking submissive parts (Gilbert, Reference Gilbert2001; Gilbert et al., Reference Gilbert, Birchwood, Gilbert, Trower, Hay, Murray, Meaden, Olsen and Miles2001). Bowman et al. (Reference Bowman, Eschenwecker, Rowa and Purdon2026) speculated that if the OCD voice embodies that of an important attachment or authority figure people may feel that disobeying or failing to appease it may be viewed as ill-advised, disrespectful, or arrogant, and as risking social sanction. It has long been noted that people with OCD are more concerned about being responsible for harm than simply avoiding harm (Rachman, Reference Rachman1976a; Rachman, Reference Rachman1976b; Salkovskis, Reference Salkovskis1985; Salkovskis, Reference Salkovskis1989). In a diary study of compulsions, Dean and Purdon (Reference Dean and Purdon2021) found that a central goal of the compulsion was to avoid being held by others to be responsible for harm, which was rated as substantially more important than the goals of avoiding harm and of holding oneself responsible for harm. This is consistent with Pozza et al. (Reference Pozza, Dèttore, Marazziti, Doron, Barcaccia and Pallini2021), who found that fear of disappointing others was a strong predictor of OCD symptoms in a large sample of sufferers, over and above other known factors.

Fourth, obsessions often threaten deeply held personal values and the sense of self. Rowa and colleagues found that participants’ most distressing obsessional thoughts were those that contradicted important values the most (Rowa and Purdon, Reference Rowa and Purdon2003; Rowa et al., Reference Rowa, Purdon, Summerfeldt and Antony2005). In Chiang and Purdon (Reference Chiang and Purdon2023), people with OCD were asked what it would mean about them if the obsessional doubt were true (e.g. if they in fact had left the stove on). They reported it would mean they were immoral or flawed in character (bad, irresponsible, untrustworthy, incompetent, careless, lazy, etc.). That is, they appraised failure to prevent harm as reflecting global, stable, negative qualities. Rachman and Hodgson (Reference Rachman and Hodgson1980) proposed that those prone to developing OCD are more likely to experience guilt and have heightened levels of morality, empathy, and cautiousness. They labelled this constellation of traits ‘tender conscience’. Those with tender conscience have a highly empathic sense of the impact of harm on others and thus view themselves as more culpable than the average person if their own acts of omission or commission result in harm (e.g. ‘I of all people, fully understand the impact of this and am honour-bound to do everything I can to neutralize/prevent it’).

These processes can give rise to a feared self-view, a set of qualities that individuals fear is part of themselves or may become so in the future (Carver et al., Reference Carver, Lawrence and Scheier1999; Markus and Nurius, Reference Markus and Nurius1986; Oyserman and Markus, Reference Oyserman and Markus1990). Feared self-concepts have been proposed as particularly relevant in OCD and may reflect the internalization of persistent moral doubts (Aardema and Wong, Reference Aardema and Wong2020). Indeed, individuals with OCD may interpret intrusive thoughts as revealing something fundamentally wrong or dangerous about their character (Ferrier and Brewin, Reference Ferrier and Brewin2005). Similarly, Bhar and Kyrios (Reference Bhar and Kyrios2007) found that people with OCD fear that their self-worth, morality, and loveability is in question. These fears trigger intense emotions such as guilt and shame, which in turn, may serve to reinforce feared self-beliefs and newly accommodated schemas, creating a self-perpetuating cycle in which moral emotions are not only outcomes but also perceived confirmations of being ‘bad’ or defective.

Moral emotions in OCD

Implications for assessment

It could prove beneficial to include at intake questions as to: (1) whether the primary distress comprises moral emotions; (2) whether the obsession is viewed as transgressive in and of itself; (3) whether failure to resolve the intrusion is considered transgressive; (4) the extent to which fear of being responsible for causing harm is central to the client’s distress; (5) how the obsessions have affected their sense of their own moral culpability and subsequent beliefs about right/wrong, goodness, and trust; (6) how OCD is affecting people’s social relationships and sense of belonging and meaning in life; and (7) avoidance of morally relevant situations and the range of compulsions used to manage moral distress, which otherwise might be overlooked in standard OCD assessment.

