A few days ago, I came across a video by Dr. K, a successful YouTuber-psychiatrist who has built his following by making his clinical knowledge on mental health digestible to the general public. In it, he spoke about something he called “deep hurt”—a pain that his clinical training couldn’t quite name or explain.

Every time I see someone who has had success in the system come out of the closet to admit the limitations of the system, I feel seen and hopeful. The moment I started studying psychology 16 years ago in search of an answer to my misery, I knew something was terribly wrong. Without any reflection or examination on the nature of human existence, psychology’s technical jargon, pathological labels, and pseudo-scientific methods failed me spectacularly. I couldn’t point my finger or articulate what was wrong until I studied philosophy.

The Hidden Epidemic: Suffering is Moral in Nature

What I experienced that psychology failed to account for now has a name: moral injury.

Leading researcher on this front B. T. Litz defines “moral injury” as the result of transgression of deeply held values or moral beliefs. Broadly speaking, it is the violation of fundamental assumptions about the world, humanity and oneself that organize perception, give meaning and guide actions. Scholars have called this set of assumptions different names: “schema” by Piaget, Beck, and Janoff-Bulman, “personal constructs” by Kelly, “structures of meaning” by Marris, “theory of reality” by Epstein, “internal working models” by Bowlby, “orienting system” or “meaning-making system” by Pargament etc. I believe it might well be called “world/self-view” for simplicity. Or, for the highest relevance, it shall be called “personal philosophy.“

According to Janoff-Bulman, traumatic events can dramatically challenge people’s basic assumptions, leading to enduring psychological distress that’s resistant to natural resolution over time. People become exposed to extreme vulnerability when the unquestioned basic assumptions about the (1) benevolence of the world, (2) meaningfulness of life and (3) worthiness of the self got shattered by events like the death of a family member, rape, killing and accident resulting in serious disability.

When researchers noticed issues that are longer-lasting, deeper and more global than accounted for by PTSD, they came up with the idea of moral injury, characterizing it as meaning-based and distinguishing it from PTSD which is fear-based (more or less a biological response to life threat, centered on hyperarousal and intrusive memories). But I want to push this further: everything is meaning-based. As opposed to animals, which are primarily driven by instincts, human beings are damned with the inherent power of interpretation and understanding, of seeing meaning out of a factual situation. As the existentialist philosopher Heidegger implies, animals have an environment but human have a world. I’d like to add to it: animals behave, but humans act. Even when faced with a biological fearable object such as snake or fire, as human beings we can choose to overcome our biological wiring and see it differently.

PTSD may have a more salient physiological component, but it necessarily involves meaning, even if it is caused by impersonal chance events such as natural disasters or accidents. PTSD patients may find themselves questioning, “I’ve been conducting myself properly, why did such misfortune happen to me? Is the universe completely indifferent?” These aren’t just cognitive thoughts, as some psychologists like to think, but moral beliefs about the fundamental justice of the world and the meaning of one’s life itself.

In other words, moral injury and PTSD aren’t two separate conditions at the same level; they’re two perceptions based on different levels of looking at human beings. One views humans primarily as biological bodies. The other views humans primarily as moral agents.

Moral Injury Beyond The War Zone

Moral injury is most widely studied in war veterans. The research, still young, identifies two pathways: betrayal-based moral injury (transgression by others: e.g. you call for the promised support from the base when your team is ambushed in a highly hostile territory but are ignored, resulting in heavy casualties) and perpetration-based moral injury (participation or failure to prevent the transgressive act: e.g. you watch your comrades be killed by the enemy and you do not anything to save them in order to save your own life). The defining emotions differ: betrayal leads to anger, disgust, contempt, and profound loneliness, whereas perpetration leads to guilt, shame, and self-condemnation.

It is easy to see that moral values are severely challenged in war zones, leading to moral injury. However, I argue that moral injury pervades civilians’ everyday lives and underlies most mental struggles and illnesses. When your parents reject you, your partner abuses you, your teacher belittles you, your friend gaslights you, the person whom you’re supposed to be able to trust has betrayed you. It doesn’t have to involve the extremity of war, but your deeply held moral beliefs in humanity are nonetheless broken. Moreover, you can also betray yourself by staying in a job that you don’t believe in for the money, or by staying in a relationship with someone you don’t truly admire for security. It sounds all too ordinary and common, but it is a kind of moral injury that, if unnoticed and unaddressed, will slowly eat you alive from the inside, leading to self-contempt and depression. Self-induced moral injury is just as devastating as other-induced moral injury.

