Trauma · Assessment

Moral Injury vs PTSD Worksheet

Sort the two threads before choosing a protocol

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These overlap constantly and are treated differently. Sorting them early prevents months of exposure work aimed at guilt, or self- forgiveness work aimed at fear.

Side by side

Dimension	PTSD	Moral injury
Core emotion	Fear, helplessness, horror	Guilt, shame, contempt, betrayal
Core threat	Life or bodily integrity	Identity, integrity, meaning
Typical avoidance	Reminders, places, sensations	Self-disclosure, being known, being forgiven
Body pattern	Startle, hyperarousal, flashbacks	Sinking, collapse, self-punishment, numbing
What helps	Exposure, reprocessing, state regulation	Disclosure, accurate responsibility, amends, self-forgiveness

Sorting this client

When the memory arrives, what comes first — fear or self-condemnation

What is being avoided: reminders of the event, or being seen by other people

Fear-driven distress (0-10)

none

most

Guilt or shame-driven distress (0-10)

none

most

Which thread to work first, and why

Both is common

Most military, medical and first-responder presentations carry both. Sequence rather than choose: stabilise arousal enough to talk, then work the moral thread, and expect the fear thread to need its own protocol.

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About this worksheet

The most common cause of stalled trauma work in military, healthcare and first-responder populations is a protocol aimed at the wrong emotion. Exposure and reprocessing were built for fear: threat to life, avoidance of reminders, startle and hyperarousal. Moral injury runs on guilt, shame, contempt and betrayal: threat to integrity, avoidance of disclosure and of being forgiven, and a body pattern closer to collapse, numbing and self-punishment than to startle. This page puts the two side by side across five dimensions — core emotion, core threat, typical avoidance, body pattern, and what actually helps — and then makes it specific to the client in front of you. Four short prompts ask what arrives first with the memory, what is being avoided, and separate ratings for fear-driven and guilt-driven distress, ending in an explicit decision about which thread to work first and why. It is a formulation and sequencing tool rather than an intervention, and its most useful function is often to explain to a client why months of work reduced their nightmares without touching the thing that keeps them awake.

When to use it

Formulation in combat, deployment, medical, policing and disaster presentations.
When a trauma protocol has produced partial gains and the residual distress is guilt or betrayal.
When a client cannot say why treatment does not feel like it is reaching the problem.
As a psychoeducation handout — it travels well between sessions and requires no briefing.
Not a diagnostic instrument; there is no score and no threshold.

How to use it

1
Read the comparison together
Most clients recognise themselves in one column within seconds. That recognition is usually the therapeutic moment on this page.
2
Ask what arrives first
Fear, or self-condemnation. The order tells you more than symptom counts do.
3
Ask what is avoided
Reminders of the event, or being seen by other people. Avoidance of being known points to the moral thread.
4
Rate both threads
Two 0-10 scales, kept separate. A client can be an 8 on guilt and a 4 on fear, which changes the treatment plan.
5
Decide and record the sequence
Write which thread is first and why. Expect the second thread to still need its own protocol later.
6
Hand off to the matching pages
Moral thread to the moral injury worksheet and self-forgiveness sequence; fear thread to window-of-tolerance and exposure-based work.

Frequently asked questions

What is the difference between moral injury and PTSD?+

PTSD is organised around fear and threat to life, with avoidance of reminders, startle and hyperarousal. Moral injury is organised around guilt, shame and betrayal, with threat to identity, avoidance of disclosure, and a pattern of collapse and self-punishment. PTSD is a diagnosis; moral injury is a clinical construct.

Can you have moral injury and PTSD at the same time?+

Yes, and in military, healthcare and first-responder populations both are usually present. The clinical task is sequencing: stabilise arousal enough to talk, work the moral thread, and expect the fear thread to need its own protocol.

Does exposure therapy work for moral injury?+

Not on its own. Repeated recounting reduces fear-based avoidance but does not resolve an accurate judgement that a value was broken. Guilt responds to disclosure, accurate apportioning of responsibility and amends.

How do you tell which one to treat first?+

Ask what arrives first with the memory and what is being avoided. If self-condemnation leads and the client avoids being seen rather than being reminded, treat the moral thread as primary.

Is moral injury a diagnosis?+

No. There is no DSM-5-TR category for it. That is precisely why it goes unaddressed — nothing in a standard diagnostic interview asks the question.

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Worksheet — Moral Injury vs PTSD Worksheet — provided by TherapistAssist for clinical use. Not a substitute for assessment or treatment.