In depth: On the frontline
Thresholds, October 2026

Several years ago, when I began thinking about the book I am currently writing, Moral Injury on the Frontline: a guide to sustaining ourselves in morally challenging contexts, I didn’t realise quite how timely and urgent the issue was becoming. Now, in 2026, it no longer seems radical to say that we are living in morally injurious times.

I wonder what the concept of moral injury entering the mainstream means for us as counselling and psychotherapy professionals? How do we feel about exploring moral complexity with our clients, and witnessing the deep hurts of moral injury? In 2025, reference to ‘moral problems’ was included for the first time within the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM–5–TR) updates under ‘Religious, spiritual and moral problems’. This is a significant moment for moral injury and some feel it may mark the beginning of a journey towards diagnosis. What do you think of the argument for this, versus the idea that we may be pathologising a moral response to suffering and injustice?

In The Body Keeps the Score,¹ trauma expert Bessel van der Kolk describes being asked if he could just talk about trauma in his conference speeches and leave the political stuff out. He replied that this was impossible because trauma is political. I believe that moral injury is both a political and a spiritual issue. The International Centre for Moral Injury at Durham University states that ‘Moral injury involves a profound sense of broken trust in ourselves, our leaders, governments and institutions to act in just and morally “good” ways.’²

Austerity, inequality and the double standards exposed during the pandemic have created a loss of trust in those who serve and lead us. The catastrophic state of our prisons and the wider criminal justice system is just one example of a betrayal of the most vulnerable by those in authority, one of the risk factors for moral injury. The rising suicide rate among doctors and nurses, the impossible workloads and low pay experienced by social care workers, and the exodus of teachers who feel they have no option but to walk away from careers they love to protect their health are all examples of this. The heartbreak of Gaza, Sudan, Ukraine, Iran, and the growing inequality that places the UK as the most unequal country in Western Europe, are not accidental outcomes but the result of political and moral decisions. And perhaps, we might argue, spiritual collapse.

Reducing the occurrence of moral injury requires systemic and political change and a cultural shift towards morally healthy organisations.³ However, change comes slowly and I believe we have a collective duty to safeguard and protect the moral wellbeing of practitioners who will continue to train, work and lead within overstretched, imperfect systems for the foreseeable future. As therapists, we can play a part by deepening our understanding of moral harm and supporting recovery through compassionate witnessing.

Moral injury and moral distress have been acknowledged in military and health contexts for several decades. Moral distress is the psychological unease that arises when a professional is unable to take the action they believe to be morally and ethically right, due to organisational constraints.⁴ Moral injury is the emotional, psychological and spiritual suffering caused by perpetrating, failing to prevent, bearing witness to, or knowing about acts that transgress deeply held moral beliefs,⁵ often exacerbated by ‘a betrayal of what’s right’ from someone in authority, as described by Jonathan Shay,⁶ who first gave us the term ‘moral injury’ from his work with Vietnam veterans. Many were unable to reconcile acts committed or witnessed during their military service with their personal moral codes. Cumulative exposure to moral distress without space to debrief and process the feelings that arise can lead to moral injury. Moral injury can also stem from one or more acutely morally injurious experiences.

Over the past two years, I’ve been privileged to have a series of conversations about moral injury and moral repair with practitioners from across the human frontline. The second part of my book is called ‘Wisdom from the field’, where experienced professionals from social work, health, journalism, criminal justice and the military share their reflections on moral injury and moral repair. I hope the book will contribute to the paradigm shift that is needed across frontline professions: the recognition that we are human as well as professional.

Frontline practitioners are frequently exposed to suffering and injustice and confronted daily by the impact of inequality, poverty and oppression on people’s lives. Some of these encounters will be traumatic and distressing. Many will also be morally complex; situations where there is no good outcome, where justice, fairness or a satisfying resolution are not available. There can be an existential dimension, a sense of being unmoored and morally disorientated. Jonathan Shay talks of moral injury as the undoing of character,⁶ a profound loss of personal and professional integrity resulting in a shattered worldview. A person may be left with questions like ‘Who am I now?’, ‘How do I make sense of my life after these experiences?’, ‘What kind of person makes the decisions I made?’ Research demonstrating the link between moral injury and suicide⁷ increases the urgency for us to improve our awareness and understanding of this phenomenon.

