# Thriving in the Midst of Moral Pain: The Acceptability and Feasibility of Acceptance and Commitment Therapy for Moral Injury (ACT-MI) Among Warzone Veterans

> **NIH VA I01** · VA EASTERN COLORADO HEALTH CARE SYSTEM · 2021 · —

## Abstract

Warzone Veterans exposed to morally injurious events frequently experience numerous difficulties in
functioning. These Veterans often report suicidal ideation and behavior, substance abuse, symptoms of
depression and PTSD, and problems in resuming valued living (e.g., spiritual practice, close relationships).1-7
Despite the transdiagnostic nature of moral injury, there are no moral injury-specific transdiagnostic
interventions. Existing interventions tend to be focused on treating moral injury in the context of PTSD.10-11
In addition to an emphasis on PTSD, these interventions target beliefs associated with moral injury as causal
factors in the development and maintenance of suffering.10-12 An emphasis on altering beliefs associated with
moral injury may not optimally facilitate functional recovery as moral pain from moral violations may be
justified. As one third of warzone Veterans endorse exposure to morally injurious events, it is vital to develop
interventions that can be efficiently disseminated in VHA to facilitate functional recovery.8-9 The ideal
intervention must simultaneously address moral emotions and promote values consistent behavior in the face
of these emotions.
 Acceptance and Commitment Therapy for moral injury (ACT-MI) is a recovery-based,
psychosocial treatment ideally suited for Veterans endorsing difficulties in functioning related
to moral injury.15 ACT teaches skills to help Veterans relate differently to painful thoughts, emotions, urges,
and sensations.40 Rather than focusing on symptom reduction, ACT is an evidence-based intervention that
directly targets functional recovery by assisting Veterans in identifying and engaging in values-consistent
behavior even in the presence of distress. In Veteran populations specifically, ACT has been demonstrated
effective in treating suicidal ideation and depression and as a result, has been “rolled-out” as an evidence based
psychotherapy for depression within VHA.59-60 ACT-MI operates on the principles of ACT, with an explicit
focus on the social functions of moral emotions.13-14 ACT-MI is the only intervention for moral injury that is
based on social functionalism which purports that moral emotions (e.g., shame, pride) serve evolutionary
purposes essential to group survival.15 Thus learning to interact with moral emotions differently is crucial to
recovery. In ACT-MI, a group-based intervention is used to facilitate in-vivo exposure to moral emotions in the
context of values. The proposed two arm randomized controlled pilot study will evaluate the
acceptability of ACT-MI and an active control treatment, and determine the feasibility of the
randomized controlled trial design for a future full-scale efficacy study. To accomplish this goal we
will continue to refine ACT-MI. Veterans enrolled will be randomized to: (a) Present Centered Therapy (PCT)
or (b) ACT-MI, both of which will consist of 12, 90-minute group sessions.
 The specific aims of this study are to: (1) Evaluate the acce...

## Key facts

- **NIH application ID:** 10114149
- **Project number:** 5I01RX002854-03
- **Recipient organization:** VA EASTERN COLORADO HEALTH CARE SYSTEM
- **Principal Investigator:** SEAN BARNES
- **Activity code:** I01 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2021
- **Award amount:** —
- **Award type:** 5
- **Project period:** 2019-04-01 → 2023-03-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10114149

## Citation

> US National Institutes of Health, RePORTER application 10114149, Thriving in the Midst of Moral Pain: The Acceptability and Feasibility of Acceptance and Commitment Therapy for Moral Injury (ACT-MI) Among Warzone Veterans (5I01RX002854-03). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10114149. Licensed CC0.

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