Implications for treatment

The first implication is that there is merit in incorporating the MI framework into the CBT formulation when relevant. This would include explaining the concept of MI and normalizing feelings of guilt and shame as understandable responses to fear a transgression has or will happen. This addresses the moral emotions and moods domain of MI. The OCD voice can be described in terms of a threat-detection and warning system operating in overdrive, misfiring in response to internally generated cues such as intrusive thoughts (Rachman, Reference Rachman2002; Salkovskis et al., Reference Salkovskis, Wroe, Gledhill, Morrison, Forrester, Richards, Reynolds and Thorpe2000). This establishes the rationale for dethroning the OCD voice as a moral authority, which has relevance for self-trust, moral emotions and mood, and self-sabotaging domains of MI. Second, clients may benefit from strategies to develop ‘moral readiness’ as preparation to resisting the OCD demands and engaging in exposure-based interventions (Purdon, Reference Purdon and Wenzel2021a, Reference Purdon and Woud2021b). It is noteworthy that exposure-based interventions are less effective when the distress evoked by the obsession primarily comprises disgust (e.g. Mitchell et al., Reference Mitchell, Coifman and Olatunji2024); if moral emotions such as shame and guilt function similarly during exposure, interventions that rely primarily on fear extinction may not fully address the client’s distress. Moral readiness can begin with a discussion of the extent to which compulsions are consistent with important values but compromise other deeply held values (e.g. checking compulsions reflect caring/responsibility but chronic lateness due to excessive checking violates the deeply held value of being conscientious and reliable). Next can follow a discussion about the extent to which each set of values are being realized at present, with focus on whether the compulsions are in fact succeeding at fulfilling a core value. At this point it can be noted that there is a 100% chance that one set of values is being compromised to stave off a vague, uncertain outcome relevant to another set of values. Furthermore, compulsions are seldom direct ways of advancing core values. For example, scouring the floor of a child’s bedroom for a dropped thumbtack is a less direct way of expressing love and of being a good parent than is spending the time reading to one’s child. Thus, reading rather than checking could be the moral choice. This addresses the social behaviour and self-harming sabotage domains of MI.

Third, people with OCD tend to see the feared outcome as happening in a flash, neglecting all the steps that would have to happen for the event to occur. As per Purdon (Reference Purdon and Wenzel2021a, Reference Purdon and Woud2021b) a second strategy would be to identify the factors that would have to be in place for the feared outcome to occur (e.g. one would have to fail to turn off a burner after use, fail to see the burner light, the burner light would need to fail, etc.). It can be informative to assess the OCD-driven ideas about the probability of each factor, calculating the overall probability of the feared event, and contrasting that probability with the 100% probability that the compulsions are compromising other values, while also recognizing that a risk-free life is impossible.

With respect to repugnant obsessions, discussion could include the opportunity for moral decision making at each stage; that is, in many cases the person would have to make a series of conscious decisions that violate deeply held values before the final transgressive act occurs. Clinicians can also borrow from treatment of panic disorder in which the idea that one is capable of losing control and engaging in undesirable behaviour is addressed. It is important to note that the goal of such discussion is not to provide reassurance but rather to develop the insight that resisting a compulsion that definitely compromises one set of values to stave off a very uncertain, low probability outcome that compromises other values could in fact be the more moral choice. This strategy addresses the feared self and perceptions of the self as untrustworthy and has the potential to help clients develop a greater sense of purpose and efficacy.

Implications for active treatment

First, if the central emotional response to the obsession is disgust, exposure may be less effective in addressing OCD symptoms. Instead, addressing self-disgust via psychoeducation about thoughts and over-generalized ideas about their meaning and importance as indices of morality may be more useful This framework also introduces targets for exposure other than the obsessional thought, including exposure to trusting the self, to seeking support, and to accepting kindness and compassion from others (see Purdon, Reference Purdon and Woud2021b). Rather than targeting the distress evoked by the obsession, exposure could target uncertainty over whether enough has been done to atone for or prevent a transgression. When the obsession occurs, the client can be instructed to do the compulsion in a normative way (e.g. 30 s hand wash, ask for assurance once) terminating before they get the ‘right’ feeling and then sit with the uncertainty. This builds tolerance for the feeling of uncertainty and developing the ability to recognize and exercise appropriate diligence. Behavioural experiments and behavioural activation can be directed at building social networks, positive experiences, experiences that give a sense of purpose, and to opting for direct ways of advancing important goals rather than opting for the compulsion. At the same time, cognitive restructuring could target moral thinking and ‘stuck points’ such as over-generalization of beliefs arising from the MI. These strategies would address all MI domains.

Cognitive behaviour therapy can be complemented by compassion-focused interventions for addressing the ‘inner critic’ which involves recognition of the protective intentions of harsh internal voices while also developing insight into their excessive, maladaptive impact on psychological functioning (Gilbert, Reference Gilbert and Baldwin2005, Reference Gilbert2009; Neff and Germer, Reference Neff and Germer2013). This is accomplished by collaboratively adopting a stance of curiosity towards the OCD voice, and acknowledging its aim to prevent harm and maintain moral standing, while gradually undermining its status as a moral authority. Cultivating self-compassion can help individuals view their suffering through a lens of humanity rather than moral failure (Gilbert, Reference Gilbert2009; Gilbert and Procter, Reference Gilbert and Procter2006). Imagined dialogue with a compassionate yet firm moral authority is a key component of adaptive disclosure therapy (AD; Litz et al., Reference Litz, Lebowitz, Gray and Nash2017), a manualized, time-limited psychotherapy developed for military service members and veterans who experienced combat-related moral injury and traumatic loss; this specific intervention may have some utility in moral injury-informed OCD treatment. Finally, Pugh’s (Reference Pugh2019) chairwork, in which the person role plays themselves and the voice, could be an important complement to standard CBT. These strategies target the moral thinking and perceptions of self and other domains of MI.