Moral Injury: How to Deal With Guilt That Will Not Lift
with Dr. Lisa Marie Bobby and Dr. Jaimie Lusk
You Hurt Because You Care
Moral injury is what happens when something you did, or failed to do, or watched happen violated a value you actually hold, and you have been trying to get away from that feeling ever since.
It comes back at the strangest times. You are rinsing a plate, or you are ninety seconds from falling asleep, and there it is again. That thing. The part that is almost impossible to explain to anybody is that it is not really that you feel bad about what happened. It is that you feel implicated by it.
If you have been carrying something like that for years without a word for it, here is the word: moral injury. It is not the event itself. It is the way the event keeps working on you afterward, and almost nobody who walks in the door has a name for it yet.
My guest is Dr. Jaimie Lusk, a board certified clinical psychologist, Naval Academy graduate, Marine Corps veteran, and one of the country’s leading moral injury researchers. In this conversation she names the difference between ordinary guilt and moral injury, walks through the four pass method for right sizing guilt against the actual facts, and gives the actual language for reaching a person you love who has gone quiet. She also brought her own unresolved material into the conversation, on the record, which is not a thing most experts will do.
What’s in this article
Is moral injury a real diagnosis?
No, and that is part of why it goes unrecognized for so long. Dr. Lusk explains that it sits in the coding system as a moral, religious, and spiritual problem rather than a diagnosable condition, which means someone can be genuinely struggling and still have trouble getting care covered. She notes on air that this changed in 2025, when moral was added to the existing religious and spiritual problems category. It is real. It just is not in the diagnostic manual.
Does this only happen to veterans and first responders?
That is where the research started, and it is where Dr. Lusk has done most of her work, but no. Some of the examples she gave me were a kid who bullied someone in middle school, an affair, and a moment somebody was not honest with a person they love. It does not require anything dramatic. It requires a value of yours getting violated.
I already know intellectually that it was not all my fault. Why does that not help?
Because you cannot argue yourself out of something you have never said out loud to another person. That is not a willpower problem. Dr. Lusk is very direct about this: compassion cannot happen inside secrecy and silence. The thing has to come out before anything shifts.
What if I actually did something wrong? Is this just letting myself off the hook?
No, and I would not respect this method if it were. Right sizing is not absolution. It is getting the gap between what you believe should have happened and what actually did down to its real size instead of the imagined one. Sometimes there is still something left over. Dr. Lusk is honest about that, and she has a specific answer for what to do with it.
Someone I love is clearly carrying something, and I do not know how to bring it up. What do I say?
Offer your observation instead of a diagnosis. Not “I think you have a moral injury.” Something closer to: I see a heaviness, and you do not have to talk to me about it, but I want you to know I see it, and if you ever want help finding someone, I will help you find them. That is the whole script, and it is one of the most useful things in this episode.
Can Growing Self help me with this?
Honest answer, because it matters more than a sale. If what you are carrying is everyday guilt, a values conflict, a decision you cannot stop replaying, or a sense that you have been quietly punishing yourself for years, then yes, that is exactly the work our therapists and coaches do. If you are dealing with a severe, specialized trauma presentation, you need a clinician with specific training in that area, and the section below on choosing a therapist tells you how to find one. We would rather point you to the right person than be the wrong one.
Moments from this episode
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Episode transcript
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Dr. Lisa: If you are feeling haunted by a regrettable incident that happened in the past, maybe you did something, maybe you didn’t do something, maybe you participated in something that now you deeply, deeply regret, it can be really hard to not just shake that off, but actually heal from it.
Dr. Jaimie Lusk: Maybe they bullied somebody as a kid, and then they see later that person’s alive, but maybe they wonder how much that affected the person, or how they got through it. It could be an affair, or a way that you betrayed your partner, or you weren’t honest with somebody you love. So it doesn’t have to be this life threat or threat to body integrity.
Dr. Lisa: We’re talking about a moral injury. That’s, believe it or not, a very specific and often one of the deepest types of psychological trauma. And this is a dark topic, but I really wanted to talk about this today on the Love, Happiness and Success podcast, because it’s not uncommon, and there are so many of us walking around carrying these kinds of wounds that often go unrecognized with others, and sometimes even ourselves.
Dr. Jaimie Lusk: A lot of times it does have to do with how we respond, maybe in that fight or flight mode, that didn’t line up with how we would respond if we had time to think about it. That can be a morally injurious event.
Dr. Lisa: And so today we’re going there with a very special guest, my friend and colleague, Dr. Jaimie Lusk. Dr. Lusk is a psychologist. She’s also a Marine Corps veteran and one of the country’s leading experts on moral injury, working with military, first responders, and healthcare. She spent over fifteen years in the VA system doing some of the hardest and most important healing work there is, and she has a gift for making it relatable, making it bearable, and making it better.
Dr. Jaimie Lusk: Moral injury is not a diagnosis, and somebody could be out there in the world struggling and maybe not get care covered, because it’s not actually a diagnosable condition.
Dr. Lisa: So Jaimie, I’m so happy to connect with you today. I’ve been looking forward to this.
Dr. Jaimie Lusk: Me too. Dr. Lisa is my mentor in learning how to be a coach, so I’m a board certified coach thanks to her, and that’s been able to help me expand my reach.
Dr. Lisa: Just as an aside, I thought that moral injury now was a DSM diagnosis. I thought I saw something that had been factored into the treatable codes.
Dr. Jaimie Lusk: No, it is a Z code. They added moral to the spiritual and religious problems, so now it’s moral, religious, and spiritual problems. So we have a way to code it as a problem, as a Z code, starting in 2025. But no, not a diagnosis.
Dr. Lisa: So Dr. Jaimie, just to jump right into this, I would love it if you could tell our friends who are listening with us what a moral injury is, and how this type of trauma impacts people.
Dr. Jaimie Lusk: So it’s not the event itself. It’s how the event is continuing to impact us.
Dr. Jaimie Lusk: So you could have a potentially morally injurious event.
Dr. Lisa: Give us an example.
Dr. Jaimie Lusk: It could be something where maybe somebody failed to help somebody and there’s harm as a result. It could be a situation where a value was potentially violated. So I guess maybe I’ll get more specific. In healthcare, a lot of times it has to do with not being able to treat someone the way that you wanted to treat them. Or perhaps within the healthcare system, there are compromises being made that violate your values, perhaps that has to do with the corporatization of care and the ways that you’re participating in that.
It could be that you made a leadership mistake, or perhaps in the heat of the moment reacted in a way that violated your values. A lot of times it does have to do with how we respond, maybe in that fight or flight mode, that didn’t line up with how we would respond if we had time to think about it. That can be a morally injurious event.
Dr. Lisa: Yeah, I can see that. So situations where there’s chaos, and regrettable things happen so quickly, and people get activated, and things happen fast. And then you’re like, oh no, what have I done? Like that kind of thing.
