Moral Injury: Now (Technically) in the DSM + Reader Survey
Happy new year, curers of addiction! Are we all feeling fully refreshed and restored? 😉
Scroll down for our regular weekly topic post. First, a quick reflection and invitation for your input.
I started this newsletter in August 2025. I had already been writing and teaching on these topics for years, but I wanted to reach beyond my fellow mental health workers because so many others are involved in substance use services and policy, and just about everyone is affected by addiction. People who are paying attention know that none of us has it figured out. We are hungry for creative thinking that integrates knowledge and skills from various approaches to substance use, rather than always reverting to one philosophy or one idea of success. We are all over the place– geographically, occupationally, and in lived experience– but this newsletter can help us find each other.
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Moral Injury: Now (Technically) in the DSM
As last year's readers know, my moral injury as a substance use counselor led me where I am today: practicing solo according to my own clinical ethics rather than agency rules, and engaging in various forms of activism in attempt to remake this field. If you missed it, my original post on moral injury will be helpful background for this one.
Rosalie Genova
My first move toward what would become a long and multi-pronged writing project was teaching a continuing education course on moral injury in 2023. (A 90-minute asynchronous version is here.) As I told attendees, it was not in the DSM and was explicitly not psychopathological. We call it an "injury" rather than a "disorder" because it does not identify anything wrong within the individual. Rather, with moral injury an external situation– in which the person participated in, enabled, or witnessed actions that violated their morality– causes the problem.
I asked attendees whether they thought moral injury should be included in the DSM, and opinions were about evenly split. But I based our discussion on PTSD (post-traumatic stress disorder) as an existing corollary, since it too was first clinically labeled in veterans of military combat. It turns out that analogy didn't make sense.
PTSD is an "Axis I" or "primary" diagnosable disorder. That means one can be diagnosed with or treated for PTSD even without any other documented clinical problems. Insurance with mental health coverage has to pay for it it. Disability determinations have to take it into account. PTSD gaining this status in 1980 now looks like a tradeoff for military veterans and other trauma survivors: it granted their distress new legitimacy, but it also pathologized their reactions to objectively terrible experiences (among other problems).
When I asked if my class thought moral injury should be in the DSM, I really meant, should it be a diagnosable disorder? The debate basically took the shape of the PTSD dilemma, with some seeing it as wrong to pathologize and others feeling it would be worth doing so to facilitate access to treatment. This tradeoff– getting a title and some validation for your difficult inner state in exchange for accepting a pathologized label– actually comes with any mental health diagnosis. But I was comparing moral injury specifically to PTSD because both require specific external events to have brought on the distress. This is not the case for most mental health diagnoses such as anxiety or mood disorders.
What I didn't foresee– though I probably should have– was that DSM labeling can happen without any relevance at all for the patient! Moral injury being included actually just means that code Z65.8 has been expanded from "Religious or Spiritual Problem" to "Moral, Religious or Spiritual Problem." "Z-codes," such as this one, are for "other conditions that may be a focus of clinical attention." (Other examples include "Occupational Problem" or "Partner Relational Problem.") These are not real diagnoses, are not required to be covered by insurance and are not eligible for disability consideration. They used to be called V-codes, which I was taught stood for Very unlikely to be covered. One time I included one of these codes as secondary on an insurance claim and the whole service got rejected even though the primary diagnosis was billable. I've never used one since.
So there you have it: moral injury is now in the DSM...as a Z-code, for which treatment is no more accessible than before. The psychopathology tradeoff (as in PTSD) has not yet been made. But the researchers involved have conceptualized a "moral injury disorder" in which someone's moral injury has impaired their long-term functioning– putting us right back in the model of individual pathology.
One impact I can imagine with the existing Z-code: tagging military members who express objection to their assignments. What are V- or Z-codes really for, since they can't be used for billing? They are a way to aggregate records, and for providers and institutions to communicate with each other about patients without releasing progress notes. As you may have noticed, how American service members should proceed under orders that are illegal, unjust or inhumane is a hot topic right now. Some of them, trying to access the mental health care to which they are entitled, might be talking to their military-affiliated clinicians about it. Some might be "referred" by commanders who want them to fix their "attitude." In this scary time, when people are being ostracized and punished for showing any sign of independent thought, even a code for moral injury that avoids pathology could be used to target rather than help.
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