Moral Injury in First Responders & Veterans: What It Is—and an ACT Plan to Heal
Quick Answer
Moral injury is guilt/shame from violated values; ACT helps you accept moral pain, realign with values, and take healing action via confidential online therapy in CA & VA.
What it is: violation of one’s moral code → guilt, shame, betrayal (distinct from fear-based PTSD).
Who it affects: first responders and veterans at higher risk; often co-occurs with PTSD/depression/substance use.
How ACT helps: acceptance of moral emotions, defusion of self-judgment, values-guided committed action.
Do this next: request a 15-minute consult to plan a paced, values-anchored path forward.
Imagine a veteran who made a split-second decision in combat that he’s regretted for years, or a firefighter-paramedic haunted by the life they couldn’t save. These men and women carry more than just memories of frightening events – they carry moral burdens. The term “moral injury” describes the inner anguish that first responders and military personnel may feel when “what happened” violates “what should have happened” in their moral view of the world. This type of wound doesn’t show up on an X-ray, but it can cut just as deep. Many who serve in uniform (whether military or emergency services) struggle in silence with profound guilt, shame, or a sense of betrayal. They might ask themselves: “Did I do something unforgivable? Did I fail my own values? Will I ever be the same person after what I’ve seen and done?”
Moral injury has only recently gained wider recognition, yet its impact isn’t new. War historians note that soldiers in every generation have grappled with soul-level pain after combat. First responders – the people who run toward danger – often face similar ethical dilemmas and heartbreak. If you’re reading this as a first responder or veteran (or someone who loves one), know that you are not alone and that what you’re feeling is not a sign of weakness. It’s a human response to extreme situations. In the sections below, we’ll break down what moral injury really means, how it shows up in daily life, and how ACT therapy can guide those in California and Virginia toward healing and self-forgiveness.
What Is Moral Injury? How It Differs from PTSD
Moral injury refers to the psychological, spiritual, and social harm that arises from actions or experiences which deeply violate your moral beliefs. In plain terms, it’s the damage done to your conscience or “moral compass” when you feel you’ve transgressed your own ethical values – or been betrayed by others who did. The concept was initially studied in military contexts, but we now know it affects first responders, healthcare workers, and others exposed to morally fraught situations.
Classic definition: Psychologists describe moral injury as “perpetrating, witnessing, or failing to prevent acts that transgress deeply held moral beliefs and values” (Litz et al., 2009). In other words, it’s not the traumatic event’s fear factor that injures – it’s the moral dimensions (e.g. “someone did something terribly wrong and I can’t reconcile it”).
Moral injury vs. PTSD: Moral injury is not identical to PTSD, though they can occur together. PTSD (Post-Traumatic Stress Disorder) is typically rooted in life-threatening danger and fear, triggering symptoms like flashbacks, hypervigilance, and startle responses. Moral injury, on the other hand, is rooted in violations of right and wrong, triggering profound shame, guilt, or existential crisis. Someone with PTSD might say, “I can’t stop reliving the terrifying moment;” someone with moral injury might say, “I can’t stop condemning myself for what happened.” There is overlap – for example, both can involve nightmares or social withdrawal – but one can have moral injury without full PTSD (and vice versa). In fact, research shows moral injury often co-occurs with PTSD and worsens its severity, linking to higher depression, substance use, and suicidal thoughts. It’s as if moral injury adds an extra layer of pain on top of trauma: beyond fear, there is guilt; beyond hurt, there is a crisis of conscience.
Core features: The hallmark symptoms of moral injury include intense guilt (“I did something unforgivable”), shame (“I am a bad person”), loss of trust or faith, and difficulty forgiving oneself or others. People with moral injury often report feeling worthless, isolated, or estranged – as if they’re no longer the person they were, or that they’ve lost their former sense of goodness. Some experience spiritual or existential conflict, questioning their faith or life’s meaning in light of what happened (“How could God let this occur? How can I live with myself?”). Importantly, moral injury is not a formal psychiatric diagnosis; it’s a context or syndrome that can underpin problems like depression or PTSD. Recognizing it is important, though, because treatment might need to explicitly address those moral emotions (like guilt and shame) and damaged beliefs (about oneself as “evil” or the world as unjust) in order for full healing to occur.