Dr. Jaimie Lusk: Absolutely. And so that event may affect people very differently. Some people may not be affected. Some people, like you said, might be haunted for years to come. So it moves to a moral injury when that moral distress, like you said, those haunted feelings, could be fear, anger, horror, disgust, guilt, shame. When we try to escape and avoid those, we don’t actually find out what’s underneath the hood there, but escape and avoidance ends up in a cycle.
So that cycle could be short term survival strategies that then actually even kick up more of the stress. So common ones could be isolating, or overworking, or going on some superhero mission to really fix the world, or maybe completely shutting down and leaning into a side of you that’s frankly not lining up with your values. So the moral injury is that functional impairment, that way that we get stuck in that cycle. And as you said in the introduction, this could last for years.
Dr. Lisa: So what you’re saying is that something happens and it’s really this deep psychological wound, because somebody is horrified about what happened because they do care, but it almost gets internalized into this thing that feels so overwhelming, that then there’s that classic trauma response, really, that avoidance or a reactivity that is actually then pretty destructive to somebody’s life going forward. But you can see, looking back on the timeline, this moral injury catalyst event is really when it started.
Dr. Jaimie Lusk: Absolutely. And there is overlap with PTSD. They are distinct. So with PTSD we have a criterion A event, so there needed to be life threat or serious threat to body integrity, or you could have witnessed that on the job. And with moral injury, it can be a lot more subtle, and it doesn’t have to be that event. It could be, as you know, an affair, or a way that you betrayed your partner, or you weren’t honest with somebody you love. So it doesn’t have to be this life threat or threat to body integrity.
Dr. Lisa: So you’re saying that with a moral injury, there can be that trauma that’s incurred even just from participating in a regrettable act, even if nobody dies in the process or there was an actual injury, and perhaps even a regrettable act that in the moment you participated in, but then looking back, there’s that, what’s the word? Gosh, you would probably have a better word than I would, but almost like a horror. Like, oh, what have I done.
Dr. Jaimie Lusk: Horror, yeah. Exactly. I have people who come to me with, maybe they bullied somebody as a kid, and then they see later that person’s alive, but maybe they wonder how much that affected the person, or how they got through it.
Dr. Jaimie Lusk: So yeah, it doesn’t have to be the level of a criterion A trauma, and the flavor’s a little different. With PTSD, it’s very much coming from that fear response. This horrible thing happened. I’ve got to make sure that thing never happens again, so I’m very much avoiding any reminders of it, because that feels dangerous. Whereas a lot of times with moral injury, it’s almost like I feel contaminated.
And so there is a little bit of a disagreement in the field right now of how to measure moral injury and what it includes. And one of the big arguments is, do we include betrayal? So an important group of researchers is saying, no, let’s make betrayal a separate thing. And then another important group of researchers are like, no, we want to put these together, because it’s not always that clear.
And I see both sides. So in my work I have done original research in moral injury, and I’ve also created and implemented some interventions both in the US and Canada. And what I saw was, it’s messy. So it’s almost how we’ve talked about internalizing and externalizing. Some people are very much same event, feeling very guilty. Some people, same event, are feeling very angry at other people. And then other people are oscillating. So I think it’s messy to separate.
Dr. Lisa: It’s always messy when you really get into it, isn’t it? And you know, one of the things that I’m really so eager to do, Jaimie, is to give you the opportunity to really take us into this. So not just what it is, not just how it impacts people, but what the process of healing looks like.
And the reason why I feel like this is so important is, as you’ve been describing, one of the hallmarks of this type of thing, feeling contaminated, feeling like a bad person, right? Going running off and hiding, or all kinds of different avoidance things. I’m going to put a mountain between me and whatever this was.
And I think in that, this is the type of injury that can so easily either become hidden from others, oftentimes hidden from the self. Or if people do know about it, could it be interpreted as, oh, that’s a really bad person. Or people feel like, oh, I’m a really bad person, therefore I need to conceal this whole thing. And so for all of these reasons, I would imagine, and maybe this is a question, but that this is one of the hardest things to get people in the door to get help with. Is that a correct assumption?
Dr. Jaimie Lusk: Absolutely. So there’s a group I created with the first Buddhist chaplain in the VA. She’s really my best friend, a really cool lady.
Dr. Jaimie Lusk: And it’s an ACT for moral injury group, and we have a betrayal version.
Dr. Lisa: Acceptance and commitment therapy, for our friends who are not familiar with it. We had to break down the lingo here, Dr. Jaimie. Okay, go ahead.
Dr. Jaimie Lusk: So yes, there’s an acceptance and commitment therapy group, and we’ve developed two versions, a betrayal one and a transgression one. And we do about five betrayal groups for every one transgression one. So that speaks to, you know, not a lot of people raising their hand to be like, you know what I want to talk about in group is the thing I did that I feel horror about and feel like a terrible person about. And yet those groups can be some of the most powerful.
And there’s almost a felt sense of, like, almost the OK Corral moment, where which direction is this going to go? Are people going to take that risk to be vulnerable and really share from their heart about some of that horror and guilt and shame, or are they going to sort of be a fly on the wall and sort of keep it close?
So it’s really beautiful. As you know, we do a lot of compassion work, you and I. And that compassion just can’t happen in that secrecy and judgment and silence. It really has to come out. So lots of compassion can happen. But you know, that ratio of five groups for every one, I think speaks to what you’re talking about.
Dr. Lisa: Well, okay. And so then let’s actually just pause here, because it’s also highly likely that our friend listening to this right now, Dr. Jaimie, might not even be the person who needs to hear this conversation. Maybe it is the spouse, the partner, the kid, the parent of somebody, the best friend of somebody who is going through this.
And so maybe one takeaway from this podcast: educate yourself on what’s going on, how to recognize and have compassion for what might be happening inside of your loved one, and forward this podcast to that person with a, hey, this made me think about some of the things you went through back in Afghanistan, or whatever. Might want to give it a listen. Would you advise something like that, or would that be shut down, do you think?
Dr. Jaimie Lusk: I think we all know deep down when we have a sliver or a piece of shrapnel that’s in there, and we’ve got to get it out. And I think this is for people who maybe just are considering addressing this. This could be a warm up. And again, I do think sometimes we need a formal therapist to really sit with us. But this is that chance to just start to acknowledge that this shrapnel’s stuck in there, and it isn’t going away.
Dr. Lisa: Oh, and not in any way, shape, or form to say, because listening to this podcast is going to make it all better. It is like, oh, there’s a name for what I’m experiencing. And there is a path to help me feel better.
And so then just to pause for a moment, how would one of our friends here with us today listening to this conversation recognize that someone they care about might be struggling with a moral injury? What does that look like to an observer?
