Moral injury

PTSD often involves fear and feeling on high alert. Moral injury is more about a broken sense of right and wrong: “I did something bad”, “I let people down”, or “The people I trusted betrayed what was right.”

Many people feel upset after an event like this, and most feel better with time. VA says moral injury is worth looking at when the pain lasts long after the event and gets in the way of relationships, work or daily life.

Psychiatrist Jonathan Shay, who worked with Vietnam veterans, described moral injury as a betrayal of what is right, by someone with legitimate authority, in a high-stakes situation.

In 2009, Brett Litz and colleagues widened the idea to include a person’s own actions: doing, failing to prevent or witnessing acts that cross deeply held moral beliefs. Researchers say both views can fit people’s experiences.

Moral injury is not a mental illness or a formal diagnosis. It can happen on its own, or alongside PTSD or depression. A mental health provider or chaplain can talk with you about it, sometimes using short questionnaires.

• Feeling nothing, or even excitement, while causing harm, and being troubled by that later
• Having to harm or kill others
• Making decisions that affected who survived

VA notes that events where a person caused harm seem to bring more reliving, guilt and self-blame than danger alone.

• Freezing, or not doing your duty, in a dangerous moment
• Not being able to care for everyone who was hurt
• Not reporting something that broke the rules

• Seeing acts of extreme violence
• Seeing others do things that went against your values

In a 2025 national study, healthcare workers were more likely than first responders to report witnessing others’ wrongful acts.

Betrayal and loss of trust are common in moral injury. It might be a leader’s order that felt wrong, a system that left people without what they needed, or someone you trusted with your life. Anger often follows.

Being betrayed can make it hard to trust anyone afterwards, at work, at home or in faith communities.

Most research on moral injury has been done with military personnel and veterans. Researchers note that modern, unconventional wars can make these moral challenges even harder.

Combat veterans were more likely than first responders to say they had gone against their own values by what they did.

VA lists healthcare work involving life-and-death decisions as a setting for moral injury. During the COVID-19 pandemic, researchers warned that shortages of beds and equipment could force staff into choices that clash with their values.

In the 2025 national study, 7.3% of healthcare workers had clinically meaningful moral injury symptoms, about the same as combat veterans.

First responders may face split-second choices about who to help first, or see harm they could not prevent. VA names first responders among those who can experience moral injury.

VA also names refugees and people exposed to community violence. Researchers have also pointed to social workers and prison staff as groups who may face moral distress.

Research outside the military is still limited, so less is known about these groups.

PTSD often involves feeling you must stay on high alert, which is not typical of moral injury. Moral injury is more about guilt, shame, betrayal and a broken sense of right and wrong.

When moral injury and PTSD happen together, PTSD and depression tend to be more severe, daily life can be harder, and the risk of suicidal thoughts and behavior is higher. Morally injurious events are also linked to substance use problems.

Guilt is remorse about a specific act. It is focused on what you did. Some guilt can be a fair response to real harm, and it can point the way toward making amends.

Shame spreads from the act to the whole self. It can make a person feel they don’t deserve love, success or help, and lead them to sabotage good things in their life.

• Anger, at yourself, others or a system
• Disgust
• Guilt and shame
• Not being able to forgive yourself

Some people say it feels like a stain they can’t wash off, or like a part of their character was damaged. These feelings are painful, but they come from caring deeply about right and wrong.

• Ending relationships because you feel you don’t deserve love
• Feeling you need to be punished
• Skipping help because you feel you don’t deserve to feel better
• Turning down good things at work or in life

Moral injury can make it hard to trust others, especially after betrayal. People may withdraw from family, friends and community, or feel that no one could understand or accept them if they knew.

Some people question their faith, their relationship with a Higher Power, or whether life has meaning. See “Faith, meaning & spirit” below.

A chaplain can help you talk through what happened and any changes in your beliefs. Chaplains can also help assess moral injury and help lead some moral injury groups.

VA, many hospitals and many military and first-responder agencies have chaplains. You can ask for one at your local VA medical center.

Building Spiritual Strength is an 8-session group that can be led by a chaplain. It focuses on your relationship with a Higher Power after trauma. VA describes it as still being studied.

Moral injury is about values, not only religion. Some people find meaning again through nature, service, art, family or a personal code. Therapies like ACT for moral injury help you live by your values even while the pain is there.

Acceptance and Commitment Therapy for moral injury helps you make room for painful feelings and live by your values even while the pain is there.

Adaptive Disclosure includes an imagined conversation with a kind, wise moral authority, to look fairly at blame. It also includes thinking about making amends.

In a trial with 122 Marines and sailors, Adaptive Disclosure worked as well as Cognitive Processing Therapy, a first-line PTSD therapy.

Impact of Killing is for veterans troubled by killing or feeling responsible for deaths in war. It works on self-forgiveness and moral repair, and can include writing forgiveness letters and making an amends plan.

In a pilot trial with 33 combat veterans, those who had the therapy improved in PTSD symptoms, general mental health and quality of life compared with those who waited.

This therapy looks closely at the beliefs behind guilt and shame. VA reports it did better than supportive therapy for guilt, PTSD and depression, and half of the people with PTSD no longer met criteria for PTSD.

This group brings together spiritual care and mental health care. It can end with a ceremony where members share their stories of moral injury with the public.

Therapies for moral injury often help people separate beliefs that can be challenged from those that need to be accepted. Hindsight can make choices look clearer than they were.

Questions that can help

• How much time did I have to decide?
• What did I know at that moment, and what couldn’t I see?
• Who else shared responsibility?
• What would I say to a friend who did the same thing?

Amends are part of several moral injury therapies. When it isn’t possible or safe to make amends directly, people can make “living amends”: living out the values that were broken.

Living amends can look like

• Being honest and present with your family
• Mentoring young people
• Serving in your community
• Supporting a cause that protects others
• Volunteering with people who are hurting

Many people resist self-forgiveness because it feels like excusing a wrong, or because they believe only the person harmed or God can forgive. Researchers describe forgiveness as an active process, often rooted in a person’s own moral and spiritual background.

Rushed or forced forgiveness tends not to last. It usually takes time, honesty and support.

Some therapies use letter writing, for example to someone who was harmed or from the view of a trusted person. These letters are not sent. They help put words to grief, regret and hope.

What helps

• Let them share only what they want, when they want
• Listen more than you talk
• Say “Thank you for trusting me with this”
• Stay calm, even if what you hear is hard

What to avoid

• Asking for graphic details
• Judging or lecturing
• Rushing to say “It wasn’t your fault” before you’ve really listened
• Telling them to just move on

Mention that there are therapists and chaplains who work with exactly this kind of pain, and that they don’t have to tell anyone everything at once. Check in again later.

Moral injury affects how people relate to others, so community can be part of healing. Moral injury touches social life as well as the inner life, and the VA Moral Injury Group can end with members sharing their stories with the public.

Ways communities can help

• Faith groups: offer spaces for confession, lament and welcome without judgment
• Leaders and employers: be honest about hard decisions and support staff after them
• Peer groups: let people hear “me too” from others who were there
• Everyone: honor service and sacrifice, and also make room for the hard stories

It is okay to feel shaken by what you hear. Talk with someone you trust, keep your own routines, and get support if it weighs on you.