Understanding Moral Distress and Injury

Moral distress occurs when we act against our deeply held values, leading to a heavy burden of pain and regret. ACT offers a transformative approach to navigate this distress, emphasizing openness, awareness, and engagement (Hayes et al., 2011).

What is a morally injurious event (MIE)?

A situation that violates an important personal value and has high stakes (Griffin et al., 2019; Litz et al., 2009)
Morality involves complex interactions of individual, familial, cultural, societal, and legal rules for social behavior (Farnsworth and colleagues, 2014; Litz and colleagues, 2009).
Morals are communal and collectively shared expectations for behavior in society—for instance, care, fairness, and loyalty (Haidt, 2012).
Could involve something you did/didn't do, witnessed, or learned about; You might feel like a victim, the person responsible, a witness, or a mix

Why do MIEs hurt?

Our morals guide our behavior and worldview; when these morals are violated, we experience moral suffering, an anguish that results from that gap between what we think "should" be happening, and what is happening (Farnsworth et al., 2017; Litz et al., 2009; Haidt, 2012).
Dr. Stephen Hayes (2019) “pain and purpose are two sides of the same thing. A person struggling with depression is very likely a person yearning to feel fully. A socially anxious person is very likely a person yearning to connect with others. You hurt where you care, and you care where you hurt” (p.23).

What does moral distress look like?

Prolonged moral emotions like guilt, shame, helplessness, rage, despair; spiritual crisis (Evans, et al, 2020)
Loss of safety, joy, connection, trust (Smith-MacDonald, et al., 2022).

When does it become moral injury?

When moral pain impairs daily functioning (Farnworth et al., 2017)
Avoiding and escaping through unhealthy coping (substance use, overworking, ruminating, self-blame) leads to more distress.
Can lead to burnout, relationship issues, PTSD, depression, suicidality (Smith-MacDonald, et al, 2022)

Breaking the Cycle of Suffering:

Move from ruminating and worrying to compassionate present moment awareness: Shift your focus to the present with curiosity and compassion, engaging with life as it unfolds.
Accept your experience of moral pain without trying to escape and avoid it, and prepare to change what you can.
Defusion is the skill of stepping back from our thoughts and stories about our moral distress, allowing us to see them for what they are—just thoughts.
Self-as-Context helps us recognize our capacity to observe our experiences without defining ourselves by them, and keeping ourselves “small.”
Move from loss of meaning to values clarification. When your way of expressing your values is taken from you, reorient towards your values and find a new way.
Replace self-destructive actions with committed action: Build habits around what truly matters, aligning your actions with your values.

ACT invites us to face our moral distress fully and without defense, asking if we're willing to experience this pain and still move towards our values. It's not about eliminating pain but learning to live a meaningful life in its midst.

For Further Exploration:

Dr. Steve Hayes, the originator of Acceptance and Commitment Therapy, has wonderful free tools on his website: https://stevenchayes.com/tools/

Click Here: Access a free ACT for Moral Injury course for healthcare workers funded by Public Health Agency of Canada that I had the privilege of building with Canadian researchers

I also write regularly about this and other related topics on my blog: https://www.psychologytoday.com/us/blog/threshold/202502/how-public-servants-can-cope-with-moral-distress

These three books are great for further reading:

Hayes, S. (2019). A Liberated Mind: How to Pivot Toward What Matters. New York: Avery.

Evans, W. R., Walser, R. D., Drescher, K. D., & Farnsworth, J. K. (2020). The Moral Injury Workbook: Acceptance and Commitment Therapy Skills for Moving Beyond Shame, Anger, and Trauma to Reclaim Your Values. New York, NY: New Harbinger Publications.

Sorenson, De. (2024). ACT for Burnout Recharge, Reconnect, and Transform Burnout with Acceptance and Commitment Therapy. Philadelphia, PA: Jessica Kinglsey Publishers.

References

Evans, W. R., Walser, R. D., Drescher, K. D., & Farnsworth, J. K. (2020). The Moral Injury Workbook: Acceptance and Commitment Therapy Skills for Moving Beyond Shame, Anger, and Trauma to Reclaim Your Values. New York, NY: New Harbinger Publications.

Farnsworth, J. K., Drescher, K. D., Nieuwsma, J. A., Walser, R. B., & Currier, J. M. (2014). The role of moral emotions in military trauma: Implications for the study and treatment of moral injury. Review of General Psychology, 18(4), 249-262.

Farnsworth, J. K., Drescher, K. D., Evans, W., & Walser, R. D. (2017). A functional approach to understanding and treating military-related moral injury. Journal of Contextual Behavioral Science, 6(4), 391-397.

Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz, M., Villierme, C., Walsh, J., & Maguen, S. (2019). Moral injury: An integrative review. Journal of Traumatic Stress. 32(3), 350–362.

Haidt, J. (2012). The righteous mind: Why good people are divided by politics and religion. Pantheon Books.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change. New York, NY: Guilford Press.

Hayes, S. (2019). A Liberated Mind: How to Pivot Toward What Matters. New York: Avery.

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. Clin- ical Psychology Review, 29, 695–706.

Litz, B. T., Plouffe, R. A., Nazarov, A., Murphy, D., Phelps, A., Coady, A., Houle, S. A., Dell, L., Frankfurt, S., Zerach, G., Levi-Belz, Y., & Moral Injury Outcome Scale Consortium (2022). Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium. Frontiers in Psychiatry, 13, 923928.

Morley, G., Ives, J., Bradbury-Jones, C., & Irvine, F. (2019). What is ‘moral distress’? A narrative synthesis of the literature. Nursing Ethics, 26(3), 646-662.

Morris, R., Rodriguez, S., & Lusk, J. (2024). ACT for Moral Injury – Healing the Harm. Department of Veterans Affairs, Portland, OR.

Morris, R., Rodriguez, S., & Lusk, J. (2024). ACT for Moral Injury – Beyond Betrayal. Department of Veterans Affairs, Portland, OR.

Rushton, C. H. (Ed.). (2018). Moral resilience: Transforming moral suffering in healthcare. Oxford University Press.

Smigelsky, M. A., Rodriguez, S., Lusk, J., Morris, R., Murphy, J., & Nieuwsma, J. A. (2025). Feasibility, acceptability, and preliminary effectiveness of an interdisciplinary group therapy for moral injury among veterans. Submitted for Publication.

Smith-MacDonald L., Lusk J., Lee-Baggley D., Bright K., Laidlaw A., Voth M., Spencer S., Cruikshank E., Pike A., Jones C., Bremault-Phillips S. (2022). Companions in the Abyss: A Feasibility and Acceptability Study of an Online Therapy Group for Healthcare Providers Working During the COVID-19 Pandemic. Frontiers in Psychiatry, 12: 801680.