Dr. Jaimie Lusk: Well, it might look like there is a pulling away, a defensiveness. Sometimes someone might, I don’t really like the term self sabotage, because I think it fails to recognize the purpose of it. This person doesn’t feel they deserve goodness, or fun, or joy, or connection, so there’s a way that they get in the way of that.
It could be that you knew this person before, and then you start to see some of these ways that they become more prickly, or difficult to experience joy or compassion with. There could be more reckless behavior. And then you might see their body language, or you might pick up on that shame. There’s a real shutdown, and maybe a hiding that’s happening.
Dr. Lisa: Yeah, that’s hard. How do you approach it with somebody like that? Because I would imagine the immediate response is avoidance, rejection, dismissal, denial. They do not want to engage in this, and that’s really hard to broach. It takes a lot of courage.
Dr. Jaimie Lusk: Yeah. I think that we can offer our observation. I see a heaviness. I see you struggling. You don’t have to talk to me about it, but I want you to know I see it, and if you want me to help you, I’ll get you to somebody.
I do think a lot of times people end up working with me, or working with somebody else, on moral injury because of something like that. Somebody said something like, hey, you aren’t yourself. You aren’t who you used to be. I don’t see you showing up for the things that used to matter to you. And those are the comments, the things that stick, that make them think, I’ve got to do something.
Dr. Lisa: I mean, we don’t have a time machine. You can’t go back into the past and do something differently, and what happened happened. So I think it can feel so true, like there’s no hope for this. Where do you even begin to help someone?
Dr. Jaimie Lusk: Well, I’ll tell you: I first want to right size the guilt and shame based on the facts. There’s wisdom we need to mine from that situation. So when there’s an incident where somebody feels deep guilt and shame, a lot of times they’re telling themselves, I shouldn’t have, the thing I did was wrong.
So we really need to look at, okay, well, let’s look at what actually happened. And let’s really look at specifically, what are you telling yourself? For instance, you should have known. And let’s see if it was actually possible for you to know.
Dr. Jaimie Lusk: And then there’s a million dollar question that I’m taking from Trauma Informed Guilt Reduction, which is a really excellent, elegant treatment for guilt and shame. There’s actually a self help version, the book is called Transforming Your Guilt and Shame by Dr. Allard. I highly recommend it.
So this million dollar question is: if you knew for certain that was going to happen, what would you have done that day, or how would you have done things differently? And a lot of times people really recognize they didn’t know for certain how things would turn out. So they’re starting to loosen up some of the things they’re telling themselves, and shrinking that gap between what they thought should happen and what did happen. It’s not so big as we start to look at it.
Dr. Lisa: Yeah, I get that. You know, can I just share, I hope this is okay to share, a teenage family member of mine, not my kid, another family member, had a bunch of other goofball fifteen year olds over at their house not too long ago, playing with fire in the garage. I don’t know what they were thinking, but one of the kids got burned and had to go to the emergency room.
And it’s not, you know, maybe as big as some of the stuff you’re talking about, but my family member felt so bad. Did not want to come out of his room, and was just, like, really beating himself up and going through all these things. And I think that instinctively maybe I did a little bit of that. I got him to talk to me. We were talking about what happened.
And it was like, it was all my fault, blah, blah, blah. And I was like, did you make the kid do this? And he’s like, no. And I was like, did you throw a Molotov cocktail at him? And he was like, no. But you know what I mean? It’s like, what is the choice? What is the agency? Would you have done that on purpose? And he was like, no.
And so I hear what you’re saying. Like, kind of making it smaller, and helping people see, what did I do exactly that contributed to that? Was that a sign of me being a horrible person, or maybe just not thinking that one all the way through, in the event of a fifteen year old kid?
But I think for so much of this there’s like a true accident. For people whose work puts them in high stress, high stakes situations, when people are flooded, your cognitive abilities diminish when you become very activated, and so much of what happens is in that context.
Dr. Jaimie Lusk: So I want to point out, you actually did use a few TrIGR skills. So that’s Trauma Informed Guilt Reduction. So I want to point out your victory there. First, you really looked at percent responsibility. So it’s all my fault is what this kid was saying, but then you sort of asked him questions to see, well, how much of this is his responsibility, and how much is the responsibility of these other kids?
Dr. Lisa: Exactly. This was a group effort. I think I said that out loud as well. Like, you guys did this together, right? Anyway, go ahead, sorry.
Dr. Jaimie Lusk: Well, I think you nailed it. And then I think the other piece there is, maybe you got at, well, what were you intending to do? What values were you honoring? It sounds like they were having fun. Fire’s awesome. Playing with their friends. So they weren’t intending harm. He didn’t throw the Molotov cocktail at somebody. So really getting at intent.
And a lot of times with these things there’s a values clash. So they had the value of having fun together. And frankly, playing with fire is better than a lot of other things fifteen year olds are doing. There’s worse things fifteen year olds could be doing. So okay, you’re having this fun with the elements in the garage.
Dr. Lisa: There’s solvents. All right. Good job.
Dr. Jaimie Lusk: And then I think the other piece is what options were really available at the time. So again, looking at it, in certain events people are holding themselves to standards or options that weren’t actually possible. So all that to say, those are interventions from Trauma Informed Guilt Reduction.
Dr. Jaimie Lusk: But that doesn’t mean we’re not left with something, right? There’s a gap. So for me, I think with therapists, we always do things partly because of our own history. I went to the Naval Academy and I joined the Marine Corps in May 2001, so before we got involved in Iraq, before 9/11.
And very early on, I was not interested in the conflict. I did not think we had justification. We have not declared war. Congress has not declared war in this country against an enemy since 1942. So I’m not interested in fighting wars that are not declared by Congress, that we have not agreed are threatening our nation. But I had to renege on my commitment.
So there’s a real values conflict, and I suffered a lot from it. It was a hard time. I had a hard choice. I wasn’t confident I made the right choice, and there’s nothing that’s going to take that away from me. Like you said in the beginning, you hurt because you care. There’s something I care about that was violated.
So when we’ve gone through and really right sized what happened versus what we think should happen, there’s still a gap sometimes. So for me, like a gap of care, or a gap of justice, a gap of, I think, righteous foreign policy in my case. So then we have to help somebody honor those violated values.
So I can’t go fix Iraq. That’s not something I get to do. But I did get to do this really cool project, where I always wear this bracelet, and this is actually part of a bomb that we dropped on Laos. So we also, as you know, didn’t declare war in Vietnam. That was never a war. And we never even admitted we were in Laos. But that is the most bombed country per capita in the whole world.
So it’ll take another 150 years to remove all the bombs that we dropped on them, at the rate they’re going. And even now, villagers can find these little bomblets from cluster bombs, and if they handle them improperly, they get blown up. So this still happens in Laos.
Dr. Lisa: Oh, gosh.