In sum: If PTSD is a wound to one’s sense of safety, moral injury is a wound to one’s sense of morality. Both need care and healing. Now, let’s look at how this plays out specifically for the people most often affected – first responders and veterans – and why they’re particularly vulnerable to moral injuries in the line of duty.
Why First Responders and Veterans Are Vulnerable to Moral Injury
It’s no coincidence that we talk about moral injury in first responders and veterans in the same breath. These professions involve situations where split-second decisions, life-and-death stakes, and exposure to human suffering are part of the job description. Over time, this can exact a heavy toll on the psyche. Here’s how moral injury tends to arise in these groups:
Moral Injury Among First Responders
First responders (such as paramedics, EMTs, firefighters, police officers, 911 dispatchers, and frontline medical staff) operate in high-pressure environments where not every outcome is in their control, yet they feel profound responsibility for those outcomes. Research indicates first responders are at elevated risk of moral injury precisely because of the chronic exposure to trauma and ethical dilemmas on the job (Joannou et al., 2017; Lentz et al., 2021). In fact, moral injury is now recognized as a serious issue in law enforcement, firefighting, EMS, and similar fields.
Common scenarios that could lead to moral injury for first responders include:
Life-and-death triage: Having to choose who to save in a mass casualty situation (and who must be left because resources are limited). For example, a firefighter might only be able to pull one person from a burning car when two are trapped – a choice that haunts them later. These impossible decisions can violate a first responder’s fundamental value of “saving everyone” and lead to lasting guilt if any life is lost. As one firefighter described, “I’m supposed to save people. Failing to save them, even if it wasn’t truly my fault, tears me up inside.”
Use of force or violent encounters: Police officers and deputies may face situations where using deadly force is legally justified but morally distressing. Even if they did “everything by the book,” taking a life (or witnessing colleagues do so) can profoundly jar one’s moral compass. Some officers report replaying scenes in their head – “Could I have disarmed him without shooting? Did I do the right thing?” – and feeling either guilt for the suspect’s death or anger at a system that put them in that position.
Feeling betrayed by the system: First responders sometimes experience what’s called “betrayal trauma” or institutional betrayal. For instance, a medic might feel let down by leadership or policies that prevent giving needed care (e.g., being ordered not to enter an unsafe scene even when someone is dying, or working in a system that under-resources and burns out its staff). Feeling unsupported by one’s agency or seeing ethical breaches by superiors can lead to moral injury as well – a sense that “the people who should have had our back did something immoral.”
Repeated exposure to suffering: Day after day, responders see victims of violence, accidents, and disaster. Over time, witnessing so much suffering – especially in cases like child abuse, fatal fires, or preventable tragedies – can erode one’s sense of meaning or fairness in the world. A paramedic might internalize blame or shame simply from being constantly surrounded by trauma (“Why couldn’t I save that child from the crash? Did I miss something? I feel responsible”). Even when logically they know they did all they could, emotionally they carry the weight of each loss. As one study noted, first responders often align their identities as “helpers” or “protectors,” so any outcome where harm occurs can feel like a personal moral failing (even when it isn’t).
It’s important to note that within first responder populations, support culture plays a role. In some departments, talking about guilt or emotional struggle is stigmatized (“suck it up” culture). This can compound moral injury – the person feels not only the shame of the event, but also shame for feeling shame, leading them to isolate rather than seek help. Initiatives like peer support teams and wellness programs are starting to change this, acknowledging moral injury as a legitimate concern for firefighter and police mental health.
