Rethinking moral injury: the shift from a syndromal to a functional model of psychotherapy for military personnel and veterans

Context and relevance. Moral injury is recognized as a phenomenon distinct from PTSD that requires specialized psychotherapeutic approaches, which calls into question the effectiveness of purely syndromal models of trauma treatment. The limitations of standard fear-focused protocols have led to the emergence of new interventions, yet their development has not been examined within a paradigm-shift perspective. Objective. To conduct a systematic analysis of psychological interventions for moral injury in military personnel, demonstrating the transition from attempts to eliminate moral pain to strategies for building a meaningful life and substantiating the shift from a syndromal to a functional model of psychotherapy. Methods. A systematic analytical review of the literature in PubMed, PsycINFO, Scopus, Google Scholar, and other databases for 2010—2025, including randomized controlled trials, meta-analyses, and theoretical papers. Results. Three waves of therapeutic approaches were identified: adaptation of PTSD gold-standard treatments (PE, CPT), which demonstrated important limitations when working with moral injury; development of highly specialized protocols targeting the core of moral injury (guilt, shame); and the emergence of functional-contextual and existential third-wave approaches (ACT, CFT, DBT, and mindfulness-based interventions) that shift the focus from symptom reduction to increasing psychological flexibility, cultivating self-compassion, and restoring a connection with personal values. A comparative analysis of their theoretical foundations, mechanisms of change, and evidence base is presented. Conclusions. The most promising approaches conceptualize moral injury not as a deficit to be removed but as an existential crisis requiring integration, thereby outlining a framework for the transition toward a functional, values-oriented model of psychotherapy.

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