Dr. Jaimie Lusk: But there’s a group called the Mine Advisory Group that’s training people to get these out in safe ways. And so there’s a village that takes all the extra stuff. It’s called Spoon Village. Takes all the extra bombs that they remove safely, and they make jewelry out of it. So it’s a little token of something I got to participate in that wasn’t maybe repairing from my war, but it was repairing another war. So that was a way I could honor that value.
Dr. Lisa: Oh my gosh. Okay. So what I’m hearing, there’s a lot here, but what I’m hearing are a couple of big things.
Dr. Lisa: And I’m just going to restate this very clearly, that even if you are telling yourself you are a terrible person for having participated in whatever, or made the mistakes, whatever it was, actually the fact that you are feeling as badly as you are is direct evidence of the fact that you are a caring person with a very clear moral center. If you didn’t have that, this wouldn’t bother you at all. So hold on to that part.
But then additionally, Jaimie, I’m hearing that perhaps part of this process, maybe even further out, is this not just the repair, not just the healing and the different relationship that you have with the event and the way you showed up in that event, but that longer term there is almost like a redemption. Like, how can I become realigned with my moral compass in a way that helps me feel like a force of good in the world again? Is that the right way to say it?
Dr. Jaimie Lusk: Absolutely. There’s a Vietnam veteran who wrote a book called At Hell’s Gate, and he said something really similar. He said, what could I do about the lives I have taken? I can’t undo them. I can’t bring them back to life. But I’ve realized that the world doesn’t work by a simple math equation, eye for an eye, tooth for a tooth, bridge for a bridge. I have taken life, and now I get to commit to giving life.
So that guy, he’s traveled around the world as a mendicant monk to war torn villages. He’s actually going to be in Ukraine in August. His name is Claude Anchin Thomas. So he’s still living his amends work in a way that’s pretty powerful.
Dr. Lisa: Well, that’s interesting, though. And I think, just in talking with you, I’m understanding this in a different way. There’s the sort of darkness part that’s internalized and sort of self destructive, right? But then if you can almost flip it through this healing process, there’s a lot of regenerative power almost that comes out of it.
Dr. Jaimie Lusk: Absolutely, yeah.
Dr. Lisa: Woof. All right. This is powerful, Jaimie. I never knew that about your bracelet. Thank you so much for sharing that story. That’s really cool.
Dr. Lisa: We’re on the final stretch here. You were sharing some really helpful interventions and ideas and resources that could help reorient people and change the relationship with what happened. But I’d really like to spend the last third of our time here together talking about what you know around what to do, where to go, where to get the right kind of help.
Because we were just chatting, and I mentioned that my biggest fear is that somebody listening to this is going to sign up for the first generic therapy subscription they find, right? Because I think the narrative in our culture is that therapy is therapy, and that’s not even a little bit true. It is so easy to get connected, and no shade on any of those services or the therapists who work for them. But what we’re talking about is not even a little bit the same. So how does someone find a specialized person such as yourself? Let’s not do that. What should they do instead?
Dr. Jaimie Lusk: Well, the VA has led both the understanding of moral injury and the treatment. Trauma Informed Guilt Reduction, which I’m presenting on, I’ve been using it since 2016. The developers are actually from the San Diego VA, Doctors Allard and Norman, and many others.
Dr. Lisa: So, reading through people’s bios, looking for that type of pedigree. A former VA psychologist with training specifically in moral injury.
Okay, and so then, Dr. Jaimie, before we let you go, I certainly want to give you some airtime. I mean, you’re such a wealth of information. And you so kindly mentioned, just get in touch with me, and if I can help you personally, I could recommend you. So tell us more about your special gifts and how you use them.
Dr. Jaimie Lusk: Well, I have been a clinician in the VA for fifteen years. I’ll be leaving in December. I’ve been able to build a private practice over the last couple of years that’s really specializing in PTSD, moral injury, and loss. And so people in high stakes situations. I work with all sorts of people, including journalists, healthcare providers, people in cybersecurity, and of course veterans.
Dr. Lisa: Cybersecurity, that’s interesting. I wouldn’t have tossed that one into the, sorry, not to digress, but.
Dr. Jaimie Lusk: Well, think of how much, a lot of times very fastidious people who really care about their job, and then constant bad actors trying to break into the system, and lots of non-adaptive guilt if there’s a breach. So people have to be on 24/7, and then of course, now they’re stuck with guilt if anything happens, even if their client wasn’t paying for the level of security that would have prevented it, even if this is a new special hack that nobody’s ever done before. It doesn’t matter. They take that on. Lots of overestimate of responsibility in that job. So many other jobs are similar.
If somebody is not ready for therapy and they’re just ready to do something, I do have a free course on my website. That is acceptance and commitment therapy for moral distress. So you can play with some of those concepts and see if they fit for you, and see if that is something you’d want to pursue in therapy.
Dr. Lisa: And mention your website.
Dr. Jaimie Lusk: Oh, drjaimielusk.com. You have to spell my name right. I have two i’s. J, A, I, M, I, E.
Dr. Lisa: So drjaimielusk.com. Okay, so there’s that free acceptance and commitment activity.
Dr. Jaimie Lusk: And then I also, if guilt is in the mix for you, guilt and shame, I love, there’s, self help books are mostly not evidence based. It’s mostly a person that just writes a book. But this one, Transforming Your Guilt and Shame, is directly based on that Trauma Informed Guilt Reduction. So this book, Transforming Your Guilt and Shame, very well written, lots of activities, by Dr. Allard. Highly recommend if you’re really stuck in that guilt and shame from a moral injury.
Dr. Lisa: And is that the cave that you’re talking about, people that are really stuck? I’ve heard you say, I go into the cave to find the person, drag them out. How could somebody listening be an ally like you? What does that involve? What are we talking about right now?
Dr. Jaimie Lusk: Well, I think we go back to how you worked with your family member. You know when somebody’s stuck. He was literally stuck in his room. So there’s the cave. That’s an actual cave.
So if there’s somebody you love that’s, I think it’s fair on the Love, Happiness and Success podcast that we believe people were born for joy and connection. And if you see somebody that absolutely is avoiding it at all cost, there’s a barrier, and one of the biggest barriers is shame.
Dr. Lisa: Yeah. No, seriously. And not to make light of it, and obviously we don’t want to be overly intrusive, that could cause new problems. But actually, maybe there does need to be somebody who cares enough and who is brave enough to say hi, to call out of the blue and say, hello. I know you’re not okay. And here I am, and I know you don’t want the help, but I’m going to do it anyway. So here’s a book, here’s a podcast, here’s Dr. Jaimie Lusk’s website. And that somebody might actually need that. So go ahead and embarrass yourself. Seriously.
Any last words to share, Dr. Jaimie?
Dr. Jaimie Lusk: No, I’m excited. I get to hang out with Dr. Lisa at the APA conference, and I get to celebrate all that she’s doing. I love this podcast. And Dr. Lisa, your T-shirt cannon. I’m going to try to have some of your joy. Take it on.