Moral Injury Among Military Veterans
Moral injury was first formally recognized in military contexts, especially among combat veterans. In battle or wartime operations, service members may have to kill or harm others, witness atrocities, or make split-second choices that conflict with moral norms of civilian life. Additionally, the hierarchical nature of the military can sometimes lead to feelings of betrayal (e.g., by leaders or the government) if a mission is perceived as unjust or if comrades are lost due to perceived command failures.
Key military scenarios tied to moral injury include:
Acts of violence that conflict with morals: A classic example is a soldier who kills an enemy combatant (or a civilian by mistake) and later struggles with intense guilt or self-condemnation. Even if the act was in self-defense or under orders, the personal moral code (“thou shalt not kill” or simply valuing human life) may be shattered. One Vietnam veteran famously described moral injury as “a corruption of the soul” after he returned from war, referring to the feeling that participating in violence had changed who he was fundamentally (Shay, 1994).
Failure to prevent a wrong: Perhaps a servicemember witnessed misconduct – such as abuse of civilians or mistreatment of detainees – and felt powerless to stop it. Or they failed to act in a split second and a comrade died. These scenarios can produce a heavy burden of regret and self-blame (“I should have done something”). Research on U.S. veterans found that about 23–25% reported witnessing others commit transgressions and a similar proportion felt betrayed by leaders or peers. Such experiences plant seeds of moral injury that can grow over time if not addressed.
Betrayal by authorities: Many veterans cite feelings of betrayal – for instance, believing that military leadership or the government made immoral decisions that they had to carry out, or that they were sent to a war under false premises. When a soldier’s trust in the institution is broken, it can manifest as anger and moral outrage (a righteous kind of moral injury). This might be directed outward (e.g., anger at the government) but often still scars the individual’s own psyche, leading to cynicism, loss of faith in society, or difficulty adjusting to civilian life.
Survivor’s guilt: A subtle but common moral injury for veterans is surviving when others did not. The thought “Why am I alive while my buddy died? It’s not fair” can evolve into a belief that one is somehow morally undeserving of life or happiness. This can drive self-sabotaging behaviors – subconsciously feeling one must “pay” for others’ deaths by punishing oneself. Survivor’s guilt blurs the line between grief and moral injury, often involving a sense of shame for feeling joy or for not preventing a comrade’s death.
It’s worth noting that moral injury can also affect family members of veterans/first responders in a secondary way. For example, spouses of veterans with PTSD/moral injury sometimes report losing their own faith or trust after witnessing their loved one’s struggles (a form of secondary moral injury in families) (Currier et al., 2015). In any case, the impact radiates beyond the individual.
The scope of the problem: Surveys of U.S. veterans from recent wars show moral injury is widespread. In one all-era veteran study, about 10.8% reported suffering “transgressions by self” (things they felt they personally did wrong), 25% reported “transgressions by others” (witnessed wrongdoing), and 25% reported feelings of betrayal by trusted entities. More than half of post-9/11 veterans in a 2020 study said they were exposed to some kind of morally injurious event during service. These numbers are significant. Translating to raw figures, researchers estimate roughly hundreds of thousands of veterans are living with moral injury symptoms in the U.S. alone.
For first responders, robust statistics are still emerging, but a recent meta-analysis found ~4% meet strict criteria for moral injury (which is already a lot of people given how many first responders there are). More broadly, up to 20–30% of first responders report persistent feelings of shame or guilt related to their work (even if not formally assessed as “moral injury”) (Thomas & Wilson, 2022). During the COVID-19 pandemic, the term “moral distress” was used to describe what many healthcare providers and EMTs felt when resources were scarce – essentially a breeding ground for moral injury (having to decide who gets a ventilator, etc.).
Bottom line: Both first responders and veterans operate in arenas where moral values and real-life duties collide. When outcomes are tragic or actions feel wrong, the result can be a deep inner wound. Recognizing this vulnerability is the first step. The good news is that just as we have specialized trauma treatments for PTSD, we’re developing specialized approaches for moral injury therapy. Next, we’ll explore one of the leading treatments – the ACT approach – and how it can facilitate healing, particularly in a confidential online therapy setting.
