Moral Injury in Focus: Why the DSM-5 Falls Short and How Therapists Can Bridge the Gap

Moral injury, characterized by profound psychological distress resulting from actions that violate one's ethical or moral beliefs, remains notably absent from the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition). This exclusion has sparked considerable debate among mental health professionals. Despite this omission, effective therapeutic approaches can significantly aid those suffering from moral injury. This article delves into the reasons behind the DSM-5's exclusion of moral injury, explores the criticisms it has garnered, and sheds light on effective treatment interventions for moral injury.

Reasons for Exclusion

1. Complexity and Scope:

• Moral injury covers a wide array of experiences related to ethical and moral breaches, making it difficult to fit within the rigid diagnostic criteria of the DSM-5.

• It includes psychological, social, and spiritual elements that are challenging to define strictly as a psychological disorder.

2. Overlap with Existing Diagnoses:

• Many symptoms of moral injury overlap with those found in PTSD, depression, and anxiety, making it hard to differentiate and possibly leading to redundant diagnoses.

• The DSM-5 already includes criteria for PTSD that cover some aspects of moral injury, such as exposure to traumatic events and resulting emotional distress.

3. Lack of Consensus:

• There is no universally accepted definition of moral injury. Researchers and practitioners often have different interpretations and descriptions, complicating its inclusion in a standardized diagnostic manual.

• This variability makes it difficult to establish specific diagnostic criteria that could be applied universally.

Criticisms of Exclusion

1. Inadequate Addressing of Moral and Ethical Dimensions:

• Critics argue that the DSM-5’s focus on psychological symptoms fails to adequately capture the moral and ethical dimensions central to moral injury.

• Excluding moral injury may lead to a lack of recognition and appropriate treatment for individuals suffering from this specific type of distress.

2. Limitations of the Medical Model:

• The DSM-5 is based on a medical model that prioritizes symptom-based diagnoses. However, moral injury involves deeper issues related to values, ethics, and personal integrity.

• This limitation can hinder the development of holistic treatment approaches that incorporate moral and spiritual healing.

3. Impact on Veterans and Service Members:

• Much of the research on moral injury comes from studies of military personnel and veterans who experience profound moral and ethical dilemmas in combat.

• Excluding moral injury from the DSM-5 may result in inadequate recognition and support for veterans and service members dealing with these specific challenges.

Addressing Moral Injury in Therapy

Psychotherapists supporting clients experiencing moral injury can leverage a combination of established therapies to provide comprehensive care tailored to the unique needs of those dealing with moral injury. Cognitive Behavioral Therapy (CBT) helps reframe negative thoughts, reducing guilt and shame, while Acceptance and Commitment Therapy (ACT) encourages clients to accept their experiences and commit to values-based actions, promoting psychological flexibility. Integrating compassion-focused techniques, such as self-compassion exercises and Compassion-Focused Therapy (CFT), addresses deep-seated guilt and self-blame, fostering a compassionate self-view. Providing a safe and supportive environment through validation, empathy, and building trust helps clients feel heard and reduces feelings of isolation. Additionally, Eye Movement Desensitization and Reprocessing (EMDR) is valuable for reprocessing traumatic events and memories that contribute to moral injury. By integrating a range of therapeutic interventions, therapists can offer a holistic approach to healing, addressing the multifaceted nature of moral injury with empathy and expertise.

Although moral injury is not formally recognized in the DSM-5, the skills and interventions used in treating anxiety, depression, adjustment disorders, and trauma are highly relevant and effective in addressing the unique challenges of moral injury. A comprehensive approach ensures that clients receive the support they need to heal and reclaim their sense of self and moral integrity.

Conclusion

The exclusion of moral injury from the DSM-5 highlights the complexities and limitations of current diagnostic frameworks in capturing the full spectrum of human psychological experiences. While the DSM-5 provides crucial guidance for diagnosing and treating mental disorders, the absence of moral injury underscores the need for a more holistic approach that addresses the moral and ethical dimensions of psychological trauma.

Addressing moral injury in therapy involves leveraging a combination of established therapies, compassion-focused techniques, a supportive environment, and trauma-informed approaches. Psychotherapists utilize treatment modalities that not only support clients in reframing negative thoughts and reducing guilt and shame but also foster a compassionate self-view and create a sense of safety for processing traumatic memories.

By understanding the reasons behind the exclusion of moral injury from the DSM-5 and recognizing the criticisms it has garnered, we can better appreciate the need for continued research and dialogue in the mental health field. Ensuring that all dimensions of psychological distress are recognized and treated effectively is essential for providing comprehensive care and helping clients heal and reclaim their sense of self and moral integrity.

References

Litz, B. T., & Kerig, P. K. (2019). Moral Injury in Veterans and Active Duty Military with PTSD. PTSD Research Quarterly, 30(1).

Jinkerson, J. D. (2016). Defining and Assessing Moral Injury: A Syndrome Perspective. Traumatology, 22(2), 122-130.

Farnsworth, J. K., Drescher, K. D., Evans, W., & Walser, R. D. (2017). A Functional Approach to Understanding and Treating Military-Related Moral Injury. Journal of Contextual Behavioral Science, 6(4), 374-379.

Frankfurt, S., & Frazier, P. (2016). A Review of Research on Moral Injury in Combat Veterans. Military Psychology, 28(5), 318-330.