The COVID-19 pandemic

‘As with soldiers in war, we know that when we stop doing, we’re going to start feeling.’ These words were written by healthcare workers in the US, during the first wave of the pandemic in March 2020,⁸ after the suicides of three of their colleagues. The pandemic brought a torrent of moral distress to a workforce already chronically exhausted and morally depleted from years of underfunding. They made an impassioned plea for time and support for staff to process the grief and trauma of the pandemic once the crisis ended. Six years on, we know that for most frontline staff, the time to stop and reflect never came and their crisis has still not ended. Several practitioners have described this to me as a collective amnesia, a surreal experience of ‘pretending it never happened’. But the consequences of this denial are severe and, possibly, preventative.

‘Reflect and Renew’ programme

Jonathan Shay argued that lasting moral and psychological harm was done to many thousands of Vietnam veterans, due to lack of opportunities to come together and ‘communalise’ their grief. He passionately advocates for collective approaches to healing and recovery. Moral injury is a social wound stemming from the breakdown of trust and it requires social healing. He suggests that moral injury might be repaired through a combination of ritual and socially-connected witnessing.

In 2016, I had been fortunate to receive a Churchill Fellowship. This is an annual award which supports people to travel abroad and research best practice in a specific field. This was a transformative experience which introduced me to the concept of moral injury and the role that creative approaches can play in moral repair.

In 2021, I collaborated with two other Churchill fellows⁹ Sophie Redlin (GP and researcher in medical anthropology) and Simon Edwards (military veteran and social entrepreneur) to develop ‘Reflect and Renew’, a group approach for frontline professionals experiencing moral distress and moral injury. The programme integrated findings from our fellowships, including theatre, storytelling and songwriting for moral repair;¹⁰ American Indian and Alaska Native talking circles for wellbeing,¹¹ and the Boulder Crest Foundation for post-traumatic growth.¹²

Sophie, Simon and I set up a social enterprise, Moral Injury Partnership, rooted in our shared understanding of moral injury as a biopsychosocial-spiritual response to moral harm.¹³ When we are compelled to act or are treated in ways that transgress our core values, it hurts us. As we consider this a normal, non-pathological response to moral violation, our approach sits outside the Western medical model of therapy or ‘treatment’. ‘Reflect and Renew’ is a guided group process, led and held by highly experienced facilitators within a supportive community of peers. Its core principle is that what has been lost to moral injury may be restored through compassionate witnessing in community.

It is a three-day residential retreat in a peaceful, rural setting that supports the sharing of morally injurious experiences and stories within a non-judgmental talking circle. The programme is structured to support participants through a reflective journey:

Day one: Who am I: making sense of my experience
Day two: Letting go of the past; self-forgiveness, self-compassion
Day three: Post-traumatic growth and a new future.

We have evaluated the programme with the International Centre for Moral Injury. My colleague, Simon Edwards, has been developing this programme with military veterans in Ukraine over the last year, with encouraging results. We hope to take this work forward in the UK, integrating a ‘train the trainer’ element which supports people to hold regular reflective spaces in their workplaces and communities. Moral challenge and moral distress are unavoidable in our current public services. Reflective spaces to debrief, process and communalise difficult experiences may prevent moral distress from progressing to the far more debilitating, and potentially life-threatening, moral injury.

The longer I am immersed in the field of moral injury, the more I discover that living and working in line with my values is essential for retaining my own moral integrity. Rutger Bregman writes that these times we’re living in, the climate crisis, the rise of autocracy and vast inequality, call for moral ambition; the will to make the world a wildly better place.¹⁴ One of my hopes in sharing my book is to give us permission to go inward a little and reflect, to slow down enough to remember who we are and what we stand for. To dare to dream of making the world a wildly better place and emerge with the clarity and courage to reach out to one another and make it happen.