ACT Therapy for Moral Injury: A Values-Driven Plan to Heal
Healing from moral injury often means learning how to live with what happened in a way that restores integrity and hope. One therapeutic approach gaining traction for moral injury is Acceptance and Commitment Therapy (ACT). ACT is an evidence-based therapy that doesn’t ask you to forget or undo what happened (which isn’t possible) – instead, it helps you change your relationship to those painful experiences and reconnect with your deepest values going forward (Farnsworth et al., 2017; Nieuwsma et al., 2015). In my practice, I utilize ACT because it offers a concrete, compassionate framework for handling moral pain. Here’s how an ACT plan can help first responders and veterans dealing with moral injury:
Why ACT? An Overview of Acceptance and Commitment Therapy
ACT (pronounced as the word “act,” not A-C-T) is a modern cognitive-behavioral therapy that emphasizes mindfulness, acceptance strategies, and committed action guided by values. Rather than trying to eliminate unpleasant thoughts or feelings, ACT teaches you to accept them as natural and not let them derail your life. The ultimate goal is to increase your “psychological flexibility” – the ability to experience even very painful emotions (like guilt or shame) while still acting in line with your values (Hayes et al., 2012). For moral injury, this is crucial. It means you can carry your moral pain in a healthier way and still live a meaningful life.
ACT is organized around six core therapeutic processes (often illustrated as points on a hexagon model). In an ACT-based moral injury therapy program (sometimes called ACT-MI), these processes are tailored to address the specific struggles of guilt, shame, anger, and loss of meaning that come with moral injury:
Acceptance: In ACT, acceptance means fully opening up to the reality of your emotions instead of constantly fighting them. For moral injury, this might involve allowing feelings of remorse, sorrow, or anger to surface without running from them. Paradoxically, avoiding guilt (“numbing out” with alcohol, or denying what you feel) only keeps you stuck. We use exercises to gently “sit with” guilt or shame – for example, noticing where you feel it in your body, breathing into it, maybe even giving it a shape or color – to reduce its power. Over time, acceptance techniques chip away at the avoidant behaviors (e.g., isolation, substance use) that often maintain moral injury. By accepting moral pain, clients discover it tends to become more manageable.
Cognitive Defusion: Moral injury often comes with harsh, looping thoughts (“I’m a monster,” “I don’t deserve to be happy”). Cognitive defusion techniques help you step back from these thoughts. Rather than buying into “I’m terrible” as literal truth, we practice seeing it as “I’m having the thought that I’m terrible.” This creates mental breathing room. In therapy, we might use metaphors or repetition to take the sting out of self-critical thoughts. For instance, repeating a self-judgment aloud until it just sounds like noise, or imagining your thoughts as clouds passing by. The aim is to loosen the grip of morally injurious beliefs (like “I’m beyond forgiveness”), so they don’t dictate your behavior. Over time, thoughts like “I’m evil” can be seen as mental events – not absolute facts.
Contact with the Present Moment: Moral injury yanks people out of the present – you may be stuck in the past (ruminating on the event) or anxious about the future (“I’ll never be a good person” or spiritual fears of punishment). ACT trains mindful attention to here-and-now. We practice grounding techniques and present-focused exercises so that when guilt-soaked memories intrude, you can anchor yourself in the safety of the current moment. For example, a veteran might learn to notice “Okay, right now I’m safe in my living room; I hear the fan humming; I feel my feet on the floor,” which helps pull them out of a downward spiral of traumatic recall or despair. Being present also means you can actually engage in life’s little meaningful moments again (enjoying a cup of coffee, truly listening to a loved one) without being hijacked by the past. This skill combats the avoidance and dissociation that moral injury survivors often develop.
