Moral injury and ART: what it might help with, and what it cannot

Moral injury is the lasting harm that can follow doing, failing to prevent, or witnessing something that goes against your deepest sense of right and wrong. There are no published studies of Accelerated Resolution Therapy (ART) for moral injury. ART may help with the vivid images and physical reactions tied to a specific memory, but it is not designed to settle questions of guilt, forgiveness or meaning, and those usually need their own work.

What moral injury is

A widely cited definition comes from Brett Litz and colleagues, writing about war veterans in 2009. It describes “potentially morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations,” which “may be deleterious in the long-term, emotionally, psychologically, behaviorally, spiritually, and socially.”

The idea is not limited to combat. People describe something similar after a decision that cost a life, after following an order they believed was wrong, after being unable to protect someone, or after being betrayed by a leader or institution they trusted.

What it can look like, in general terms:

• Guilt or shame that does not ease when someone says “it wasn’t your fault”
• Anger at leaders, institutions or God, or a sense of having been betrayed
• Feeling you no longer deserve good things, or pulling away from people who care about you
• Losing faith, or losing the sense that the world makes moral sense
• Replaying the moment and the choices you could have made

These are descriptions, not a checklist. Many people carry some of this without it becoming a lasting problem, and the same reactions can come from other causes.

How it differs from fear-based PTSD

Much of what is written about post-traumatic stress centers on threat: the body reacting to a memory as though the danger were still present. Treatment is often about helping the nervous system learn that the danger has passed.

Moral injury, as Litz and colleagues describe it, centers on something else. The problem is not mainly that a memory signals danger. It is that the memory conflicts with what you believe is right, or with who you believed you were. Reassurance that you are safe now does not touch that. Neither does being told you did nothing wrong, particularly if part of you is sure you did.

The two often overlap. A single event can be both terrifying and morally wounding, and a person can have PTSD symptoms and moral injury at the same time. Sorting out which parts are fear and which are guilt, grief or betrayal is often a useful early step.

What ART might address

ART works on how a memory is stored and felt. You bring a scene to mind briefly, follow sets of about 40 eye movements while the body’s reaction settles, and then use Voluntary Image Replacement to change the images the memory carries. You keep the memory itself; what can change is how intensely the images and physical sensations hit you.

For someone with moral injury, that may help with:

• Intrusive images of a specific moment that arrive without warning
• The physical charge of the memory: the jolt, the nausea, the tightness
• Being able to think about the event deliberately, instead of either avoiding it or being flooded by it

The ART protocol also includes a technique called the “Director,” which researchers have described as helping a person establish a new narrative to address “unfinished business,” in a way similar to Gestalt therapy. In moral injury, unfinished business is often the heart of it: something unsaid to someone who died, or an apology never made. Some people find it useful to work on that in the imagination. That is a description of how the technique is used, not evidence that it resolves moral injury.

You do not have to tell me the details of what happened for ART to be used. For people carrying shame about something they did, that can matter a great deal.

What ART is unlikely to address on its own

• The moral question itself. Changing an image does not change what happened or decide what it means. ART is not a way of arguing someone out of guilt, and it should not try to excuse something that was wrong.
• Repair. Moral injury often calls for acknowledgment, making amends where that is possible, and rebuilding relationships. Those happen over time, in conversation and in life, not in a few eye-movement sets.
• Faith and meaning. If the injury is spiritual, a chaplain, pastor or faith community may be as important as any therapist.
• Betrayal by others. Anger at an institution is often an accurate reading of what happened. Therapy can help you carry it; it is not meant to make you stop minding.

What the guidelines say about treating moral injury

No major treatment guideline has an established first-line treatment specifically for moral injury. The 2023 VA/DoD PTSD guideline reviewed three therapies built with moral injury or guilt in mind (Adaptive Disclosure, Impact on Killing, and Trauma-Informed Guilt Reduction) and rated the evidence for each as insufficient to recommend for or against. It gives ART the same rating for PTSD.

Where moral injury comes with PTSD symptoms, the guideline’s strongest recommendation goes to cognitive processing therapy (CPT), prolonged exposure and EMDR. CPT is worth particular mention here. It works directly on the thoughts people hold about why a trauma happened, and its themes include safety, trust, power and control, esteem and intimacy. When guilt, blame and a changed view of yourself are at the center, a therapy that examines those beliefs head-on may be the better first choice. There is more on this in ART compared with CPT.

A reasonable way to think about it: if the images are what keep you from functioning, ART may help lower their intensity so the harder conversations become possible. If the images are manageable and it is the meaning that will not settle, a belief-focused therapy, faith support, or both, may be the better place to start.

If you are a veteran

Much of the writing on moral injury, including the Litz definition, comes from work with veterans, and moral injury can be part of what veterans bring to therapy even when they do not use the term. I have used ART with veterans, and I am also trained in EMDR. The veterans and TRICARE page covers the practical side, and therapy for veterans describes the wider work. When you are ready, you can get started here.