Moral Injury and Moral Repair in War Veterans — A Preliminary Model and Intervention Strategy

The 2009 Clinical Psychology Review paper by Brett Litz and six co-authors is the most-cited single article in the moral-injury literature and the citation point for almost every post-2010 clinical and healthcare paper. Litz, the lead author, was director of the Massachusetts Veterans Epidemiological Research and Information Center at the Boston VA and a long-standing PTSD-research figure; the co-author list includes William P. Nash (a U.S. Navy psychiatrist who had worked on combat-stress doctrine inside the Marine Corps) and Shira Maguen (a National Center for PTSD researcher working specifically on the psychological consequences of killing in combat). The collaboration spans VA, DoD, and academic-clinical locations, which is part of why the paper had the institutional reach it did.

Clinical Psychology Review is one of the highest-impact peer-reviewed journals in the field; an article landing there with this author group was always going to be widely read. The paper is framed as a preliminary model and intervention strategy — the authors acknowledge they are reorganising existing clinical and research literature into a synthesis rather than introducing a construct de novo — and the principal moves are two. First, the construct of moral injury is broadened from Shay's narrower betrayal-by-authority frame to a perpetration-and-witnessing frame: the morally injurious event can come from one's own actions, from things one failed to prevent, or from witnessing what others did, and need not involve betrayal by a commander. Second, the construct is operationalised through the potentially morally injurious event (PMIE) — the language deliberately echoes the potentially traumatic event of the PTSD literature — and an intervention strategy is sketched, which became the adaptive disclosure psychotherapy protocol manualised in 2012.

The stake is professional, scientific, and institutional. Litz and his co-authors are clinical psychologists and psychiatrists working inside the VA and DoD research apparatus; the construct as they articulate it has to be tractable to factor analysis, treatment trials, and the evidence-based review processes those institutions use. Critics in the philosophical and theological literature (particularly Kinghorn in 2012 and Wiinikka-Lydon in 2019/2022) read the paper as the source of what they call the medicalisation of moral injury — the move that took an originally moral and communal phenomenon and made it a measurable individual-clinical construct. The paper is not unaware of this risk; it includes an explicit discussion of moral and spiritual content and gestures toward chaplaincy and community involvement. But the centre of gravity is clearly clinical.

For the moral-injury corpus this is the second foundational text after Achilles in Vietnam, and the principal disagreement of the field — which definition of moral injury you work with — is a disagreement between this paper and Shay. They are best read in sequence and against each other, with the secondary literature (Kinghorn, Sherman, Wiinikka-Lydon) as commentary on the disagreement.