Trauma · Core

Moral Injury Worksheet

Guilt, shame and betrayal rather than fear

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Moral injury is what remains after an act — committed, witnessed, or failed to prevent — that violated what the person believed to be right. The dominant feelings are guilt, shame and betrayal rather than fear, which is why fear-based protocols often leave it untouched.

Perpetration

Something the person did, or was ordered to do, that violated their own code.

Witnessing or failing to prevent

Being present to harm without the power, information or time to stop it.

Betrayal

A leader, institution or system that violated what it claimed to stand for.

Not a diagnosis

Moral injury is a clinical construct, not a DSM disorder. It can occur with or without PTSD.

The event

What happened, in plain words (roles and setting — no names, units or dates)

Which type it was: something I did, something I saw, something I could not stop, or something done to me by an institution

The value or belief it broke, stated as a sentence

What I concluded about myself

The verdict I reached about who I am

How much I hold myself responsible (0-10)

none

most

How much shame is in it, as opposed to guilt (0-10)

none

most

What the situation actually contained

What I knew at the time, versus what I know now

What choices genuinely existed, including the ones with worse outcomes

Who else held power in that moment — people, orders, systems, conditions

A more complete sentence about responsibility, with proportions named

Do not aim for exoneration

Moral injury work that argues the client did nothing wrong usually fails; they were there. The target is accurate apportioning, then repair — what can be carried differently and what can be put toward living.

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About this worksheet

Moral injury is the lasting psychological, social and spiritual harm that follows an act which violated a person's own moral code — something they did, something they were ordered to do, something they witnessed and could not prevent, or something an institution they trusted did in their name. Jonathan Shay named it in work with Vietnam veterans; Brett Litz and colleagues gave it the definition most clinicians use now. The signature emotions are guilt, shame, contempt and betrayal rather than fear, and the damage is to identity, meaning and the ability to be known rather than to a sense of physical safety. It is not a DSM-5-TR diagnosis, and it can occur with or without PTSD. This worksheet works one event end to end. It first sorts which route into moral injury applies, then asks what happened in plain words, the value or belief it broke stated as a sentence, and the verdict the person reached about who they are. From there it opens the situation back up: what was known at the time versus now, what choices genuinely existed including the ones with worse outcomes, and who else held power — people, orders, systems, exhaustion, conditions. The output is a sentence about responsibility with proportions named, not an acquittal. Prompts are role-and-setting only: no names, units or dates of service.

Moral injury terms

01
Potentially morally injurious event (PMIE)
An act of commission, omission or betrayal that transgresses deeply held moral beliefs.
Example — Being ordered to withhold care that was clinically indicated.
02
Moral distress
Knowing the right action and being structurally prevented from taking it.
Example — A nurse who cannot give the time a dying patient needs because of staffing.
03
Moral residue
What accumulates when moral distress repeats without resolution.
Example — The flatness that arrives after months of shifts spent apologising for the system.
04
Institutional betrayal
Harm caused by an organisation failing to protect those depending on it.
Example — A report of assault met with transfer of the person who reported it.

When to use it

Military, veteran, first-responder, healthcare and faith-context presentations where guilt, shame or betrayal dominate.
Trauma work that has stalled under an exposure or reprocessing protocol aimed at what is actually a moral wound.
After the Moral Injury vs PTSD page has established which thread to work first.
Alongside the self-forgiveness sequence and the amends plan, which turn the formulation into action.
Pace in session rather than as unsupported homework — this page reliably activates shame.
Avoid while a client is acutely suicidal; stabilise and assess risk before opening a moral wound.

How to use it

1
Identify the route
Something done, something witnessed or not prevented, or institutional betrayal. Many clients carry more than one; work the one that intrudes most.
2
State the event plainly
Roles and setting only. Softened language keeps the injury out of reach; identifying detail is never needed for the work.
3
Name the value it broke
One sentence. 'You do not leave people behind.' 'I protect children.' The value is what makes the event injurious rather than merely distressing.
4
Write the verdict
The conclusion reached about the self, in its own wording, then rate responsibility and how much of the distress is shame rather than guilt.
5
Reopen the situation
What was known then, what choices actually existed, who else held power. Do not argue — ask, and let the client do the apportioning.
6
Write the fuller sentence
Responsibility with proportions named. Then move to amends or self-forgiveness; insight alone does not shift moral guilt.

Frequently asked questions

What is moral injury?+

Moral injury is the lasting harm that follows perpetrating, failing to prevent, witnessing or being betrayed over an act that violates deeply held moral beliefs. The dominant emotions are guilt, shame and betrayal rather than fear, and the injury is to identity and meaning rather than to physical safety.

Is moral injury in the DSM?+

No. Moral injury is a clinical construct, not a DSM-5-TR diagnosis. It can occur with or without PTSD, and it is often the reason a fear-based protocol has produced limited change.

What are examples of moral injury?+

A veteran who followed an order that harmed civilians; a medic who had to choose which patient to treat; a nurse who watched a policy override what a patient needed; a police officer who witnessed a colleague's conduct and stayed silent; a service member betrayed by the command that was supposed to protect them.

What is the difference between moral injury and PTSD?+

PTSD centres on fear, threat to life and avoidance of reminders. Moral injury centres on guilt and shame, threat to integrity, and avoidance of disclosure and forgiveness. Both are common in the same client, so sequence the work rather than choosing between them.

How do you treat moral injury?+

Not by exoneration — the client was there. The workable sequence is disclosure to someone who does not flinch, accurate apportioning of responsibility including conditions and other people's power, then action: direct repair where it is safe, indirect amends where it is not, and finally permission to live without paying daily.

Can I send this worksheet to a client?+

It is PII-free by design and can be sent as a secure client link, but it activates shame reliably. Most clinicians work it in session first and use the amends plan or the vs-PTSD comparison for between-session work.