Self-as-Context (Observing Self): Moral injury shrinks one’s identity to the “bad thing” they did or saw. ACT introduces the idea that you are more than the sum of your actions or thoughts. We cultivate a sense of self-as-context – a stable, observing self that is distinct from the content of your experiences. Practically, this might involve mindfulness meditations where you observe your thoughts and feelings as passing phenomena, reinforcing that a part of you is the witness that remains whole and unchanged. For a first responder who feels broken, this can be powerful: realizing “I am not simply a ‘bad cop’ or ‘failed medic’ – I am a human being who had an experience, and there’s a part of me that can observe it without judgment.” This perspective helps separate who you are fundamentally from what happened or what you did. It creates room for self-compassion – you can acknowledge mistakes or hurts while knowing at your core you still have worth and capacity for goodness.
Values: At the heart of ACT is reconnecting with your values – the qualities that truly matter to you (like courage, kindness, loyalty, family, service). Moral injury often causes people to abandon or lose sight of their values out of shame or cynicism (e.g. a veteran who values honesty and compassion feels he betrayed those values, so he gives up trying to live by them). In therapy, we spend time clarifying your core values. What kind of person do you want to be moving forward? What principles do you want to stand for, even after this moral trauma? We might do a “values card sort” or writing exercises to identify what matters most to you beyond your pain. Often, those with moral injury still have a strong moral compass – it’s why they hurt so much. We leverage that: for example, a medic might realize “I still deeply value saving lives and caring for others,” which we can use as a beacon. Values work allows us to transform guilt into moral growth – e.g., guilt might indicate you violated a value of kindness; going forward, you can decide to double down on kindness in your life as a way to heal. We distinguish between shame-based paralysis and values-based guilt that can motivate making amends or positive changes. This process gives a sense of direction out of the moral injury: no matter what happened yesterday, who do I choose to be today?
Committed Action: Lastly, ACT is about taking concrete action guided by values. In moral injury recovery, this means gradually re-engaging in meaningful activities, relationships, and roles that align with your values – even if you still feel pain or doubt. We set small, achievable goals that stem from the client’s values. For example, a veteran who values service might volunteer at a community organization; a former police officer who values justice might mentor at-risk youth. Committed action might also involve making amends where appropriate (if that’s possible and safe) or other restorative acts that help reclaim one’s sense of honor. In therapy, we’ll problem-solve barriers and build skills needed to follow through. An example exercise could be “behavioral activation”: scheduling positive activities that were avoided due to shame (like reconnecting with a friend or attending a religious service again if faith was abandoned). Even very small steps count, such as getting out for a walk each morning (valuing health) or expressing appreciation to a colleague (valuing camaraderie). Over time, these valued actions, taken consistently, rebuild a fractured sense of self. You start to see evidence that “I am living by my values again,” which counteracts the negativity of moral injury.
In essence, ACT provides a roadmap from pain to purpose: Accept what you cannot change, step back from self-judgment, ground yourself in the present, tap into the self that observes (not just the self you criticize), remember what and who matters to you, and then take committed steps in that direction. It’s not about one big cathartic breakthrough; it’s about slowly but surely living in a way that heals the moral wounds and builds a new narrative for your life.
Tailoring ACT for Moral Injury via Online Therapy (California & Virginia)
One of the advantages of ACT is that it can be effectively delivered via telehealth. As a psychologist licensed in California and Virginia, I offer ACT-based moral injury therapy 100% online, which means veterans and first responders anywhere in those states can access help confidentially from home. This is especially important for populations that may be averse to seeking help due to stigma or job concerns (such as law enforcement officers worrying about career impact, or military folks in remote areas).
In an online ACT therapy program for moral injury, we structure the treatment to ensure safety, privacy, and a pace that respects your readiness. Some key elements include:
Confidential, judgment-free space: I emphasize from the start that this is a safe space to talk about the “unspeakable.” Many clients fear that if they share their darkest guilt or anger, the therapist will judge them. I make it clear that my role is not to judge past actions, but to help you work through the feelings around them. Everything is protected by privacy laws, and since I’m also familiar with military and first responder culture, I approach these discussions with cultural sensitivity and respect. (It’s worth noting: getting mental health support does not jeopardize security clearances or your job – in fact, addressing issues early is seen as a strength and protective factor. According to official guidelines, seeking therapy is considered a positive step in most cases, not a liability.)