Dr. Lisa: Well, Dr. Jaimie Lusk, it was such a pleasure to hang out with you, as always, and thank you so much for sharing your insight and expertise with our audience. So you guys, I’m sure listening to this like, I need more Dr. Jaimie in my life. So again, the website is drjaimielusk.com. And you’re on?
Dr. Jaimie Lusk: On LinkedIn. I’m trying to figure out Instagram. And can I just tell you one thing? So I got involved with a group. It’s nonpartisan, but it’s a bunch of veterans who have moral distress and moral injury.
Dr. Lisa: Are these the ones you took surfing?
Dr. Jaimie Lusk: I do take veterans surfing a lot, but these are Veterans For Public Lands. So they started a nonprofit to start trying to protect public lands. So as you know, there’s public lands under threat. And it’s a really cool group, in that it kind of goes back to my bracelet here. Veterans who fought for our country and want to protect what they love best, which is public lands. So I’ve been pretty inspired by that group.
And I think that’s why I’m trying to figure out Instagram, because I’m doing my own posts, but I’m blasting some of the Veterans For Public Lands. And hey, if you’re an Instagram person and you’ve got tips, I could learn a few things.
Dr. Lisa: Me too, Jaimie. I don’t even know what this is. But okay, so Veterans For Public Lands. What a wonderful place to land.
And I think full circle, right, is that the end of the story, the end of this is one of redemption. There are many different ways to foster that type of energy. Some people find it spiritually. Some people find it through these acts of service, or getting involved with organizations that are intentionally making the world a better place. Our country, literally the land itself, a better place. And that’s what lies ahead.
So thank you so much for spending this time with me today.
What to take with you
Moral injury is not the event, it is the aftermath.
Two people can live through the same thing, and one walks away untouched while the other is still turning it over fifteen years later. What separates them is not the event. It is what happened next.
It is a values violation, not a fear response.
A fear based trauma reaction says make sure that never happens again. Moral injury says something different and much harder to live with: I am contaminated.
The guilt can be right sized against the actual facts.
Percent responsibility, what you actually intended, which of your values you were honoring, and which options were genuinely available to you. Most people are holding themselves to choices that were never on the table.
Right sizing does not close the whole gap, and it is not supposed to.
What remains is a gap of care. The work then becomes honoring the violated value through action, which is a much more possible thing than undoing the past.
Not all therapy is the same, and this is one of the specialized areas.
Reading a provider’s bio for specific training in this work is not being difficult. It is the difference between help and a wasted opportunity.
The pain is evidence of your conscience, not your character.
If you did not have a working moral center, none of this would bother you at all. There is also a group coaching program for people working on exactly this kind of thing, alongside one on one therapy and coaching, if working through it with other people sounds better than doing it alone.
Moral Injury: How to Deal With Guilt That Will Not Lift
It comes back at the strangest times. You are rinsing a plate, or you are ninety seconds from falling asleep, and there it is again. That thing. And the part that is almost impossible to explain to anybody is that it is not really that you feel bad about what happened. It is that you feel implicated by it. Like it told you something true about who you are, and you have been quietly managing around that information ever since.
If you have been carrying something like that for years without a word for it, here is the word: moral injury. Moral injury is what happens when something you did, or failed to do, or watched happen violated a value you genuinely hold, and you have been trying to get away from that feeling ever since. It is not the event itself. It is the way the event keeps working on you afterward. This is one of the most common things people bring to us in therapy and coaching for personal growth, and almost nobody who walks in the door has a name for it yet.
Before we go a single step further, I want to say the thing you have probably been waiting a very long time for somebody to say to you. The fact that this hurts as much as it does is not evidence that you are a bad person. It is evidence that you have a working moral center. You hurt because you care. If you did not care, none of this would bother you at all.
Now let me be honest with you about what an article can and cannot do, because I think you deserve that. Most of the people who come to my team carrying something like this have already read the articles. They have already been up at 1am with their phone, reading. They know intellectually that they were fifteen, or that they were flooded, or that they were doing the best they could with the information they had in that moment. And it has not touched the feeling even slightly. That is not because they are not smart enough. It is because you cannot argue yourself out of something you have never said out loud to another human being. So here is my promise for the rest of this piece: I am going to give you a name, a mechanism, and a real method you can start working on by yourself, and I mean that, it genuinely helps. But the part where the thing actually comes out of your mouth in front of someone who does not flinch, that is the part my team does with people every single day, and in my experience it is the part that actually changes the temperature of it.
This came out of my conversation with Dr. Jaimie Lusk, a board certified clinical psychologist, Naval Academy graduate, Marine Corps veteran, and one of the country’s leading moral injury researchers. She spent fifteen years as a clinician in the VA system and she has built and studied moral injury programs in both the United States and Canada. She is also a friend, and she said something to me in this conversation that I have not stopped thinking about.
What is moral injury, and how is it different from ordinary guilt?
Moral injury is the lasting damage that follows an event that violated your own moral code. Ordinary guilt is about something you did. Moral injury is about who you have decided you are because of it. That distinction sounds small on the page and it is enormous in a life.
Dr. Lusk draws a line that reorganized how I think about this. There is the event, which researchers call a potentially morally injurious event, and then there is the injury, which is something else entirely. Two people can live through the same thing. One walks away and is essentially fine. The other is still turning it over fifteen years later. The event did not decide that. What happened afterward did.
The research language backs this up. The foundational 2009 paper by Litz and colleagues in Clinical Psychology Review defines the territory as perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs, and it describes consequences that are emotional, psychological, behavioral, spiritual, and social all at once (Litz et al., 2009). Notice how wide that is. Failing to prevent something counts. Learning about something counts.
There is also a texture difference that I found clarifying. A fear based trauma response tends to say: that horrible thing happened, and my job now is to make sure it never happens again, so I am going to avoid every reminder of it because reminders feel dangerous. Moral injury says something else. Dr. Lusk described it as feeling contaminated. Not endangered. Contaminated. Sit with the difference between those two words for a second and you will understand why the usual advice has not worked for you.
And here is the part that quietly makes everything harder: moral injury is not a diagnosis. It sits in the coding system as a moral, religious, and spiritual problem rather than a treatable condition, which means a person can be genuinely suffering and still run into trouble getting care recognized or covered. It is real. It has a research literature. It just does not have a box on the form.
What are some moral injury examples? Usually the ones nobody calls moral injury.
The most common examples are ordinary. Not war. Not headlines. Something you did at nineteen, or last spring, that violated a value you actually hold.
When I asked Dr. Lusk for examples, this is where she went. Somebody who bullied another kid in middle school, and years later sees that the person is alive and well, and still wonders what it cost them and how they got through it. An affair. Another kind of betrayal of a partner. A moment when you were not honest with somebody you love. A leadership mistake, the kind where other people absorbed the consequences of your call. And one that I think catches almost everybody: a reaction in fight or flight mode that did not line up at all with how you would have responded if you had been given ten seconds to think about it.
