Acceptance and commitment therapy for moral injury: conceptualizing and intervening on moral injury through the lens of contextual behavioral science.

Moral injury is at a critical juncture in its conceptualization. Current dominant approaches to conceptualizing and assessing moral injury are rooted in syndromal frameworks with implicit medical model assumptions. In these approaches, painful moral emotions and cognitions are often conceptualized as pathological symptoms to be reduced or corrected. Such approaches risk pathologizing deeply human moral responses and may inadvertently position clinicians as arbiters of which moral appraisals or emotional reactions are appropriate, proportionate, or adaptive. In this paper, we present Contextual Behavioral Science (CBS), the philosophical foundation of Acceptance and Commitment Therapy for Moral Injury (ACT-MI), as an alternative framework for conceptualizing and treating moral injury without pathologizing moral pain or requiring clinicians to adjudicate the validity of clients' moral judgments. Drawing on CBS, Relational Frame Theory (RFT), and evolutionary science, we examine the social functions of moral emotions, the human capacity to construct verbal moral narratives, and the implications of these processes for intervention. Building on these foundations, ACT-MI is described as an approach aimed at disrupting the behavioral patterns that maintain moral injury at both individual and group levels. Rather than targeting moral pain to reduce symptoms, using ACT-MI can facilitate transforming the individual's relationship to it. Through functional assessment, clients' efforts to avoid, control, or resolve moral pain are identified and addressed with core ACT processes, including acceptance, defusion, contact with the present moment, self-as-context, values, and committed action. Within this framework, individuals learn to hold moral pain while continuing to engage in values-based living and meaningful social functioning at individual and group levels of treatment. Assessment targets, methods, and hypotheses are identified to support testing the mechanisms and impacts of ACT-MI in future research.