When the Soul Says No
Moral distress, the DSM-5, and what one young Iranian woman can teach us.
Posted May 4, 2026 | Reviewed by Margaret Foley
A young Iranian woman came into my office carrying what she called a heaviness she could not explain. Anahita — I will call her that — was 35, the daughter of Iranian parents who had left Tehran before she was born. She had trouble sleeping . She said she felt as though something had been torn inside her. Not grief exactly, though grief was there. Not fear , though fear was present too. Something else. A feeling that the world had broken a promise she had not even known she had trusted.
As a clinician, I recognized what she was describing. I have heard it many times in my 35 years as a psychotherapist.
In December 2024, the American Psychiatric Association took a historic step: It formally approved the addition of moral distress and moral injury to the DSM-5 -TR—not as diagnoses, but as conditions that may be a focus of clinical attention . Moral distress and moral injury apply to experiences that disrupt our sense of the goodness of ourselves, others, or our institutions. To provide a more unified approach to understanding and assessing this type of distress, researchers at Harvard's Human Flourishing Program have formulated what they call the moral trauma spectrum.
At one end is moral distress: the suffering that arises when our sense of right and wrong — or our trust in the goodness of the world — is deeply violated. When that distress becomes persistent and severe, it deepens into moral injury. This formulation acknowledges that some wounds are not primarily about fear but about a rupture in one's relationship with goodness and in our basic trust in life.
Moral injury can be distinguished from PTSD , though the two often coexist. Moral injury can include feelings of shame and guilt , a loss of faith in institutions, and spiritual struggle, and it often leads to social withdrawal. There may be a sense that something irreparable has occurred. I might describe it as a wound to our sense of meaning and connection.
The Lump in the Throat
Anahita had grown up steeped in Iranian poetry, music, and the stories her parents told about a country of ancient beauty that had been silenced by decades of oppressive rule. She had watched, from a distance, the Green Movement of 2009 rise and be crushed. She had watched the Woman, Life, Freedom uprising of 2022, ignited by the death of Mahsa Amini, be met with brutality again. Each time there was a glimmer of hope, a wave of aliveness, and brutal violence that silenced the protest.
There is a Persian word for what she was carrying: boghz . It means the lump in the throat that comes just before the tears — what the body knows before the mind can form words. It is the grief of living far from the family's home country, watching its people risk everything, and enduring the helplessness that distance creates.
When the Lion and Sun Revolution of 2026 erupted — the largest uprising in Iran's modern history, with over a million people in the streets — followed by a massacre and the chaos of foreign military intervention in the region, that helplessness became unbearable. Anahita’s sleep and appetite deteriorated. She withdrew from friends. She told me quietly that she no longer trusted the world.
This is not a pathology. It is a coherent response to morally injurious events. Her nervous system reflected the stress she experienced.
The Physiology of a Violated World
Research on politically induced moral distress shows that this suffering is both physiological and philosophical. Living under — or witnessing from afar — sustained violations of human dignity produces chronic activation of the stress response. This leads to disrupted sleep, depression , hypervigilance, and erosion of what researchers call moral trust. For diaspora communities, this is often compounded by intergenerational trauma. These are wounds genetically carried in the body across generations. They become reactivated each time the cycle of violence repeats.
There is also what researchers call the “anguish of constrained action,” in which people know what is right yet feel powerless to act on that knowledge. For Anahita, as for many who watch from afar, this helplessness is a heavy burden.
What Heals a Moral Wound
Understanding our suffering clinically matters. It reduces shame and gives voice to what is hard to express. But understanding alone does not heal.
Resilience research consistently shows that what sustains people through collective moral trauma is the experience of being witnessed and knowing that others see their pain. For Anahita, something began to shift when she stopped trying to suppress her grief and instead allowed it to be held, first in our therapeutic relationship , then in a small diaspora community she found. What also helped her was a meditation practice, in which she experienced a deep sense of warmth.
John Makransky, a Buddhist scholar and meditation teacher, whose Sustainable Compassion practices I draw on in my clinical work, describes this as the Field of Care: a quality of warmth woven into the very nature of awareness itself. For those whose moral wound includes the shattering of faith in institutions and in the goodness of the world, discovering that something steady exists beneath it all can be genuinely transformative.
This practice does not bypass the grief. Anahita still carries the weight of what the Iranian people, and many others in this world, have endured. But she carries it now within the context of something larger. One day in my office, she found what she called a place she could trust.
VanderWeele et al. (2025). "The Importance of Recognizing Moral Trauma in Clinical Care," Psychology Today.
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical psychology review , 29 (8), 695-706.
Sangalang, C. C., & Vang, C. (2017). Intergenerational trauma in refugee families: A systematic review. Journal of immigrant and minority health , 19 (3), 745-754.
Condon, P., & Makransky, J. (2020). Sustainable compassion training: Integrating meditation theory with psychological science. Frontiers in Psychology , 11 , 2249.
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Radhule Weininger, M.D., Ph.D., is a clinical psychologist in private practice. She is the author of Heart Medicine: How to Stop Painful Patterns and Find Peace and Freedom—at Last.
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This article is part of the Bringwise Psychology Journal — daily insights on human behavior, mental health, and personal growth.