Initial focus on stabilization: If you are also experiencing acute PTSD symptoms (nightmares, severe anxiety) or depression, we address immediate coping skills first. ACT can incorporate techniques like grounding exercises, breathwork, and mindfulness to help reduce intense arousal or numbing. This ensures you have tools to manage distress between sessions. We won’t dive into heavy moral injury processing until you feel some stability under your feet. The idea is pacing: we go as slow as your nervous system needs. (Remember, trauma-informed care means no forced recounting of events – we only go into detail if and when it’s helpful for your healing.)
Exploring the story (at your pace): When you’re ready, we gently unpack the narrative of the morally injurious event(s). In ACT, this isn’t prolonged exposure, but we do want to identify what beliefs you’re carrying (“I should have done X,” “I can’t be forgiven,” “The world is unjust,” etc.). Sometimes writing a narrative or sharing it verbally when you feel safe can be therapeutic – putting words to the moral injury rather than letting it fester unspoken. Throughout, we apply the ACT lens to help you hold that story with compassion: recognizing the context (e.g., the impossible situation you were in, the fact that you’re human and not omnipotent), and seeing how your pain reflects your positive values (you feel guilt because you care deeply about human life, which is a strength, not a weakness).
Values-guided forgiveness and self-compassion: A pivotal piece in moral injury recovery is often forgiveness – sometimes of others, but very often of oneself. This doesn’t mean excusing wrongdoing, but it means releasing oneself from perpetual punishment. Using ACT, we tie forgiveness into values: for instance, if you value family, perhaps you can see that forgiving yourself will make you a better father, mother, or friend to those you love (because you’ll be less tormented and more present with them). If you value honesty, forgiveness might mean honestly acknowledging “I made a grave mistake” and allowing that you’re more than that mistake. We often incorporate self-compassion exercises (developed by Dr. Kristin Neff and colleagues) to help you treat yourself with the same kindness you would offer a fellow veteran or responder who came to you with a similar story. Often, clients can imagine forgiving or understanding someone else far more readily than themselves – we leverage that by asking, “What would you say to a brother-in-arms or your best friend if they confessed the same thing to you?” and then reflect that back to oneself.
Reconnection and making amends: For some, healing involves reconnecting with community or faith. ACT doesn’t prescribe any specific moral or spiritual beliefs, but we welcome discussion of spiritual injury if it’s relevant (many find strength in reconnecting with spiritual practices or communities that affirm forgiveness and purpose). We also explore opportunities for “reparative action” – is there a way to atone or make amends that sits well with your values now? This could be symbolic (writing a letter you never send, creating a memorial, etc.) or active (volunteering, apologizing to someone if appropriate). Taking action to give back or pay tribute can transform that sense of moral debt into something meaningful. For example, a veteran who feels guilt over civilian casualties might choose to volunteer building homes in a war-torn region as an act of service that honors those lives. These steps are very individual, and we only pursue them if they aid your healing (there’s no checklist of required amends – sometimes the work is entirely internal).
Maintaining progress: As therapy nears an end, we consolidate your ACT skills into a long-term self-care plan. Moral injury wounds can flare up during anniversaries or reminders; you’ll have a toolkit now – mindfulness practices, defusion techniques, values lists, perhaps supportive peers or clergy – to navigate those moments. We also identify ongoing support: maybe continued group therapy (there are veteran moral injury groups and first responder support groups), or simply scheduling regular “check-ins” with yourself to process feelings in a healthy way (journaling, prayer/meditation, etc.). The goal is that you leave therapy feeling empowered: yes, the past remains, but it no longer dictates your future. You are writing new chapters of your life story, ones that are aligned with who you truly want to be.