Toward a Moral Framework

To recap, research has started to pay attention to moral injury only in war veterans, where the moral nature of the issue is starkly prominent. Yet, I argue that moral injury underlies most mental illnesses. What we call “mental illness” is but the calcification of unaddressed moral injury. To reframe in a more emotionally neutral language, “mental illnesses” result from the precipitation of chronic existential disorientation and moral dissonance as one’s world/self-view or personal philosophy is fractured, either gradually or abruptly, by oneself, by others or even by impersonal events. Consistent with scholars’ definition of moral injury, disorientation results when one’s inherent assumptions about how life should be is necessarily challenged by how life actually is. When one fails to make sense of life for a prolonged period of time, one deteriorates into a state of emotional and behavioral deregulation and further into dysfunction.

Since moral injury is the most fundamental and therefore deepest and subtlest layer of our struggle, it often goes unnoticed unless it is devastatingly massive or until it’s too late. By the time someone meets criteria for Major Depression or PTSD, they’ve often been in moral crisis, unrecognized and unaddressed, for months or years. I attest to that as someone in this exact position.

In this light, mental illness shall be reframed as moral crisis, as the collapse in meaning, that requires the moral effort of compassion and patience on the therapist’s part instead of technical skills and book knowledge. Healing, by the same token, is a matter of moral achievement on the client’s part. It demands the courageous reinvention of the self and the world. This task necessarily involves the incorporation of traumatic events from the past into a more robust and comprehensive personal philosophy. What used to be unacceptable needs to be transformed through philosophical reflection to fuel the enrichment of the meaning of life.

A metaphor

Let me offer a metaphor for how philosophy, psychology, and philosophical counseling each contribute to healing:

Your moral framework, personal philosophy or world/self-view is your compass. It’s about finding direction in life.

Philosophy is cartography. It’s the study of the conceptual sea and stars and how they can be orchestrated to create a sense of direction.

Psychology is about navigation. Psychotherapy may involve repairing the ship and improving navigation tools. CBT adjusts your sails, trauma therapy patches holes and fixes leaks, and medication stabilizes the listing hull. All is necessary if you’re facing immediate danger.

Philosophical counseling is about repairing your moral compass or reconstructing your map and finding the right direction. Without that, any amount of navigation or ship improvement is ultimately futile. You can sail very skillfully, but toward a destination that doesn’t actually matter to you, or worse, away from what you truly value.

Of course, if your ship is actively sinking, the most urgent thing is to repair the hull. Triage matters. But here’s what I’ve observed: Most people would keep sailing if their ship feels okay, without ever questioning the direction they’re going. They’re functional, meeting social expectations and life’s demands. By psychology’s standards, they’re perfectly “normal,” but something deeper feels off and they may recognize that only very late in life as mid-life crisis, or even only at the moment of death.

On the other hand, some people may be equally “functional” but suffering from a sense that something is wrong, like life is heading the wrong way or the presumed destination is not worth pursuing. There is no diagnosable disorder in this case either according to psychology, but I argue that it is feeling “off” chronically that makes one slowly give up or lose the ability to keep up with the general maintenance of the ship and basic navigation.

The modern society has given us a broken compass that keeps pointing us toward waters so loaded with storms, and fragmentary maps that confuse rather than guide us. We’re told to sail toward endless productivity, consumption, accumulation and competition. The compass says “this way to fulfillment,” but instead we arrive at exhaustion, alienation, and desperation. In a sense, we all suffer from the moral injury of feeling betrayed by the society.

Existing Scholarly Effort

With its focus on human cognition, emotion and behavior as its scientific object, psychology falls short in accounting for the moral aspect of human struggle. Without the philosophical reflection on the deeper nature of human struggle, psychology has been mistaking labeling for explanation and naming for true insights. Theoretically impotent terms and isolated modalities proliferated exponentially, but psychotherapy has not become more effective, and mental health problems have remained on the rise. As D.W. Sue puts it:

“We have become preoccupied with technique and disorganised without relating our ideas and practices to a larger conceptual framework… we must make clear and explicit the generic characteristics of counselling and the particular value assumptions inherent in the different schools of thought.”

