Moral Injury

## Definition of Moral Injury

Moral injury, a relatively new term, still is yet to have a concrete definition. Shay (1994) defined moral injury as a wound to one's character due to an injustice committed by someone of higher status. Litz and colleagues (2009) took a slightly different approach and defined moral injury as moral beliefs that were broken despite possibly being preventable, someone witnessing them being broken, or someone finding out about them. Litz and colleagues also suggested that a moral injury may mirror symptoms of posttraumatic stress disorder (PTSD). Others suggested that moral injury may have more to do with damage to social bonds (Nash & Litz, 2013) or other functional impairments (Harris, Park, Currier, Usset, & Voecks, 2015).

It is generally believed that moral injury derives from a traumatic event that went against a person's core values and beliefs. This can be through committing an act that goes against morals, having a leader betray their subordinates, or even failing to save a life.

## Moral Injury in a Military Context

Moral injury is often examined through the lens of the military, as service members regularly are exposed to traumatic events that call into question their morals. Some examples in the military context where moral injury may occur are killing enemy troops, failing to save a civilian, or being betrayed by command. While exposure to one of these circumstances does not guarantee a moral injury, they do increase the likelihood for one to occur. Most moral injury research has been done in a military context. Moral injury is also a concept recognized by the National Center for PTSD through Veterans Affairs.

## Moral Injury and PTSD

Moral injury and PTSD have many similarities (Norman & Maguen, n.d.). First, they both often begin with a traumatic event, usually where a life is in danger. The feelings of guilt and shame are often present in moral injury, and are also symptoms in PTSD. There is also the possibility of experiencing both moral injury and PTSD. For example, if a service member helps attack a city in a foreign country, they may experience moral injury from the loss of the life. The attack can also cause PTSD, as many people died and the service member may have been at rick of dying themself.

While moral injury and PTSD have many similarities, differences present as well. When looking at the DSM-5's diagnostic criteria, there are several additional symptoms required for a PTSD diagnosis that are not present with a moral injury (American Psychological Association, 2013). For example, hyperarousal is a required feature of PTSD that is often not met with moral injury, meaning someone with a moral injury may not meet criteria for a PTSD diagnosis. Having both PTSD and moral injury does place an individual at a higher risk for greater severity with PTSD symptoms, greater severity with depressive symptoms, and a greater likelihood of suicidal ideation and behaviors (Bryan et al., 2018).

## How to Assess for Moral Injury

Moral injury is most often assessed through self-report questionnaires (Norman & Maguen, n.d.). These questionnaires ask various questions to explore what kind of traumatic experience a person has had and how they have reacted to them. A few examples of popular moral injury assessments are the Moral Injury Questionnaire (MIQ) (Currier et al., 2015) , the Moral Injury Events Scale (MIES) (Nash et al., 2013), and the Expression of Moral Injury Scale (EMIS) (Currier at al., 2017). These assessments measure what kind of exposures a person has had, the frequency of exposure, reaction of exposures, feelings around exposures, and other questions around war-related events. These assessments have been normed for military populations.

In non-military populations, trauma inventories are best to use to assess for moral injury. For example, the Trauma Related Shame Inventory is an assessment that measures the shame felt related to a traumatic event (Ã˜ktedalen at al., 2014). This would be a better fitted assessment tool for non-military individuals, as it was normed with a civilian population.

## Treatment for Moral Injury

Moral injury has limited treatment options, as it is still a relatively new concept. Most treatment options involve PTSD treatment modalities, which targets feelings of guilt, shame, and distorted thinking patterns (Harwood-Gross, 2020). Another option that can alleviate symptoms is guided meditation. Doing so can help clients externalize the thoughts and feelings they have surrounding their moral injury (Nakashima Brock, n.d.). Externalizing their experience can help clients fully process what happened rather than assume it as a piece of their identity. Overall, finding a way to express the moral injury to someone who is ready and able to actively listen without judgement can begin the healing process, and this can happen in many different capacities.