From a practical standpoint, online ACT therapy in California and Virginia means you can do all of this work from the privacy of home. Many first responders have irregular schedules or live in rural areas – teletherapy makes access easier. Veterans similarly may prefer telehealth to avoid VA waitlists or to find a provider who really matches their needs (maybe you want a therapist experienced in both ACT and military culture – that might not be available in your small town, but via telehealth you can connect state-wide). I ensure our video platform is secure and HIPAA-compliant, and I’ve structured my practice to be self-pay (insurance-free) which maximizes confidentiality (especially important for federal employees or those with security clearances who worry about therapy records – paying privately keeps things off insurance reports).
Ultimately, moral injury therapy is a journey of restoring wholeness. With ACT, we walk that journey focusing on your strengths and values. It’s incredibly moving to see a client go from “I’m broken and unworthy” to gradually holding their head up again, maybe even mentoring others through similar struggles. The pain may not vanish 100%, but it becomes an integrated part of your story – one that no longer controls you or eclipses the good in you.
Taking the Next Step: Healing is Possible
Recovering from moral injury is not about forgetting what happened or magically erasing guilt. It’s about learning to live again, with integrity, in light of what happened. First responders and veterans often come to therapy feeling that they don’t deserve healing – but I want to emphasize that you do deserve to heal, and it is absolutely possible. People can and do overcome moral injury, especially with the right support.
If you or a loved one in California or Virginia is struggling with the weight of moral injury, consider reaching out for help. Therapy provides a structured, compassionate way to work through the moral pain instead of carrying it alone. With approaches like ACT, we focus on what matters to you – your values, your future – rather than judging the past. You’ll learn that it’s okay to seek forgiveness (including from yourself) and that moving forward with your life is not a betrayal of those you lost or the values you hold – in fact, it can be a tribute to them.
At Next Mission Recovery, I offer specialized moral injury therapy online for first responders, veterans, and others impacted by trauma. Confidential telehealth is available across California and Virginia. My approach is trauma-informed and culturally sensitive – whether you’re a firefighter from Los Angeles, a police officer from Sacramento, a combat veteran from Norfolk, or a healthcare worker from Richmond, you’ll be met with understanding and respect. We’ll work at a pace that feels safe, building coping skills and trust before delving deeper. Healing moral injury is tough work, but you won’t be doing it alone – we’ll navigate it together, step by step.
Feel free to contact me for a free 15-minute consultation to discuss your situation and ask any questions. This consult is a no-pressure chance to see if we’re a good fit. If I’m not the right person to help, I’ll do my best to connect you with resources that are.
You’ve carried this burden long enough. Recovery starts with one act of courage – reaching out. Your next mission can be one of healing, growth, and reclaiming the values that make you who you are. You answered the call to help others; now it’s time to help yourself. There is hope, and there is a path forward – let’s walk it together.
Further Reading & References
Farnsworth, J. K., Drescher, K. D., Nieuwsma, J. A., Walser, R. D., & Currier, J. M. (2017). The role of moral emotions in military trauma: Implications for the study and treatment of moral injury. Review of General Psychology, 21(2), 144–160.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and Commitment Therapy: The process and practice of mindful change (2nd ed.). New York: Guilford Press.
Koenig, H. G., & Al Zaben, F. (2021). Moral injury: An increasingly recognized and widespread syndrome. Journal of Religion and Health, 60(5), 2989–3011.
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.
National Center for PTSD. (2022). Moral injury. U.S. Department of Veterans Affairs.
Nieuwsma, J. A., Walser, R. D., Farnsworth, J. K., Drescher, K. D., Meador, K. G., & Nash, W. P. (2015). Possibilities within acceptance and commitment therapy for approaching moral injury. Current Psychiatry Reviews, 11(3), 193–206.
Shay, J. (1994). Achilles in Vietnam: Combat trauma and the undoing of character. New York: Simon & Schuster.
Wisco, B. E., Marx, B. P., May, C. L., Martini, B., Krystal, J. H., Southwick, S. M., & Pietrzak, R. H. (2017). Moral injury in U.S. combat veterans: Results from the National Health and Resilience in Veterans Study. Depression & Anxiety, 34(4), 340-347.
