Most of us recognize that nagging feeling of regret that comes from agonizing over some real or perceived misdeed from our past. Maybe we harmed someone directly or failed to act when we felt we should. This feeling has value: guilt, when it is adaptive, motivates us to appraise its presence and to perhaps take reparative action or to think twice the next time we are faced with a similar situation.

But what about when this guilt is based on actions taken in life-or-death situations—such as on the battlefield or in an emergency room—and is distinctly nonadaptive? What happens when an act that was, or at least seemed to be, crucial and justified in a moment of extreme adversity is reanalyzed now with the critical element of an immediate threat to life removed? What about when it gives rise to a guilt that becomes more distressing over time and gets mixed up with shame, avoidance and despair?

This is the kind of guilt that is associated with moral injury, a term described by Brett Litz of Boston University and his colleagues in 2009 as the psychic fallout of “morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress [one’s own] deeply held moral beliefs and expectations.” In recent years, the concept has generated a great deal of research attention, much of it focused on U.S. veterans who have failed to respond well to treatment for post-traumatic stress disorder (PTSD) or on descriptive analyses of its prevalence among general veteran populations. Although the symptoms of moral injury overlap in many ways with those of PTSD (and the two often come together), research has shown them to be distinct conditions, with moral injury causing great suffering even in veterans who were not diagnosed with PTSD. With the fear aspect of PTSD absent in those suffering from moral injury, many are thus ineligible for treatment for that condition or do not seek treatment at all. There is great incentive not to pathologize moral injury, but understanding the unique difficulties apparent in this distinct state may be key to developing more effective treatments for the many thousands of veterans suffering from war-related trauma.

Though PTSD symptoms such as avoidance of reminders of the traumatic event and intrusive thought patterns may also be present in moral injury, they appear to serve different purposes, with PTSD sufferers avoiding fear and moral injury sufferers avoiding shame triggers. Few comparison studies of PTSD and moral injury exist, yet there has been research that indirectly compares the two conditions by differentiating between fear-based and non-fear-based (i.e., moral injury) forms of PTSD, which have been demonstrated to have different neurobiological markers. In the context of the military, there are countless examples of potentially morally injurious events (PMIEs), which can include killing or wounding others, engaging in retribution or disproportionate violence, or failing to save the life of a comrade, child or civilian. The experience of PMIEs has been demonstrated to lead to a larger range of psychological distress symptoms, including higher levels of guilt, anger, shame, depression and social isolation, than those seen in traditional PTSD profiles.

Guilt is difficult to address in therapy and often lingers following standardized PTSD treatment (that is, if the sufferer is able to access therapy). It may, in fact, be a factor in the more than 49 percent of veterans who drop out of evidence-based PTSD treatment or in why, at times, up to 72% of sufferers, despite meaningful improvement in their symptoms, do not actually recover enough after such treatment for their PTSD diagnosis to be removed. Most often, moral injury symptoms that are present in the clinic are addressed through traditional PTSD treatments, with thoughts of guilt and shame treated similarly to other distorted cognitions. When guilt and the events it relates to are treated as “a feeling and not a fact,” as psychologist Lisa Finlay put it in a 2015 paper, there is an attempt to lessen or relieve such emotions while taking a shortcut to avoid experiencing those that are legitimate and reasonable after-wartime activities. Continuing, Finlay stated that “the idea that we might get good, as a profession, at talking people out of guilt following their involvement in traumatic incidents is frighteningly short-sighted in more ways than one.” On the one hand, guilt, shame and moral injury symptoms can cause a host of psychological suffering and even self-destructive behaviors, while on the other hand, “treating” them without allowing space to process their legitimacy and long-term effects within a sufferer’s moral, societal and religious frameworks could whitewash the conflict without addressing its core.

Moral injury, especially outside of the U.S., is poorly understood, and the implications of its different treatment choices are even less comprehended. What is known is that across the world, those suffering from greater moral injury have difficulty addressing their internal conflicts and that a failure to do so can lead to somatic symptoms, withdrawal from social interaction, unhealthy relationship functioning, and risky or self-destructive behaviors. Treatment based on increasing willingness to experience painful emotions, developing greater psychological flexibility, and understanding and working toward personal values, which may have been violated during service, has demonstrated preliminary benefits to suffers of moral injury. A basic tenant of all treatment programs, however, appears to be a willingness of the therapist to facilitate the experience of the patients’ guilt- and shame-based feelings in an exploratory and nonjudgmental fashion without displacing or delegitimizing their presence.

Understanding moral injury is of great importance, given the number of veterans who do not appear to benefit from traditional PTSD treatments, the high level of guilt symptoms among veteran populations and the voices of clinicians who describe moral injury without having the tools to deal with it. Furthermore, this concept could prove relevant to understanding the high levels of burnout in medical staff and, indeed, even in those with careers faced with high levels of exposure to morally problematic scenarios, such as journalism. Moral injury provides an ideal opportunity for multidisciplinary approaches that include attention to spiritual, societal and psychological components. While many therapists and researchers would claim that attention to guilt and shame symptoms are already present in their trauma-based treatments, the research suggests that feelings of betrayal and anger toward military forces are easier for therapists to broach than morally questionable acts perpetrated by the sufferer. Dealing with those moral dilemmas is far more difficult to stomach.