Additionally, there is some research to suggest cognitive behavioral therapy (CBT) for moral injury (Murray et al., 2021). The cognitive model for PTSD aims to modify threatening cognitions of the trauma, reduce reliving the trauma by elaborating on what happened and disrupting the link between everyday stimuli and the traumatic memory, and reduce cognitive strategies that maintain a sense of threat. By addressing the errors in thinking, CBT can rewire the way clients recall their moral injury situation and work through some of the guilt and shame that they are feeling.

## Further Readings

Frankfurt, S., & Frazier, P. (2016). A review of research on moral injury in combat veterans. Military psychology, 28(5), 318-330.

Brock, R. N., & Lettini, G. (2012). *Soul repair: Recovering from moral injury after war*. Beacon Press.

Bryan, C. J., Bryan, A. O., Anestis, M. D., Anestis, J. C., Green, B. A., Etienne, N., ... & Ray-Sannerud, B. (2016). Measuring moral injury: Psychometric properties of the moral injury events scale in two military samples. *Assessment*, *23*(5), 557-570.

## References

Ã˜ktedalen, T., Hagtvet, K. A., Hoffart A., Langkaas, T. F., & Smucker, M. (2014). The Trauma Related Shame Inventory: Measuring trauma-related shame among patients with PTSD. *Journal of Psychopathology and Behavioral Assessment, 36*(4), 600-615. https://doi.org/10.1007/s10862-014/9422-5

American Psychiatric Association. (2013). *Diagnostic and statistical manual of mental disorders* (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Bryan, C. J., Bryan, A. O., Roberge, E., Leifker, F. R., & Rozek, D. C., (2018). Moral injury, posttraumatic stress disorder, and suicidal behavior among National Guard personnel. *Psychological Trauma: Theory, Research, Practice, and Policy, 10*(1), 36-45. https://doi.org/10.1037/tra0000290

Currier, J. M., Farnsworth, J. K., Drescher, K. D., McDermott, R. C., Sims, B. M., & Albright, D. L. (2017). Development and evaluation of the Expressions of Moral Injury Scale--Military Version. *Clinical Psychology & Psychotherapy, 25*(3), 474-488. https://doi.org/10.1002/cpp.2170

Currier, J. M., Holland, J. M., Drescher, K., & Foy, D. (2015). Initial Psychometric Evaluation of the Moral Injury Questionnaire--Military Version. *Clinical Psychology and Psychotherapy, 22*, 54-63. https://doi.org/10.1002/cpp.1866

Harris, J. I., Park, C. L., Currier, J. M., Usset, T. J., & Voecks, C. D. (2015). Moral injury and psycho-spiritual development: Considering the developmental context. Spirituality in Clinical Practice, 2, 256–266. https://doi. org/10.1037/scp0000045

Harwood-Gross, A., (2020) Treating "Moral" Injuries. Retrieved from: https://www.scientificamerican.com/article/treating-moral-injuries/

Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695–706. https://doi.org/10.1016/j.cpr.2009.07.003

Murray, H., & Ehlers, A. (2021). Cognitive therapy for moral injury in post-traumatic stress disorder. *Cognitive behaviour therapist*, *14*, e8. https://doi.org/10.1017/S1754470X21000040

Nakashima Brock, R., (n.d.) Moral Injury FAQs. Retrieved from: https://www.voa.org/moralinjury-faq

Nash, W. P., & Litz, B. T. (2013). Moral injury: A mechanism for war-related psychological trauma in military family members. Clinical Child and Family Psychology Review, 16, 365–375. https://doi.org/ 10.1007/s10567-013-0146-y

Nash, W. P., Marino Carper, T. L., Mills, M. A., Au, T., Goldsmith, A., & Litz, B. T. (2013). Psychometric evaluation of the Moral Injury Events Scale. *Military Medicine, 178*(6), 646-652. https://doi.org/10.7205/MILMED-D-13-00017

Norman, S. B. & Maguen, S. (n.d.) Moral Injury. Retrieved from: https://www.ptsd.va.gov/professional/treat/cooccurring/moral\_injury.asp

Shay, J. (1994). Achilles in Vietnam: Combat trauma and the undoing of character. New York, NY: Scribner.