Frequently Asked Questions
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PTSD (Post-Traumatic Stress Disorder) is mainly a fear-based reaction to life-threatening events, whereas moral injury is rooted in guilt, shame, or a violation of your moral code. PTSD symptoms include flashbacks, hypervigilance, and nightmares tied to trauma. Moral injury symptoms center on ethical pain – e.g. “I did something wrong” or “I witnessed an unforgivable act.” The two often overlap, but you can have one without the other. Notably, moral injury can occur even in events that aren’t physically dangerous but are morally conflicting. Treatment for moral injury focuses more on forgiveness, meaning, and values, whereas PTSD treatment often focuses on fear extinction and memory processing.
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Yes. Moral injury isn’t solely about death or killing. Any situation that deeply violates your sense of right and wrong can cause moral injury. For example, a paramedic might feel moral injury after being forced to follow a protocol that feels unethical, or a police officer might feel it after seeing a colleague abuse a civilian and not being able to intervene. It’s about the moral conflict and the emotions (guilt, shame, outrage) that result – not just the outcome in terms of life or death. Even cumulative exposure to suffering (like repeatedly encountering child abuse cases) can lead to a form of moral exhaustion or injury over time.
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Regret is a common emotion – we all have things we wish we’d done differently. Moral injury tends to be more intense and enduring. Signs of moral injury include: persistent feelings of worthlessness or self-loathing because of the event, intrusive memories specifically around what you did or didn’t do (“reliving” the moral aspect), avoidance of people or situations that remind you (for example, isolating from comrades or avoiding work) out of shame, and a feeling of being “cut off” from your former values or faith. You might also notice negative changes in your worldview – like becoming very cynical or losing trust in everyone. If your level of guilt/shame is so high that it’s impairing your relationships, work, or well-being, that goes beyond ordinary regret and could indicate moral injury. A mental health professional can help assess this in more detail.
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No – “Acceptance” in ACT does not mean approval or saying an immoral act was fine. It means accepting that the event happened and that you feel the way you feel about it. For instance, if you’re grappling with guilt over a shooting, we aren’t trying to convince you that “it was okay” if in your heart it wasn’t. Instead, we help you accept the reality (it happened, you can’t change it now) and accept your feelings (you feel guilt because you have a strong moral compass). From there, we work on not letting those feelings destroy you, and finding ways to make meaning from them. Acceptance is basically acknowledgment – removing the added suffering of denying or avoiding the truth – so that you can then figure out how to live with that truth in a healthier way. In ACT, you’re encouraged to keep your moral values; we just want you to find self-forgiveness and a path forward aligned with those values.
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Yes, ACT is one promising approach, but there are others in development. For example, Adaptive Disclosure (AD) is a brief therapy originally for combat-related moral injury that involves imaginal dialogues and forgiveness strategies. The Impact of Killing (IOK) treatment is a specific protocol for veterans troubled by having killed in combat. There are also spiritually-integrated interventions like Building Spiritual Strength (BSS) for those whose moral injury has a religious or spiritual dimension. Another approach, Trauma-Informed Guilt Reduction (TrIGR) therapy, directly targets trauma-related guilt and has been used with moral injury presentations. Many of these therapies share common elements: processing the event, cultivating forgiveness and self-compassion, and re-engaging in valued roles. The field is evolving – researchers are even looking at group therapies for moral injury (sometimes co-led by chaplains and clinicians) to allow people to heal in community. The best approach can depend on the individual; some may prefer a more religious or spiritual counseling approach if their faith is central, while others benefit from a cognitive-behavioral approach like ACT. What matters is finding a therapy that you feel comfortable with and that addresses the moral dimension of your experience. If you start therapy, don’t hesitate to discuss your preferences and beliefs with your therapist – the treatment can often be tailored to respect your worldview (for example, integrating your spiritual beliefs into ACT if that’s important to you).