She works with people in high stakes jobs too, and the pattern there is instructive even if your job is nothing like theirs. Healthcare workers who could not treat someone the way they wanted to, or who found themselves participating in compromises the system required of them. Journalists. And, in a detail I did not expect, people in cybersecurity, who tend to be extremely conscientious people responsible for holding off constant attacks, and who take on enormous guilt when something gets through, even when the breach involved a method nobody had ever seen before and even when the client had declined the level of protection that would have stopped it. Her phrase for that was overestimate of responsibility, and once you hear it you start seeing it everywhere.
If you are reading this and thinking that yours is not big enough to count, that is the injury talking. Almost everyone I have ever worked with on this arrived with an argument for why their thing did not qualify and also could not put it down. Our coaches see that particular contradiction constantly, and there is nothing unusual about you for holding both at the same time. If it has been running in the background of your life for years, it counts, and it is workable.
Why do I still feel guilty about something that happened years ago?
Because avoidance preserves it. Every time you steer around the memory, you confirm to yourself that it is unbearable, and you never get the chance to find out what is actually underneath it.
Dr. Lusk describes the mechanism as a cycle. The event produces moral distress, and that distress can arrive as fear, anger, horror, disgust, guilt, or shame. Then you try to escape it, which is entirely human. But the escape strategies are short term, and they generate more of the very stress they were meant to solve. The forms she named: isolating, overworking, launching a kind of superhero mission to fix the whole world, or shutting down into a version of yourself that does not match your values at all.
Look at that list again, because it is easy to skim past. Overworking is on it. So is a mission to make the world better. Some of the most admired people you know may be inside a cycle nobody has ever named for them.
The injury, in her framing, is not the emotion. It is the functional impairment. It is the shape your life takes once you have organized it around not looking at something. And the current research supports treating this as its own phenomenon with its own trajectory rather than a subtype of something else (Griffin et al., 2019). This is also where unhealthy guilt does its quietest damage, since the guilt stops being about an event and starts functioning as a standing verdict about you.
There is a version of this that shows up as pulling away from people, getting prickly, and finding ways to block your own access to joy, and if you want to hear more about how that pattern forms and unwinds, we have a whole conversation on dealing with regret that pairs well with this one.
How do you deal with guilt when you actually did something wrong?
You right size it against the actual facts. Not talk yourself out of it, and not confess your way through it. You look at what genuinely happened and check your verdict against the evidence, which almost nobody has ever actually done.
This is the method, and it comes out of Trauma Informed Guilt Reduction, a brief structured approach developed at the San Diego VA that Dr. Lusk has been using since 2016 and is presenting on at the 2026 APA convention. The published protocol was designed specifically to reduce trauma related guilt and shame rather than treating them as side effects of something else (Norman, Wilkins, Myers, and Allard, 2014). It moves in four passes.
- Percent responsibility. You start with “it was all my fault,” and then you actually do the math. Who else was there. What else was in motion. What percentage was genuinely yours.
- Intent, and the values you were honoring. What were you actually trying to do at the time? Not what happened. What you were going for. There is almost always a values clash hiding in here, and the value you were honoring is usually a decent one.
- The options genuinely available to you. This is the one that undoes people, in the good way. Most of us are holding ourselves accountable for choices that were never actually on the table. You play the scenario out honestly and discover that the alternative you have been punishing yourself for was not a real option.
- And then the million dollar question. Dr. Lusk’s phrasing, which she takes from the protocol: if you had known for certain that was going to happen, what would you have done differently that day? People answer that question and hear themselves say, well, obviously I would have done it completely differently, which means they did not know. Which means the thing they have been carrying is not what they thought it was.
What made this conversation different from every other explanation of guilt I have read is that we did not just describe the method, we accidentally demonstrated it. I told Dr. Lusk a story about a teenage family member of mine, not my kid, who had a bunch of other fifteen year olds over and was messing around with fire in the garage, and one of the kids got burned badly enough to need the emergency room. My family member would not come out of his room. He was absolutely certain it was all his fault. And I did what you do, which in my case meant asking him whether he made the other kid do it, whether he threw anything at anybody, whether he would ever have done that on purpose, and pointing out that this was a group effort by five kids and not a solo act.
Then Dr. Lusk stopped me and named what I had just done. Percent responsibility. Intent. The values being honored, which in the case of five fifteen year olds in a garage were having fun together and, in her generous read, doing something less dangerous than several available alternatives. Options actually available. I had reached for a formal evidence based protocol without knowing I was doing it, in a hallway, with a teenager. That is how ordinary this is, and how usable.
Reading those four passes and doing them are genuinely different activities, and I want to name why. You cannot cross examine yourself. The person doing the examining is the same person who wrote the verdict, and they are not a neutral party. What makes this work is a second set of eyes that has heard a lot of stories and is not going to flinch at yours, asking the next question you were about to skip. That is a specific thing our therapists and coaches do, and it is unglamorous and it is effective. Practicing self compassion makes the process survivable, but somebody else asking the questions is what makes it move.
The free What’s Holding You Back? quiz gives you a personalized read on where you are stuck across thinking, emotions, behaviors, and relationships, and what to work on first.
Take the Free Quiz →“You hurt because you care. There’s something I care about that was violated.” — Dr. Jaimie Lusk, PsyD, ABPP
What about the part that does not resolve?
Sometimes the guilt shrinks and something still remains. That is not a failure of the method. It is information, and there is a specific thing to do with it.
Dr. Lusk was remarkably direct with me here, and she used her own life to make the point. She entered the Naval Academy and joined the Marine Corps in May of 2001. Early on she found that she did not believe in what she had committed to, and she had to renege on that commitment. She described a real values conflict, said she was not confident she made the right choice, and said plainly that nothing is ever going to take that away from her.
I want you to notice what just happened. A board certified psychologist and moral injury researcher, on the record, saying she has something unresolved. Her framing is that what is left over is a gap. A gap of care. A gap of justice. And no amount of accurate accounting closes it, because it was never an accounting error. It was a value getting violated, and the value is still yours.
If you have been waiting to feel finished before you talk to anyone, this is your permission to stop waiting. You do not need to arrive at a conversation with your material resolved, and you do not need to have failed at this on your own first. Most of the people who come to us are somewhere in the middle of exactly this, holding something they have partly made sense of and partly not, and that is a completely normal place to start from.
How do you make amends for something you cannot undo?
You honor the violated value through action. Not by fixing the original thing, which is usually impossible, but by putting real weight behind the value that got broken.
This is where the conversation stopped being clinical for me. Dr. Lusk wears a bracelet made from a bomb. It came from Laos, one of the most heavily bombed places per capita on earth, where recovery crews are still clearing ordnance and villagers can still be hurt handling what turns up. A group trains people to remove it safely, and one village takes the recovered material and turns it into jewelry. She described the bracelet as repairing not her own war, but another one.