Farah Ibrahim adds:

“The lack of a philosophy to understand human beings seems to be one of the most pervasive deficits in the models [of counselling] in the United States… Counselling and psychotherapy are not simple technical activities. The assumptions in counselling and psychotherapy are rooted in philosophical views of human nature and people’s place in the universe.“

Among the dazzling array of ever-fluctuating variables of mental phenomena, we are in need of something about human beings that is slower changing, more global and more fundamental, and therefore has higher predictive power… something that touches the philosophical and bridges it to the psychological. The below are three theoretical candidates to start with:

Although differing in theoretical angle, Kluckhohn the anthropologist and Yalom the existential psychotherapist both contend that there are some ultimate questions about life that all humans across all cultures must try to answer at all times. For Kluckhohn, these ultimate questions include:

1. Nature of human beings: are they good or evil, it is mutable or immutable?
2. Relationship to nature: should we live in harmony with, mastery of or submission to nature?
3. Relationship to others: is everyone equal or does someone worthier than others? Are we a network of roles or individuals?
4. Relationship to time: should we prioritize the past, the present or the future?

For Yalom, everyone shares the ultimate concerns of

1. Freedom: we inherently carry the burden of self-creation and therefore self-responsibility.
2. Meaninglessness: the seeming lack of objective or preordained meaning in the universe, the Abyss or the Void that looks back at you when you stare at it long enough.
3. Aloneness: the unbridgeable gap between oneself and others; the fact that we are born alone and die alone, and no one else can life our lives for us, regardless of interpersonal connections.
4. Death: we will inevitably die one day and no longer exist. (more on this next blog)

Recapturing an earlier paragraph, Janoff-Bulmans adds that everyone holds the core assumptions that:

1. The world is benevolent
2. Life is meaningful
3. I am worthy

Adding to My Approach

These works are not yet consciously applied in mainstream psychotherapy, but they align perfectly with philosophical counseling. By synthesizing these frameworks, I am excited to offer a better-informed approach to assessment and structured analysis of your personal philosophy. When you work with me, you can expect to be questioned about your take on some of life’s biggest questions:

• Are people generally trustworthy?
• Do you believe that people deserve what they get?
• Do you think you have anything to do with the things that happened to you?
• What’s the most shocking reality you’ve learnt in your life?
• What truths about the world, society and humanity do you find hard to accept?
• When major negative events occur, do you tend to see them as primarily a result of personal choices, systemic forces, or random luck?
• Where do you think the worth of a person comes from?
• Do you believe the universe is just?

This list is inexhaustible, and rather than being abstract and divorced from daily life, these questions precisely underlie the most persistent layer of your suffering. Negligence to these questions is the reason why some symptoms remain resistant to clinical treatment.

Philosophical counseling helps examine whether your current compass is broken and whether your map has missing gaps. Following that, it offers to help you recalibrate the coordinations and reorient yourself via dialogue and guided self-inquiry, not treatment via technical intervention. The goal is for you to develop a personal philosophy robust enough to weather hardships, flexible enough to grow with experience, coherent enough to guide authentic choices, and ultimately yours—not borrowed from family, culture, or society’s fragmented messages.

Important: If you’re experiencing severe mental illness, i.e. if your ship is sinking, please seek clinical support first. Otherwise, those who’ve stabilized through therapy but still feel incomplete and those who are actively suffering from moral struggle can benefit from philosophical counselling.

If this resonates, let’s examine your compass together.

About the Author

I am someone who, for a period of time, met the DSM criteria of Major Depression and PTSD. However, I never went to see a therapist because I was very clear that what I suffered was primarily moral and spiritual struggle. Everyday I was tormented by the questions of “how should I live my life?” “is there an ultimate judge on what is right or wrong?” “am I selfish if I follow my heart?”

I’ve gone through an incredible journey of healing with the aid of plant medicine, philosophical study and Vipassana meditation. No philosophical counselling was sorted because it didn’t exist in my world, but I wish it did, so now I offer it to you.

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One final note: I didn’t say moral injury is THE root cause of mental illness in the title because I learnt from my meditation practice that there is more to it. Perhaps I’ll get to it in a future blog!