She also passed along a framing from a veteran who became a monk and has spent his life traveling to war torn places. His version: the world does not run on a simple math equation, one thing traded for another. Having taken life, he now gets to commit to giving life. That is not a formula for erasing anything, and he is not pretending it is. It is a direction to walk in.
For most readers this is going to look much smaller and much more ordinary than a bracelet, and that is the point. If the value that got violated was honesty, then the amends live in a lifetime of being the person who says the harder true thing. If it was care, the amends live in how you show up for people now. If it was justice, there is probably an organization near you that needs exactly your kind of stubbornness. Some people find this route spiritually, some find it through service, and it is closely related to finding forgiveness in the sense that neither one requires the past to change.
Where this gets genuinely hard is figuring out which value actually got violated, because most people have never been asked and cannot name it cold. That is a real piece of work, and it is the kind of thing that happens naturally in coaching, usually somewhere around the third or fourth conversation, often while you are talking about something that seems unrelated. Our coaches do this constantly, and it tends to open into much larger questions about finding your purpose than anyone expects when they start. What comes out the other side of this is not just relief. There is real regenerative power in it, and the research literature on post traumatic growth has been describing that outcome for decades.
How do I help someone I love who has gone quiet?
Offer your observation, not your diagnosis. Name what you see, tell them they do not have to talk to you about it, and tell them you will help them find help if they ever want it. Then let it sit.
A big part of this episode turned out to be for a completely different reader: not the person carrying something, but the person watching someone they love disappear into it. If that is you, here is what Dr. Lusk says it looks like from the outside. A pulling away. Defensiveness. Someone becoming harder to feel joy or compassion with. A shutdown. A hiding.
She rejects the word self sabotage for this, and her reason is good. That label misses the purpose of the behavior. This is not someone undermining themselves at random. This is someone who does not believe they deserve good things, so they get in the way of good things arriving. Once you see the behavior as protective rather than self destructive, your whole approach to the conversation changes.
And then she gave me the actual language, which is the practical gift of this episode. Not a diagnosis. An observation. Something in the neighborhood of: I see a heaviness in you. I see you struggling. You do not have to talk to me about it, but I want you to know that I see it, and if you ever want help, I will help you find someone. That is it. You are not extracting a confession. You are removing the reason to hide.
One more thing, from me rather than from her. If a thought bubbles up that you should check on somebody, make the call. Do not wait until you have the right words. The worst realistic outcome is that they are puzzled and slightly touched, and you have lost nothing at all.
If you are the one on the outside, two things are worth reading next: our conversation about how to help someone get help, which is the closest companion piece to this section in our whole library, and our piece on toxic shame, because shame is the barrier you are actually up against. And I will say this plainly: supporting someone who is carrying something they will not name is exhausting, and it is a completely legitimate reason to talk to someone yourself. Our team works with the people on the outside of this as often as the people on the inside of it, and you are allowed to need support for the position you are in even though it is not your event.
Why reading this article probably isn’t enough
I want to be straight with you about something, because I would rather lose your click than mislead you.
Everything above is real. The method works. People right size guilt they have carried for twenty years and come out the other side different. But I would be doing you a disservice if I let you close this tab thinking that reading it was the work.
Here is what almost always happens instead. You read something like this. Something clicks, and you feel a flicker of hope, and you make a quiet mental note to try the four passes on your own thing later. And then later arrives, and you sit down with it, and within about ninety seconds you are back inside the same verdict you have been living under, because the prosecutor and the defense attorney and the judge are all you, and they have already agreed on the outcome. That is not a discipline problem and it is not a character problem. It is a structural problem. You cannot get a second opinion from yourself.
Then there is the other reason, which Dr. Lusk names better than I can. Compassion cannot happen inside secrecy, judgment, and silence. Whatever this is has to come out of your mouth, out loud, in a room with somebody, and then not be met with a flinch. That is the actual mechanism. That is not a nice extra on top of the technique, it is the thing that makes the technique work at all.
You do not need to be in crisis to do this. You do not need a dramatic story. You do not need to have tried and failed first. A first conversation with someone on our team is not an intake for a program, it is a real conversation about what is actually going on with you and whether what we do here is the right fit for it. Sometimes the honest answer is that you need something more specialized, and we will tell you that too.
If something in this article landed somewhere specific, that is the signal.
Schedule a free consultation with a therapist or coach on our team. No pressure, no commitment. There are also a few ways in at different price points, including one on one therapy or coaching, a group coaching program for people working on this alongside other people, and a low cost practicum option if cost is the thing standing in your way. You do not have to figure out which one is right before you talk to us. That is genuinely what the first conversation is for.
What kind of therapist do I need for guilt and moral injury?
Look for someone with specific training in this area rather than a general practice, read their bio for it directly, and treat prior work inside the VA system as a strong signal. This is one of the genuinely specialized corners of our field, and the difference between the right provider and a nearby one is not small.
This is the part of the conversation I pushed hardest on, because I have a real fear about it. There is a narrative in our culture that therapy is therapy, that any licensed person is roughly interchangeable, and that is not even slightly true. There are highly specialized spaces inside this profession. When someone finally gathers the courage to bring the hardest thing they have ever done into a room, and they land with a provider who has no training in it, they very often conclude that therapy does not work and never try again. That is not a small loss. That is a wasted opportunity that can cost somebody a decade.
Dr. Lusk’s practical guidance: the VA has led both the understanding and the treatment of this, so a clinician who trained in that system has usually had access to the deepest bench available. Read bios for named training rather than a general list of specialties. And she offered, genuinely, to help people find someone. She is licensed in three states and connected to trained clinicians nationwide, which matters, because the list of people who actually do this work is shorter than you would hope. If you want a wider frame on how to evaluate any provider before you commit, we have a whole page on what kind of therapist do I need that walks through it.
Now let me be honest about us, because you deserve that more than you deserve a smooth sales pitch. Growing Self is not a specialized moral injury treatment program, and I am not going to pretend otherwise on a page about moral injury. What our therapists and coaches are genuinely excellent at is the very large territory next door to it: everyday guilt that will not lift, a decision you cannot stop replaying, a values conflict you have never articulated, a pattern of quietly punishing yourself, a marriage or a friendship or a career that got smaller because of something you have never said. If that is your material, that is our work, and a free consultation is the right next step. If your material is more specialized than that, tell us in the consultation and we will help you figure out where to go instead. I would much rather send you to the right person than keep you.
Your pain is evidence of your conscience
If you take one thing out of this, take this one, because it is the thing I stopped the conversation to say out loud.
Even if you are telling yourself that you are a terrible person for whatever you did or participated in or failed to prevent, the fact that you feel as badly as you do is direct evidence of something else entirely. It means you are a caring person with a very clear moral center. If you did not have one, this would not bother you at all. It would have slid off years ago the way it slides off people who do not have your conscience.
Dr. Lusk’s version, said from inside her own unresolved story, is shorter and better than mine. You hurt because you care. Something you care about was violated.
So the thing that has felt like proof of the worst thing about you is actually proof of the best thing about you. That does not make it hurt less today. It does completely change what the hurt means, and what it means determines what you do next. Some of what comes next is letting go of resentment, including the resentment you have been aiming at yourself for a very long time.
Here is what I would love for you to do. Think of the person you have never told. It might be a friend, it might be a professional, it might be someone on my team. Then say the thing out loud to one human being. That is the whole first step. It is smaller than you think and it changes more than you would expect.
And if you want that first person to be someone whose entire job is to hear it without flinching, we do free consultations for exactly this. Not to sign you up for something. To find out together whether what you are carrying is something we can actually help with.
xoxo,
Dr. Lisa Marie Bobby
P.S. If you are not ready to talk to anyone yet, that is completely allowed. Take the What’s Holding You Back? quiz instead. It takes a few minutes and it is a reasonable way to find out whether the thing standing between you and the life you want is the thing you think it is.
P.P.S. If you read the section about someone you love and thought of a specific person, do not close this and get on with your day. Text them. Right now. I see a heaviness is a complete sentence.
About the author. Dr. Lisa Marie Bobby, PhD, LMFT, BCC. Licensed marriage and family therapist, board certified coach, founder and clinical director of Growing Self Counseling and Coaching, and author of Exaholics: Breaking Your Addiction to an Ex Love. Host of the Love, Happiness and Success podcast. Full bio and credentials.
About this episode’s experts
Dr. Jaimie Lusk
Dr. Jaimie Lusk is a board certified clinical psychologist, a Naval Academy graduate, and a Marine Corps veteran who spent fifteen years as a clinician inside the VA system before moving into private practice. She is a moral injury researcher who has developed and implemented interventions in both the United States and Canada, she is licensed in Oregon, California, and Idaho, and she is presenting on Trauma Informed Guilt Reduction at the 2026 APA convention. She is also, and she will tell you this herself, a Board Certified Coach who came through our certification program, which is a detail I mention mostly because I am proud of her. What makes her unusual is not the resume, though the resume is real. It is that she brought her own unresolved material into this conversation without being asked to. Her practice works with people in high stakes roles, and she also runs group programs built around this work. If what you are carrying needs a specialist rather than the kind of coaching and therapy my team does, she is a good person to talk to.
Dr. Lisa Marie Bobby
Licensed marriage and family therapist, board certified coach, and founder and clinical director of Growing Self Counseling and Coaching. Author of Exaholics: Breaking Your Addiction to an Ex Love. Host of the Love, Happiness and Success podcast. Creator of the Growing Self Institute, where she trains licensed mental health professionals in evidence-based coaching psychology.
Resources mentioned in this episode
Sources cited in this article
- 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. https://doi.org/10.1002/jts.22362
- 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. https://doi.org/10.1016/j.cpr.2009.07.003
- Norman, S. B., Wilkins, K. C., Myers, U. S., & Allard, C. B. (2014). Trauma informed guilt reduction therapy with combat veterans. Cognitive and Behavioral Practice, 21(1), 78–88. https://doi.org/10.1016/j.cbpra.2013.08.001
Moral injury: frequently asked questions
What is moral injury?
Moral injury is the lasting psychological and moral distress that follows an event that violated your own deeply held values. It can come from something you did, something you failed to prevent, or something you witnessed. Critically, it is not the event itself. It is the way the event continues to work on you afterward, and the way your life reorganizes around not looking at it.
Is moral injury the same as PTSD?
No. They overlap and they are distinct. A fear based trauma response is organized around danger and typically says: make sure that never happens again. Moral injury is organized around a values violation, and the characteristic feeling is closer to contamination than to fear. A person can have one, the other, or both.
Is moral injury a formal diagnosis?
No. It is not a diagnosable condition. It sits in the coding system as a Z code, under moral, religious, and spiritual problems, a category updated in 2025 to include the word moral. That has practical consequences, because someone can be genuinely impaired and still struggle to get care recognized or covered.
What are examples of moral injury?
The most common ones are ordinary. Bullying someone as a child and wondering years later what it cost them. An affair or another betrayal of a partner. Not being honest with someone you love. A leadership decision other people paid for. Reacting in a fight or flight state in a way that did not match who you are when you have time to think. It also shows up in healthcare, journalism, and cybersecurity, where people take on responsibility far beyond their actual share.
Why does moral injury last for years when other memories fade?
Because escaping a feeling preserves it. Avoidance keeps you from finding out what is underneath the feeling, and the short term strategies people use to escape it, including isolating, overworking, and taking on a mission to fix everything, tend to generate more distress over time. The result is a self sustaining cycle, and the lasting damage is the functional impairment rather than the emotion itself.
How do you deal with guilt when you genuinely did something wrong?
You right size it against the facts using four passes. First, examine your actual percent responsibility instead of accepting that it was all your fault. Second, establish what you intended and which of your values you were honoring at the time. Third, identify which options were genuinely available to you, since most people hold themselves to choices that were never on the table. Fourth, ask the question that matters most: if you had known for certain what was going to happen, what would you have done differently? The goal is not absolution. It is getting the gap between what should have happened and what did down to its real size.
What do you do about the guilt that does not go away after all that?
You honor the violated value through action. What remains after right sizing is usually a gap of care or a gap of justice, and it does not close by thinking about it, because it was never a thinking error. It closes, as much as it ever does, by putting real weight behind the value that was broken. If it was honesty, you become the person who says the harder true thing. If it was care, you show up differently for people now.
How do you make amends for something you cannot undo?
By committing to the value rather than trying to balance a ledger. There is no equation where one act cancels another. What is available is a direction. One veteran turned monk described it as having taken life and now getting to commit to giving life. For most people this looks much smaller and much more ordinary, and it works anyway.
How can I tell if someone I love is struggling with something like this, and what should I say?
Watch for pulling away, defensiveness, becoming harder to feel joy or compassion with, and a general shutdown or hiding. When you speak to it, offer an observation rather than a diagnosis. Tell them you see a heaviness, that they do not have to talk to you about it, and that if they ever want help you will help them find it. You are not trying to extract a confession. You are removing the reason to hide.
What kind of therapist do I need for guilt and moral injury?
Look for specific training in this area rather than a general practice, and read the provider’s bio for it directly rather than assuming. Prior work inside the VA system is a strong signal, since that system has invested the most in understanding and treating this. If your material is everyday guilt, a values conflict, or a decision you cannot stop replaying, a broader therapist or coach who works in personal growth is a good fit. If your presentation is severe or highly specialized, you want a specialist, and it is worth the extra effort to find one.
